Treatment of Fractures REPORTS OF THE COMMITTEE ON FRACTURES OF THE American Surgical Association For 1913, 1914, 1915, 1916, 1917, 1918, 1921 EDITED BY J. F. Binnie, M.D., and John H. Jopson, M.D. Recorders of the Association AND John B. Roberts, M.D., and William L. Estes, M.D. Chairmen of the Committee PUBLISHED BY THE ASSOCIATION 1922 CONTENTS PAGE 1913 Report . . . 1 1914 “ . . 15 1915 “ 21 1916 “ 67 1917 “ 69 1918 “ 70 1921 “ 75 Fractures in Military Service. By John B. Walker, M.D. 84 Simple Fractures of the Humerus. By Thomas W. Hunt- ington, M.D 91 Fractures of the Bones of the Forearm. By Edward Martin, M.D., and E. L. Eliason, M.D 103 Fractures of the Tibia and Fibula. By Astley P. C. Ashhurst, M.D 112 Fractures of the Femur. By W. L. Estes, M.D. . . . 127 Copyright, 1923, by John H. Jopson, M.D., Recorder of the American Surgical Association RESOLUTION Adopted May 31, 1912, at Montreal Meeting of American Surgical Association: “Resolved, That the President (Dr. Arpad G. Gerster) appoint a Committee of Five to prepare a statement of the relative value of the operative and non-operative treatment of fractures of long bones (closed and open) to which shall be added an opinion as to the value of radiography in the determination of the choice of the method of treatment.” COMMITTEE FOR 1912, 1913, 1914 Dr. W. L. Estes Dr. Thomas W. Huntington Dr. John B. Roberts Dr. John B. Walker Dr. Edward Martin COMMITTEE FOR 1915, 1916 Dr. W. L. Estes Dr. John B. Walker Dr. Edward Martin Dr. Thomas W. Huntington Dr. Astley P. C. Ashhurst PREFACE The great interest in the treatment of fractures evoked by the visit in 1909 of Sir W. Arbuthnot Lane to the United States, reinforced in 19 n by an address on the same subject read before the American Surgical Association by its President Dr. Richard H. Harte, led to an important symposium at the meeting of the Association in 1912. The formal papers on that occasion were presented by Drs. W. L. Estes, Howard Lilienthal, Edward Martin, John B. Walker, and Joseph Ransohoff. The other speakers were Drs. Charles L. Scudder, John B. Roberts, Thomas W. Huntington, M. H. Richardson, Otto Kiliani, F. B. Lund, A. T. Bristow, George E. Armstrong, Leonard Freeman, Charles L. Gibson, G. G. Davis, Richard H. Harte, Francis J. Shepherd, John H. Gibbon, Dudley P. Allen, L. L. McArthur, A. Vander Veer, S. J. Mixter, Willy Meyer, Arpad G. Gerster, Thorkild Rovsing, of Denmark, Robert G. LeConte, James E. Moore. The divergence of opinion shown by the speakers convinced one of the Fellows of the desirability of obtaining, if possible, an authoritative opinion from the Association on what might be called a standard or routine method of dealing with the bulk of fractures of the long bones of the extremities. A formal opinion had been formulated and adopted by the Association in 18911 as to the results of treatment of fractures of the femoral shaft. A somewhat similar action was taken in 19002 when the z-rays became an adjunct in the diagnosis and treatment of bone injuries. Accordingly the Resolution printed on a preceding page was presented on May 31, 1912, and adopted. At the time, the 1 Transactions, Vol. IX, p. 81, and Minutes, 1891, p. 211. 2 Transactions, Vol. XVIII, p. 461, and Minutes, 1900, p. 415. VI TREATMENT OF FRACTURES mover of the Resolution did not know that the British Medical Association had a committee at work on a similar study. The Report of that Committee was published in the British Medical Journal, November 30, 1912, while the Report of the American Surgical Association Committee for 1913 was still in preparation. Much valuable information was obtained by the American Committee from the members of the British Frac- ture Committee and from its published Report. The Committee of the American Surgical Association presented its first preliminary report on May 6, 1913, at the Washington meeting. During the same meeting Dr. Ellsworth Eliot, Jr., read an important paper on “The Legal Responsibility to the Surgeon and Practitioner which the Use of the X-ray Involves.” This communication gave rise to a suggestion that the Committee on Fractures take up the consideration of this phase of profes- sional action in connection with the Treatment of Fractures. Accordingly, the Committee issued in June, 1913, a letter to the Fellows asking aid in the study of the topics mentioned in its Report, and included a query as to medico-legal relations of radiography. The request stated that: “To make the results of the investigation authoritative and worthy of the Association, it is necessary for the members of the Committee to have the co-operation of every Fellow. It seeks, therefore, memoranda on the following points: 1. The value of mobilization with light frictions (Lucas- Championniere) as a routine method of treatment. 2. The fixing of standards for the determination of the dura- tion of absence from work necessitated by the required treat- ment of particular fractures, and of standards for determining the degree of permanent disability likely to accrue from the injury. 3. The value of abduction and the best method of its applica- tion in fractures of the upper end of the humerus. 4. The value of steady fixed extension (Robert Jones), com- pound pulley traction (Robert Jones), vertical traction (Thomas Bryant) in adults, and of nail extension (Steinmann) in fractures of the shaft of the femur. PREFACE VII 5. The use of the Thomas knee splint in fractures of the shaft of the femur; the use of the abduction frame in fractures of the upper third of the femur; the value of forced abduction (Whit- man) and of double traction (Maxwell) in fractures of the femoral neck. 6. The advantages and disadvantages of direct fixation of the fragments in open, so-called compound, fractures infected and non-infected. 7. The part that radiography should play in the diagnosis of fractures, and its medico-legal relation to fracture treatment in general. If the Fellows will investigate these topics during the next six months, and report their results to the Fracture Committee, they will confer a favor upon its members. Reports, reprints, statistics and conclusions should be sent to the Chairman of the Committee.” The information so received was to be used by the several sub-committees of the Committee in its Report for 1914. Pressure of professional work prevented the carrying out of this plan in its entirety, and the Report of 1914 contained only a study of the sixth topic, which was prepared and read by Dr. William L. Estes, as a Preliminary Report on Compound Fractures. At this date Dr. Roberts resigned as a member of the Com- mittee because of illness and press of professional work and Dr. A. P. C. Ashhurst was appointed to fill the vacancy. The Report presented in 1915 took up the subject with vigor and will be found of importance. John F. Binnie, Recorder. REPORT OF 1913 COMMITTEE Dr. William L. Estes Dr. Thomas W. Huntington Dr. John B. Walker Dr. Edward Martin Dr. John B. Roberts Chairman Synopsis. Topics considered. Conclusions in report of British Committee. Defects in conclusions of British Committee. Two methods of non-operative treatment: immobilization and mobilization. Mal-union and non-union not under discussion. Relative value of non-operative and operative treat- ment in closed fractures. Routine of treatment in: general practice; in small hospitals; in hands of experts. Need of fracture wards. Twelve queries for future study. At the meeting of the Association held in Montreal last year there was adopted on May 31 a resolution that the President appoint a Committee to prepare a statement of the relative value of the Operative and the Non-operative Treatment of Fractures of the Long Bones; to which was to be added an opinion as to the value of radiography in the choice of the method of treatment. In the discussion stress was laid upon the fact that the Committee should consider open as well as closed fractures. It will be seen, therefore, that the duty assigned to the Committee involves the study of five topics. These are: (a) The value of the treatment of recent closed fractures of the long bones of the extremities by non-operative methods, the value of the treatment of these lesions by operative fixation, and the relative worth of these opposed plans as a routine treatment. (b) The value of operative and non-operative treatment of recent open fractures. (c) The comparative usefulness of these two methods in treating vicious union and non-union of closed fractures. 2 TREATMENT OE FRACTURES (d) The part that radiography should play in the diagnosis of closed fractures and in the selection of the particular method to be used in treating the individual case. (e) The determination of the proportion of patients which, after fracture of one of the long bones of the lower limb, is able to return to work without disability, and what method is most likely to insure such complete restoration of function. Not until after adjournment of the meeting, at which the Committee was appointed, did its members realize the importance of the investigation assigned them. The gravity of the duty has been further emphasized by the publication on November 30, 1912, of the elaborate report of the Committee of the British Medical Association on the Treatment of Simple Fractures. A study of the British report proves the necessity of a thorough examination of the therapeutics of fractures, and makes it imperative that the Committee of the American Surgical Asso- ciation pursue the investigation in a manner creditable to American scientific spirit. Your Committee has therefore determined to present at this time simply a preliminary report, and asks to be continued, so that it may consider in a thorough manner the five propositions committed to it. The members of the British Medical Association Committee believe it possible to obtain a high percentage of good results in children under the age of fifteen years, by either non-operative or operative treatment in closed fractures of the shafts of the long bones, except in fractures of both bones of the forearm. They reached the conclusion also that the aggregate results of non- operative treatment in patients over fifteen years of age are not satisfactory, and that in persons beyond the age mentioned the deleterious influence of age upon the functional result is less marked when they are treated by immediate operation than if they are treated by non-operative methods. In addition to these conclusions they express the opinion that the operative treatment of fractures requires such special skill REPORT OF 1913 3 and experience and such facilities to prevent sepsis as makes it a method not to be undertaken except by those who have constant practice and experience in such surgical procedures. In their own words, “ a considerable proportion of the failures of operative treatment are due to infection of the wound, a possibility which may occur even with the best technique.” Their report states that the mortality directly due to the operative treatment of closed fractures, in skilled hands and in propitious surroundings, is so small that it cannot be urged as a sufficient reason against operative treatment. It admits, however, that “for surgeons and practitioners who are unable to avail themselves of the operative method, the non-operative procedures are likely to remain for some time yet the more safe and serviceable.” The British Committee points out further that the operative material available under its time limit was so small that it is undesirable to draw any final conclusions from its statistics as to the relative value of operative and non-operative treatment. It avers that the collection of facts relating to the non-operative treatment is a very large one and yields conclusions having a considerable degree of finality. It believes that at a later date future results of operative treatment could be analyzed on the same basis, and that thus the relative value of the non-operative and operative therapeusis of fractures could be finally ascertained. It seems to your Committee that the main defects in the very valuable investigation of the British Committee lies in the fact that it apparently includes in the non-operative category all those recent closed fractures that had not been treated by incision and fixation of the fragments. It is pretty clear, there- fore, that in the non-operative class are included some cases that not even the ardent advocates of operation would consider proper for operative treatment. Reference is made, of course, to fractures with coincident local complications, such as com- minution of bone, injuries of skin, nerves, muscles, or bloodvessels, and luxation of joints, or accompanying general complications, 4 TREATMENT OF FRACTURES such as alcoholism, old age, or cardiovascular disease. These complicated fractures serve to lower markedly the percentage of good results in the non-operative class. Another misleading agency in such a statistical inquiry is the varying degrees of skill everywhere recognizable in practitioners who undertake the treatment of broken bones. Many such lesions are, and ever must be, treated by doctors who lay no claim to special surgical skill or experience. The family physician, the young hospital officer, or the recent graduate in medicine takes care of a considerable number of recent fractures. These doctors usually cling to non-operative procedures. Even if the 2000 or more non-operative cases examined by the Committee of the British Medical Association were all hospital cases in whose management the family doctor was not concerned, many must have had their fractures reduced and treated by doctors not equal to the surgical standards of those who essayed the treatment of the 200 or more operative cases. Yet at least a degree of comparison is made between the results of the non- operative (conservative) method and the operative (blood- shedding) method on this dissimilar basis. It is true that the committee of our British colleagues utters a warning against making a comparison between the 200 plus operative and the 2000 plus non-operative cases examined. It, however, lays stress rather on the numerical difference than on the fact that the operative statistics refer almost entirely to selected cases under the care of surgical experts. The non- operative class bears, however, the burden of some fractures complicated with serious general and local lesions and of many fractures under the care of unskilled, indifferent, or incompetent practitioners. When any new system of treatment is on trial, an expert surgeon anxious to do well for his patient naturally selects his cases and gives them marked personal attention. These agencies play a telling role in the battle against morbidity and mortality. It is to be regretted that the results obtained by the two chief methods of non-operative fracture treatment could not have been REPORT OF 1913 5 separated for statistical study by the committee of the British Medical Association. It is also credible that a better showing would have appeared in the non-operative end-results if patients in the hands of experienced surgeons only had been examined. Had the complicated fractures been eliminated also it is probable that the percentage of good functional results would have been higher than 90.8 for children under fifteen years of age, and 45.4 for adults. The percentages probably would have equaled those for operative treatment which are given as 93.6 for children and 66.3 for adults. Indeed, it is not unlikely that the percentage of good functional and good anatomical restoration in non- operative cases would have surpassed the end-results in operative cases. It is well known that there are two dissimilar methods of handling closed (simple) fractures, which have been thus grouped together unfortunately in the non-operative category. Patients treated by these unlike methods should be separated for statistical purposes; and due regard needs to be given to their respective ultimate results. Otherwise a true estimate of the value of the best non-operative means of treating closed fractures will not be scientifically established. It is only the best non-operative method that should be compared with an operative method used in selected cases at the hands of experts. The two chief methods of non-operative management of fractures are: 1. Prolonged continuous immobilization of the seat of fracture and the adjacent joints by the external application of rigid splints or dressings. This may be called the “Immobilization” method. It is the one probably very generally employed in Great Britain. It is, therefore, perhaps the method chiefly concerned in the anatomical and functional results which have caused the distinguished Mr. Lane and his followers to urge a more general adoption of operative exposure and direct fixation of fragments in fractures of the limbs. 2. Immediate gentle massage or friction, relaxation of displacing muscles, with almost no fixation, and very early 6 TREATMENT OR FRACTURES mobilization of the neighboring joints. This may be called the “Mobilization” method. It has long been urged by Lucas- Championniere the celebrated French surgeon. This mobiliza- tion method is used by some British surgeons and by a good many French surgeons who have become convinced of its value. The writings of Lucas-Championniere have had for years a direct influence on the practice of at least one of the members of the American Committee making this report. It is believed probable that in the United States neither the “Immobilization” nor the “Mobilization” method has been employed in full. Certainly some American surgeons do not practise prolonged continuous immobilization of the seat of fracture and the neighboring joints, but permit a considerable amount of passive and active mobility with frictions very early in the treatment of fractures. In the United States this inter- mediate method is probably much more frequently adopted in the treatment of fractures of the upper than of the lower extremity. The reason is that in American hospitals persons with fractures of the upper limb are largely ambulant, and therefore are treated in dispensary services under surgeons of greater surgical experience than medical house officers, to whom the details of treatment of fractures of the thigh and leg in hospital wards are often delegated. In taking up the discussion of the value of non-operative and operative methods in handling simple fractures of the long bones it is essential to begin with an exact statement as to what should be included in the terms non-operative treatment and operative treatment. By non-operative treatment the reader will under- stand that the Committee means the treatment by (i) the “Immobilization” method, which consists, as has already been said, in prolonged continuous fixation by means of external splints or apparatus; (2) the “Mobilization” method with light massage and little, if any, fixation splints. The former of these methods was used even by the early Egyptians. The latter was introduced to modern practice by Lucas-Champion- niere. By the operative method this Committee desires to indicate REPORT OF 1913 7 that treatment of recent fractures which consists in incising the soft parts, so as to disclose the seat of fracture and permit the application, if necessary, of plates, screws, or wire directly to the fragments for fixing them. By these definitions it is seen that the treatment of malunion or non-union of fractures is not under discussion. In fact, the investigation is limited to those cases in which the seat of fracture is exposed to view for reposition of fragments practically within two weeks after receipt of injury. By this means are ruled out also those cases in which operative treatment has been adopted only after a recognized failure of non-operative methods. This failure may have been due to difficulty in maintaining coaptation of fragments, to deficient or faulty union or to absolute non- union. Obviously these delayed cases should not be put in the same category with cases submitted to immediate operative treatment within seven to fourteen days. In the same manner tenotomies, osteotomies, removal of callus or projecting frag- ments, freeing of nerves, excision of joints, the controlling of hemorrhage, the reducing of coincident dislocation, should be excepted from classification as a part of either non-operative or operative treatment, so far as the present inquiry is concerned. These subsidiary procedures are mere coincidences affecting at times both systems of treatment. So far as is possible the investigation should determine the relative value of the two methods, namely, the non-operative and the operative, in closed fractures of the long bones of the limbs when circumstances are the same. The surgical attendant in each case should be equally skilled; the fracture identical in character and situation, and the patients similar in tempera- ment, in environment, and in social and financial standing. Diagnosis in both forms of treatment should be made with the x-rays and immediate reduction attempted under anesthesia, and the method of treatment then selected. After a few days the correctness of the reduction should be confirmed by x-rays, and attention given to active and passive motion of the joints to prevent stiffness occurring as the result of traumatic arthritis, 8 TREATMENT OE FRACTURES which often happens in fractures as it does in sprains. Prolonged abstinence from weight-bearing must be insisted upon in fractures of the bones of the lower limb. It will be seen from these axioms that the determination of the exact value of any method of treatment, and especially of the comparative worth of divergent methods, can scarcely be reached even by the study of a large number of case reports. The conclusions of your Committee, therefore, are founded upon what experience a study of the recent literature and a careful reading of the statistics and conclusions of the Committee of the British Medical Association seem to justify. The inquiry presents itself in the form of three questions: 1. What should be the routine method for the average general practitioner and those unskilled in surgery as a specialty? 2. What should be the routine treatment for trained surgeons with the usual facilities afforded by small or “cottage” hospitals? 3. What should be the routine treatment for skilled surgical experts with adequate hospital facilities? For all three classes of medical attendants the Committee believes that prolonged immobilization with continuous fixation by means of external splints or apparatus should be abandoned. This ancient method frequently leads to bad anatomical and bad functional results. The evil sequels may be caused by conceal- ment of imperfect reduction or by overlooked later deformity from imperfect maintenance of coaptation of fragments. Anky- losis of joints may arise from unrecognized coincident traumatic arthritis or from prolonged immobility of proximal joints. Pressure sores, ischemic palsy, or gangrene may follow the omission of frequent examination of an exposed limb. This method fortunately has long been abandoned by the surgical expert. Some surgeons and medical attendants mentioned in the first class may not yet have replaced the immobilization method by more modern procedures. What then shall be the method recommended for each of the three classes of practitioners mentioned? REPORT OE 1913 9 A. For the first class, which includes all those not trained in surgery as a specialty, the Committee suggests the study and adoption of a routine method midway between that of immobilization, on the one hand, and the mobilization of Lucas- Championniere or the traction method of Bardenheuer on the other. It is believed that both the method of the French surgeon mentioned and that of Bardenheuer, the German expert, probably will be found to require too much skill, experience, and attention to be safe in the hands of those who only occasion- ally have need to treat the more troublesome fractures. For these, general anesthesia should nearly always be employed for the diagnosis and reduction of the fracture, unless x-rays are used during the manipulation preceding the application of the fracture dressing. General anesthesia should always be used by such practitioners in the diagnosis and reduction of fractures involving joints. It alone will solve many difficulties of diagnosis and often simplify the subsequent treatment of the injury. If reliance is placed upon x-ray readings, the study of the skiagraphic plate must be under the direct supervision of a medical man accustomed to both clinical and radiographic examination of bone lesions. The radiographic reports of even expert radi- ographers alone are not always reliable guides to surgical practice. They must, as other pathological reports, be studied in association with expert surgical experience and clinical observation. The maintenance of reduction of the fragments should be assured by position, traction, splints, or other easily removable and adjustable apparatus. Splints should be so arranged as to allow easy and frequent inspection of the condition of the fragments and soft parts, and to permit early passive and slight active movements. Molded splints of gauze and gypsum or other plastic materials fit well and best fulfil the above require- ments. The watchwords for this first class of practitioners are general anesthesia, plastic splints or traction, frictions and frequent inspection, early mobility, delay in weight-bearing. B. What should be the routine for the second class, viz., 10 TREATMENT OF FRACTURES trained surgeons restricted by the moderate facilities of small or cottage hospitals? Prolonged immobilization has probably been largely discarded already by most American surgeons, when they take personal care of the entire treatment of a fracture. This is especially true of patients in private practice. Mobilization, less than that advised by Lucas-Championniere, or traction apparatus, to a less extent than that used by Bardenheuer, varying with the locality of the injury, has been adopted by many and probably should be adopted by all such surgeons for the usual run of fractures. One or the other method will probably continue to be the routine at the hands of the class of surgeons mentioned in private practice and in small hospitals with moderate facilities. This opinion suggests, it will be observed, that the operative treatment be restricted to especially rebellious fractures known to be such or found to be such after a very few days’ study. This judgment is recorded because of the difficulty under many circumstances of insuring perfect asepsis and sufficient trained assistance. The troublesome fractures that may with propriety be mentioned as probable candidates for operative treatment are: Fractures of the surgical neck of the humerus, T-fractures at the lower end of the humerus, fractures of the upper third of the radius, fractures of the upper third of the radius with dislocation of the radial head, fractures of the radius and ulna in the shafts, especially in adults, fractures of the upper third of the femur, supracondyloid fractures of the femur, fractures of the tibia and fibula near the ankle occasionally. In a general way it may be said that operative treatment suggests itself as the preferable method in any fracture, which cannot be properly reduced, or satisfactorily retained after reduction. If operative treatment be selected, the metal plate under absolute asepsis is the final resource, unless open reduction alone, or sutures, nails, or screws be effective. When reduction of fragments is not easily gained or its maintenance is doubtful, plating will be usually found better than wiring. A few cases report oe 1913 11 will not need direct fixation after the reduction has been accomplished through the incision. The operation should be immediate, that is, within a week or ten days, after the receipt of injury. It is, in fact, better to operate within a few hours than to delay even a few days, unless shock or other contra- indication requires delay. The method selected by the surgeon within the first week should, as a rule, be continued, if the surgeon be familiar with both operative and non-operative procedures. C. What should be the routine treatment for the third class, viz., skilled surgical experts with adequate hospital facilities? If prolonged immobilization has not been discarded, the surgeon can hardly be termed a skilled surgical expert in fracture treatment. He is behind the times in the surgery of fractures, though he be a recognized expert in abdominal, cerebral, thoracic, or pelvic surgery, or other branches of the medical art. To a fracture specialist with the facilities, a sufficient number of trained assistants, and the other essentials of a well-organized, modern hospital, it makes little real difference in morbidity or mortality whether he selects the non-operative or the operative plan. The latter, like all aseptic surgical procedures, requires more time, more care and more conscientious service at the beginning but makes the after-days easier for the surgeon, less painful for the patient, and less troublesome for the nurses. These surgeons may at times gain great advantage from the use of the fluoroscope, while adjustment is in progress. The time must soon come when metropolitan hospitals will not be considered satisfactorily organized unless fractures are assigned for treatment to specially equipped wards under the care of surgeons particularly interested in the pathology and treatment of these injuries. Gunstock deformities of the elbow, forearms incapable of full pronation and supination, deformed wrists, valgus ankles, coxae varae, and shortened and crooked femurs all too frequently prove the need for increased surgical skill, perhaps specialism, in the treatment of fractures of the tubular bones of the extremities. 12 TREATMENT OF FRACTURES It is probable, though not certain, that consolidation of a fracture takes place a little more slowly after direct fixation of fragments with a metal plate than in a well-reduced fracture under non-operative treatment. The statement that the surgical expert will be able to conduct in safety the patient to the point of recovery with good result in most fractures by either the operative or the non-operative route is only true, provided he personally dominates the situation as to reduction, fixation and after-treatment, and sets the time at which the patient shall be allowed to resume his original occupation. Such a surgeon, if of a mechanical turn of mind, will obtain good anatomical and good functional results in many fractures without blood-letting measures. In others he will not fail to recognize early the need for open reduction and direct fixation, nor will he fear sepsis, hemorrhage or shock. Similarly, he will seldom fail to recognize those cases in which these risks of operation out- weigh the benefits likely to be obtained through it. Then some of his patients will be treated by non-operative methods and may per- haps show poor anatomical restoration of the skeleton, as well as bad functional use of the injured limb. They will, however, live. If, on the other hand, this expert have more liking for operative surgery and a mind less mechanical in its attitude toward fracture repair, he will apply operative procedures to a greater number of fractures than will his colleague above mentioned. He will, however, equally recognize those cases in which operative surgery of the blood-letting kind has no place. There are certain investigations which the Committee desires the Fellows of the Association, if they feel disposed, to pursue during the next ten months. Succinct reports of the results of these inquiries could then be placed at the disposal of this Committee to aid in the preparation of a more complete report on the topic incompletely considered at this time. They are: i. The effect of immediate efficient reduction under general anesthesia with and without the coincident use of z-rays. This is especially desirable in fractures of the lower end of the radius, lower end of the humerus, upper end of the humerus, REPORT OF 1913 13 lower end of the tibia and fibula, lower end of the femur and neck of the femur. 2. Mobilization with light frictions (Lucas-Championniere) in all fractures. 3. Molded splints, not circular encasements of gypsum, for routine use immediately after reduction. 4. Increasing the usual time of convalescence for consolidation in fractures of the weight-bearing bones of the lower limb. 5. Fixing standards for the determination of the probable period of absence from work demanded by required treatment, and of the degree of partial or total permanent disability likely to accrue from particular fractures. This inquiry is important, because time of absence from work and period of convalescence are not convertible terms. Tempera- ment, kind of previous work, attitude of the employer, hope of legal recovery of damages, as well as the personal equation of the surgeon, are important incidents in establishing the period of treatment and the degree of disability. 6. The worth of the straight dorsal splint or the plastic palmar splint in fractures of the lower end of the radius. 7. The value of abduction in certain fractures of the upper end of the humerus. 8. The value of heavy weight traction (Buck), of steady fixed or rigid extension (Jones), of compound pulley traction (Jones), of vertical traction (Bryant) in adults, and of nail extension (Steinmann) for fractures of the femoral shaft. 9. The use of the Thomas knee splint in fractures of the shaft of the femur (Jones). 10. The use of the abduction frame in fractures of the upper third of the femur (Jones). 11. The value of forced abduction in fractures of the femoral neck (Whitman). 12. The use of double traction in fractures of the femoral neck (Maxwell). The importance of settling the points raised by these inquiries, of gaining acceptance of average standards of efficient fracture 14 TREATMENT OF FRACTURES treatment, of furnishing railroad surgeons, accident insurance examiners, and judicial tribunals the results of the deliberate judgment of this Association, and of advancing the practice of the surgical art for the public benefit and for scientific truth impels your Committee to respectfully ask that it be permitted to continue the investigation which, under the authority of the Association, it has had the honor to begin. All of which is respectfully submitted. REPORT OF 1914 DR. W. L. ESTES Synopsis. Treatment of compound (open) fractures; personal statistics; results of treatment. The almost insuperable difficulty of obtaining reliable and full data from the profession has compelled the reporter to compile from his own clinic at St. Luke’s Hospital the cases herewith presented. These cases are taken from the records of the last five years and represent the cases which could possibly be traced and the final results definitely determined. As they are the product of only one hospital they cannot be taken and are not offered as fully representative of the methods and results of the profession, generally, in the United States. This is therefore but a contribution to the fuller investigation, which it is hoped will be presented at a subsequent meeting of the Association. Fifty-one cases are analyzed. They represent the following classes: Compound fracture of the femur 8 cases Compound fracture of both bones of the leg ...15 “ Compound fracture of the tibia 10 “ Compound fracture of the patella 2 “ Compound fracture of the metatarsal bones ... 2 “ Compound fracture of the humerus 4 “ Compound fracture of both bones of the forearm . 7 “ Compound fracture of the radius 1 “ Compound fracture of the ulna 1 “ Compound fracture of the humerus, radius and ulna 1 “ Total 51 “ 28 cases were plated l , ,, ,. , ,, , . , > Direct fixation of the fragments. 7 were wired J 35 “ had direct fixation of the fragments. 13 “ were treated with external fixation only. 3 “ were moribund when admitted and died within a few hours after admission. (No special treatment and not enumerated further.) 16 TREATMENT OE FRACTURES The plated cases were as follows: Compound fracture of the femur 7 cases Compound fracture of both bones of the leg . . 12 “ Compound fracture of the tibia 5 “ Compound fracture of the humerus 4 “ The wired cases were as follows: Compound fracture of both bones of the leg ... 2 cases Compound fracture of both bones of the forearm . 3 “ Compound fracture of the humerus and both bones of the forearm 1 “ Compound fracture of the patella 1 “ Total . . 7 “ The external fixation apparatus was practically the same in all cases, namely, a reinforced gypsum splint carefully molded over a thick dressing of sterile gauze and cotton-wool. Average length of confinement in bed: Forearm cases 6 days Humerus cases 11“ Leg cases 28 “ Femur cases 38 “ Average time in the hospital: Forearm cases 23 days Humerus 48 “ Leg cases 53 “ Femur cases 69 “ The average length of time the patient was out from work, that is, until he returned to his occupation: Leg cases 6 months Femur cases 13 “ For the upper extremity fractures the time of disability has not yet been thoroughly worked out; it seems to be about four months. REPORT OF 1914 17 All the cases, but three, who had direct fixation were operated within forty-eight hours. Two cases of compound fracture of both bones of the legs were plated on the fifteenth and eighteenth day after injury respec- tively, because the fragments could not be kept in place. The case of compound fracture of the humerus and both bones of the forearm was wired on the tenth day after injury, also because by other means the fragments could not be kept in apposition. Though compound fractures should always be regarded as infected wounds, it is noteworthy that it is recorded of these cases that but two which were fixed by direct applications to the bones suppurated. One compound fracture of the femur, plated, had a strepto- coccic infection, but made a good recovery. One compound fracture of the humerus, radius, and ulna suppurated from a mixed infection but also made a good recovery. Not one of the direct fixation cases died. Results. Of the forty-eight cases treated, there were two deaths, both from septicemia. One case, a compound commin- uted fracture of the femur with very extensive injuries to the soft tissues, should have been amputated, but the patient refused amputation and died on the fourth day from acute sepsis. The other case was a prolonged septicemia from mixed infection in a man who had a compound fracture of both bones of the leg, for which no direct fixation was done. Mortality, 4.16 per cent. One case of compound comminuted fracture of the bones of the leg with dislocation of the ankle-joint had a mixed infection, destruction of the joint and tarsus followed; an amputation was necessary. Of the forty-six cases who left the hospital, all but one had useful limbs, that is to say, the one noted above which was amputated. 40.32 per cent, of these cases have returned to their former laborious occupations and report that they notice no disability. 18 TREATMENT OE FRACTURES Skiagrams are taken in cases of compound fractures: 1. After the first permanent dressing. 2. After the fixation plates have been removed. 3. When the union seems complete. 4. When the individual has returned to his occupation. The number of cases is too small for any set conclusion in regard to the treatment of compound fractures, but certainly in this small series direct fixation has produced much the quicker recoveries, and far better results than the former conservative methods. REPORT of 1915 COMMITTEE Dr. W. L. Estes Dr. John B. Walker Dr. Edward Martin Dr. Thomas W. Huntington Dr. Astley P. C. Ashhurst 1. Upper extremity. (a) Humerus 1. Neck 2. Shaft 3. Condyles (b) Radius... x. Extremities 2. Shaft 1. Extremities 2. Shaft (c) Ulna.... 1. Shaft 2. Colles (d) Both bones of forearm.. 2. Lower extremity. 1. Neck 2. Shaft. (a) Femur.. f (a) Upper third (b) Middle third ( (c) Lower third 1. Extremities 2. Shaft Cb) Tibia. 1. Extremities 2. Shaft (c) Fibula.. (id) Both bones of the leg. C i. Shaft [ 2. Pott’s Compound fractures are studied under the same divisions and classification as are the simple ones. The committee set itself the task of trying to determine espe- cially three points: 1. To find out the average present-day results in both simple and compound fractures as regards anatomical and functional results in the several age groups, and the average time of dis- ability. This latter period is determined to mean the average time the patient lost from work or his ordinary duties. 20 TREATMENT OF FRACTURES 2. The comparative value of (a) the conservative or closed methods; (b) the operative or open methods. 3. The comparative value of immediate or delayed treatment in each group of cases. In order to accomplish the collection and examination of cases a number of Fellows, surgeons in the various cities of the United States and Canada, were asked to serve as associate members of the committee. The following Fellows undertook the task of collecting and examining or having examined the end results of fractures in the hospitals of their respective cities: Dr. M. L. Harris, Chicago, Illinois. Dr. J. F. Buchanan, Pittsburgh, Pennsylvania. Dr. R. Matas, New Orleans, Louisiana. Dr. C. L. Scudder, Boston, Massachusetts. Dr. A. F. Jonas, Omaha, Nebraska. Dr. A. Primrose, Toronto, Canada. Dr. A. MacLaren, St. Paul, Minnesota. We wish gratefully to acknowledge their very great help in this work. Also, the committee is indebted to Dr. W. E. Lee, Dr. Ser- geant P. Martin, Dr. C. R. Steinke, and Dr. R. L. John, all of Philadelphia, for their efforts in collecting and examining cases and the free offering to the committee of the labor they had expended in personally examining and formulating the record of a large number of cases. The Committee wishes to give credit to these gentlemen and to offer them sincere thanks for their assistance. The set of questions indicated by the accompanying blank form were used in collecting the data: AMERICAN SURGICAL ASSOCIATION Committee on Fractures A. P. C. Ashhurst, M.D., Philadelphia Edward Martin, M.D., Philadelphia J. B. Walker, M.D., New York City T. W. Huntington, M.D., San Francisco W. L. Estes, M.D., Chairman, South Bethlehem, Penna. Committee Auxiliary Committee. M. L. Harris, M.D., Chicago, Illinois J. F. Buchanan, M.D., Pittsburgh L. Freeman, M.D., Denver, Colorado R. Matas, M.D., New Orleans C. L. Scudder, M.D., Boston J. E. Thompson, M.D., Galveston A. F. Jonas, M.D., Omaha J. F. Stokes, M.D., Washington, D.C. A. Primrose, M.D., Toronto, Canada A. Maclaren, M.D., St. Paul, Minn. 1. Patient’s Initials Age Occupation. 2. Cause of Fracture Direct Violence... Indirect Violence. ’ Neck Upper Third.. Middle Third. Lower Third. . „ Condyle 3. Bone Affected Transverse... Oblique Spiral Comminuted. Simple Compound. . 4. Kind of Fracture 5. Method of Reduction and Treatment a. Anesthetic or not? b. Fixation. Closed Method. Open Method. 1. Splints Kind 2. Plaster of Paris x. Immediate or delayed operation. . 2. Simply for reduction 3. Plates Kind 4. Wire 5. Nails 3- Traction ' Buck’s Bardenheuer. . Steinmann...., Jones 22 TREATMENT OF FRACTURES 6. Amount of Shortening. 1. First dressings 2. When all apparatus was removed 3. When discharged from the hospital 4. At latest observation 5. State how measurements were taken 7. Was X-ray used? At what stage of treatment What did it show the position of fragments to be 8. Length of time in bed 9. Length of time crutches, canes, or other aids to walking were used 10. Length of time absent from work 11. Is patient able to take his former job? 12. Disability at last observation, estimated by: a. Deformity b. Endurance c. Pain d. Swelling e. Interference with joint function 13. Mortality a. Cause of death b. Location and kind of fracture c. Age of patient The Committee collected 1745 cases: non-operative, 1358; operative, 387. There were 258 cases of the simple fractures operated on; and 129 cases of the compound. The results of all these cases have been carefully investigated. Unfortunately the records of many of these cases were so incomplete they could not be used in their entirety. These cases have been tabulated under six principal heads, viz.: 1. To show the results in the following age periods, viz.: (a) Under fifteen years; (b) 15 to 45 years; (c) 45 to 60 years; (e) over 60 years. 2. To show the effect of good anatomical restitution in shorten- ing the period of disability and restoring full function. 3. To show the comparative results in the treatment of simple fractures of the operative (open) method and the non-operative (closed) method in the several age groups. 4. To show the result of the operative and non-operative methods in the treatment of compound fractures also considered as regards the several age groups. REPORT OP 1915 23 5. To show the results of treatment of the fractures of the several long bones in the various regions, in the several age groups, in order to determine the average period of disability and to standardize the average recovery. 6. To show the comparative results of immediate and delayed treatment of the closed and open methods of treatment in the several age groups. The operative cases are considered as 1. Immediate. 2. Delayed. It was determined to class all operations performed within ten days after the injury under immediate operation, those done after this period are classed as delayed operations. The results of operations for non-union and for deformities resulting from fractures are not included nor considered in the report at all. The Committee finds: 1. The results are best in the age period under fifteen years. Conservative treatment is generally effectual during this period. 2. Good anatomical restitution of a fractured long bone always results in the best functional result, and has the shortest period of disability. 3. While few open operations are reported under the fifteen- year age period, it seems to make little difference in the result, except in senile cases (where it is unfavorable), what the age period is when the operation is done. 4. The end results of non-operative and operative treatment of compound fractures show very little difference in the ana- tomical result, but the functional results are better after opera- tive treatment, except in compound fracture of the shafts of both bones of the leg; here the reverse seems to be true. The age period except in senile cases has no marked effect on the result of the treatment. 5. The average period of disability (that is the time lost from work) in simple fractures, is as follows: 24 TREATMENT OF FRACTURES For fracture of the shaft of the humerus 14.0 weeks For fracture at head and neck of the humerus 11.5 “ For fracture at condyles of the humerus 9.0 “ For fracture of the shaft of both bones of the forearm . . 10.8 “ For fracture of the femur, all sites 7.37 months For fracture of the leg, all sites 4.75 “ Note.—This determination must still be held as not quite conclusive on account of the comparatively few clear reports on this point. Periods of disability were not recorded accurately in many of the reported cases and very seldom in compound fractures. The reporter finds in his own compound cases (51 in number) the period of disability to be: For fractures of the femur 13 months For fractures of the leg 6 “ For fractures of the upper extremity 4 “ 6. The humerus should show not more than 1 cm. shortening and no appreciable angulation. Musculospiral paralysis should not result. The forearm bones should show no appreciable shortening, and pronation and supination should be unhindered. Function should always be good and no lasting pain result. Fracture of the shaft of the femur should not result in shorten- ing greater than 2 cm., nor in a fixed position of angulation or rotation which will affect the joints and require new habits of balancing or tilting of the pelvis; joint function should be good. No permanent disability of the affected member should result. Fracture of the shaft of the bones of the leg should result in no appreciable shortening and no angulation or rotation. Joint function should be preserved. 7. There is no method or splint universally applicable, nor has any given splint or apparatus proved its superiority. All depends upon the discrimination of the surgeon and the manner in which the apparatus is applied and maintained. It is evident that traction methods are most frequently unskilfully employed. As a rule too little weight is used. The gauge of the proper weight required is that necessary to overcome the shortening. This should be determined by careful daily REPORT OF 1915 25 measurement. Traction methods require as a rule counter traction. Plaster casts and moulded splints are especially indicated and useful after a fracture has been satisfactorily reduced. Recommendations, i. The Committee recommends as a general principle that fractures be treated by a skilled surgeon. 2. X-ray pictures should be made by a competent radiographer or a fluoroscope should be used for diagnostic purposes before the permanent dressing is applied. At least two skiagrams should be taken, and they should be taken from opposite perpendicular directions. Skiagrams should also be taken after permanent dressings are applied to prove proper reduction, and at the end of the treatment to show the results of the union and for the purpose of a graphic record. 3. Fractures should be reduced immediately after the injury if possible to obtain and apply proper retaining apparatus or splints. The statistics show markedly better results when the treatment is begun at once. It is, however, not only useless but cruel to subject the patient to the pain of manipulation for reduc- tion unless the surgeon has proper fixation apparatus at hand and the patient is where he may have a permanent dressing applied. 4. General anesthesia should be employed, as a rule, to facili- tate reduction and prevent pain unless the condition of the patient contra-indicates it. 5. Neither the non-operative nor the operative method is to be recommended exclusively. Each has its indication and should be employed when required. Generally speaking the age period under fifteen years is the period in which non-opera- tive methods are especially effectual. In the other age periods up to sixty years, operative methods may with confidence be employed when non-operative treatment has proved ineffectual in reducing or controlling the fragments in proper position. The operation should not be delayed longer than one week after the injury. 6. The open method when adopted should be employed early. It may be used at any age period except in senile cases whenever 26 TREATMENT OF FRACTURES a skiagram shows a deformity or a position of the fragments which obviously cannot be reduced, or when proper efforts at reduction and retention have proved unavailing. 7. Some form of rigid plate applied directly to the bone or a bone “inlay” seems to be the best fixation method in operative cases. 8. Open operations for simple fractures should be undertaken only by experienced surgeons who are thoroughly equipped by training and who have proper instruments and apparatus to meet all the possible indications of the operation. 9. The work of this committee has been greatly hampered by the inadequacy of the records submitted for its consideration. A large proportion of the cases had to be rejected entirely, and most of them were so incomplete as to make deductions based upon them possibly misleading. The first step in the betterment of practice is the study of results achieved by present-day methods. An adequate study is impossible without adequate records. The committee strongly urges the American Surgical Associa- tion to set its seal of approval upon the standard form of record submitted by the committee,1 and further to petition the American Medical Association to do the same. The committee also urges each member of this Association faithfully to keep these records in his practice and to see that they are kept in the hospitals to which he is attached. The committee further recommends that a copy of the approved form be sent to all corporations within the United States of sufficient importance to have their own relief organiza- tions or medical service, or both; to all accident insurance companies to be embodied and incorporated in the papers given to the insured, with the requirement that they be filled at the time of an accident involving fracture; to all hospital boards with the request that these records be made a part of the routine records of fracture patients, pointing out that thus not only are the hospital and its surgeons protected in case of litigation, 1 See pages 27 and 28. REPORT OF 1915 27 but that most valuable material is being collected to serve for attaining better results in the treatment of fractures. Edward Martin John B. Walker T. W. Huntington Astley P. C. Ashhurst W. L. Estes Chairman. Inquiry Form for Fractures General Results: good moderate bad Anatomical Functional 1. Bone 2. Site—Neck Upper Middle Lower 3d. Condyle Involving joint 3. Name 4. Sex—M F 5- Age 6. Occupation. 7. Time fracture occurred—Date Hour 8. Hospital entered—Date Hour 9. First treatment—Date Hour 10. Cause of fracture 11. Kind of fracture—Oblique Transverse Spiral Impacted. Comminuted Simple. Compound. 12. Was there serious injury to soft parts—Skin—Yes No Muscles—Yes. No Vessels—Yes No Nerves—Yes No 13. Reduction: How many hours elapsed after accident before reduction? 14. Was anatomical reposition of fragments obtained? Yes No 15. Anesthetics used: Yes No Ether Gas 28 TREATMENT OF FRACTURES 16. Fixation: Closed Method. Position—Hyperflexion ....full supination abduction Splints Plaster of Paris T raction—Buck’s J ones Hodgen. Bardenheuer Steinmann... Amount of weight used 17. Open Method. Was non-operative treatment tried first How long after injury was operation performed Was open reduction alone performed What form of internal fixation used—Steel plates Wire Nails Screws Bone transplants Was it later necessary to remove fixation materials 18. Shortening at first examination cm. When all apparatus removed :...cm. Date When discharged from hospital cm. Date At last observation cm. Date 19. X-ray—Yes No. First finding on the day before; on the day after reduction. Fragments Displaced—Slightly Markedly Fair apposition—Yes No Anatomical— Yes No Overriding cm. Rotation—Yes No At last finding on the. day Overriding cm. Apposition Fair—Yes No Anatomical—Yes. No 20. How long confined in bed? How long in hospital? 21. How long did patient use crutches? Cane? 22. Results—Final examination made. weeks months after injury. Union bony fibrous Non-union. 23. Disability—Partial Complete Estimated by deformity Shortening Angulation. Swelling of soft parts Pain. Nerve involvement Interference with joint function. Endurance. 24. Mortality—Age of patient Main cause of death 25. Duration of absence from work weeks months 26. Is patient fully able to take his former job? 27. Present wage-earning capacity compared with former 28. Compensation under insurance, legislative act or legal process obtained— Yes .'.....No Expected—Yes No report or 1915 29 Simple Fractures The following investigations (Tables I to XXIX inclusive) concern only recent closed fractures. The questions to be answered by the tables are: I. (a) Does a good anatomical result imply a good functional result? (Answer on p. 34.) (b) Does a good anatomical result lessen the period of dis- ability? (Answer on p. 44.) II. Does operative treatment lessen the period of disability as compared with non-operative treatment? (Answer on p. 51.) Included in the analysis are the following 829 individual cases of fracture: TABLE I Humerus, upper end Total. ■ 30 N on-operative. 15 Operative. 15 Humerus, shaft . • 27 19 8 Humerus, lower end ■ 69 56 13 Total . 126 90 36 Radius, head • 3 I 2 Radius, shaft . 6 3 3 Radius, wrist (Colies’s, 2tC.) • 15 12 3 Ulna, olecranon . 6 0 6 Ulna, shaft .... • 4 1 3 Radius and ulna, shafts • 77 53 24 Total . hi 70 4i Femur, neck . 69 63 6 Femur, trochanters . 12 8 4 Femur, shaft • 364 264 100 Femur, condyles . 8 4 4 Total • 453 339 114 Fibula, shaft • 3 3 0 Tibia, shaft .... . 24 17 . 7 Tibia and fibula, shafts . 68 56 12 Tibia and fibula, ankle • 15 15 0 Tibia, ankle .... • 3 3 0 Fibula, ankle . 26 26 0 Total • 139 120 19 Grand total . . 829 619 210 30 TREATMENT OE FRACTURES A much larger number of reports was examined, but very many returns had to be rejected owing to insufficient data. Even among those acceptable, the groups in some instances are so small that it is useless to analyze them further. The only groups which approach a worthy number are: Cases. 1. The lower end of the humerus 69 2. The shafts of the radius and ulna 76 3. The neck of the femur 68 4. The shaft of the femur 364 5. The shafts of the tibia and fibula 92 It is only the fractures in these groups, therefore, that have been analyzed in any detail. Definitions. The anatomical result denotes the position as- sumed by the fragments of bone at the time of consolidation. It has been estimated by (i) shortening, and (2) x-ray findings. It is on account of deficiencies in statements on these two points that very many reports were rejected. If any errors of inter- pretation have been committed it probably has been in recording as good anatomical results such as were really only moderately good anatomical results. We believe that a “good” anatomical result implies that “anatomical reposition” of the fragments was obtained before consolidation occurred. If such absolute ana- tomical reposition was not secured the anatomical result should be (and so far as possible has been) recorded as “moderate,” even if eventually the bone ends became rounded off so that no palpable deformity remained when the patient was last examined. As regards shortening, only cases where no shorten- ing was noted have been classed as good; if shortening of 2 cm. (three-fourths of an inch) or less existed, the anatomical result has been classed as moderate. All shortening of more than 2 cm. has been classed as a bad anatomical result. It is incon- ceivable that so much shortening should be present without either overlapping of the fragments, angulation, or loss of tissue. Functional results are considered good only when no disability exists as to the part affected. If there is pain in damp weather, even though the patient resumes his former job, the function report of 1915 31 is classed only as moderate. If the patient’s earning capacity is notably diminished as a consequence of the fracture, the functional result is classed as bad; this may be the case, for instance, if a stiff but painless joint incapacitates a man. Again, the function of an individual joint or limb may be bad, without disabling its possessor; such a result is classed as moderate. The functional result is known in a much larger number of cases than is the period of disability. The anatomical and functional results in the whole series of cases may be seen in Table II. In Table III the same data are given for non-operative cases, and in Table IV for operative cases. TABLE II.—FRACTURES OF THE LONG BONES Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 469 ( 57%) 397 (85%) 6l (13%) II ( 2%) Moderate . 251 ( 30%) 126 (50%) 98 (39%) 27 (10%) Bad 109 ( 13%) 22 (20%) 26 (24%) 51 (56%) Total 829 (100%) 545 (65%) 185 (22%) 99 (12%) TABLE III.—619 FRACTURES OF THE LONG BONES (NON-OPERATIVE) Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 318 ( 51%) 280 (88%) 32 (lO%) 6 ( 2%) Moderate . 213 ( 34%) 118 (55%) 73 (34%) 22 (10%) Bad 88 ( 14%) 18 (20%) 20 (23%) 50 (57%) Total 619 (100%) 416 (67%) 125 (20%) 78 (12%) TABLE IV—210 FRACTURES OF THE LONG BONES (OPERATIVE) Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 151 ( 72%) 117 (77%) 29 (19%) 5 ( 3%) Moderate . 38 ( 18%) 8 (21%) 25 (66%) 5 (13%) Bad 21 ( 10%) 4 (19%) 6 (28%) 11 (52%) Total 210 (100%) 129 (61%) 60 (29%) 21 (10%) The next interesting point is the influence of the age on the functional result: 32 TREATMENT OF FRACTURES TABLE V.—INFLUENCE OF AGE ON THE FUNCTIONAL RESULT Anatomical result. Under 15 years: Good Moderate Bad . . . Total. 221 (70%) 80 (25%) 17 ( 5%) Good. 209 (94%) 63 (79%) 6 (35%) Functional result. Moderate. II ( 5%) 15 (18%) 3 (i7%) Bad. 1 (0.5%) 2 ( 2%) 8 (47%) Total . 318 278 (87%) 29 ( 9%) II ( 3%) 15 to 45 years: Good Moderate Bad . 174 (56%) 96 (31%) 41 (13%) 136 (78%) 41 (43%) 11 (27%) 32 (18%) 47 (49%) 12 (30%) 6 ( 3%) 8 ( 9%) 18 (43%) Total . 311 188 (60%) 9i (29%) 32 (10%) 45 to 60 years: Good Moderate Bad . . . 52 (41%) 41 (32%) 33 (26%) 39 (75%) 13 (32%) 4 (12%) 11 (21%) 19 (46%) 7 (21%) 2 ( 4%) 9 (22%) 22 (67%) Total . 126 56 (44%) 37 (30%) 33 (26%) Over 60 years: Good Moderate Bad . 22 (30%) 34 (46%) 18 (24%) 13 (60%) 9 (26%) 1 ( 5%) 7 (3i%) 17 (50%) 4 (22%) 2 ( 9%) 8 (23%) 13 (72%) Total . 74 23 (31%) 28 (38%) 23 (3i%) All over 15 years Good Moderate Bad . 248 (49%) 171 (33%) 92 (18%) 188 (75%) 63 (37%) 16 (17%) 50 (20%) 83 (48%) 23 (25%) 10 ( 4%) 25 (14%) 53 (57%) Total . 5ii 267 (52%) 156 (30%) 88 (17%) TABLE VI.—INFLUENCE OF AGE ON NON-OPERATIVE TREATMENT Anatomical result. Under 15 years: Good Moderate Bad . Total. 169 (66%) 73 (28%) 15 ( 5%) Good. I6l (95%) 62 (85%) 6 (40%) Functional result. Moderate. 8 ( 5%) 9 (12%) 3 (20%) Bad. 0 (-) 2 ( 3%) 6 (40%) Total . 257 229 (89%) 20 (7-7%) 8 ( 3%) 15 to 45 years: Good 90 (46%) 78 (87%) 10 (11%) 2 ( 2%) Moderate 75 (38%) 36 (48%) 34 (45%) 5 ( 6%) Bad . 32 (16%) 8 (25%) 9 (28%) 15 (47%) Total . 197 122 (62%) 53 (27%) 22 (11%) REPORT OF 1915 33 45 to 60 years: Good Moderate Bad . . . 43 (42%) 33 (32%) 26 (25%) 32 (74%) 12 (36%) 4 (15%) 9 (21%) 14 (42%) 5 (19%) 2 ( 4%) 7 (21%) 17 (65%) Total . 102 48 (47%) 28 (27%) 26 (25%) Over 60 years: Good 16 (25%) 9 (56%) 5 (3i%) 2 (12%) Moderate 32 (50%) 8 (25%) 16 (50%) 8 (25%) Bad . 15 (24%) 0 (—) 3 (20%) 12 (80%) Total . 63 17 (27%) 24 (38%) 22 (35%) All over 15 years: Good . . 149 (41%) 119 (80%) 24 (16%) 6 ( 4%) Moderate 140 (38%) 56 (40%) 64 (45%) 20 (14%) Bad . 73 (20%) 12 (19%) 17 (23%) 44 (60%) Total . 362 187 (52%) 105 (29%) 70 (19%) TABLE VII.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical result. Under 15 years: Good Moderate Bad . . . Total. 52 (86%) 7 (10%) 2 ( 3%) Good. 48 (92%) I (15%) O Functional result. Moderate. 3 ( 6%) 6 (85%) 0 Bad. 1 ( 2%) 0 (-) 2 (lOO%) Total . 61 49 (82%) 9 (13%) 3 ( 5%) 15 to 45 years: Good 84 (74%) 58 (69%) 22 (26%) 4 ( 5%) Moderate 21 (18%) 5 (24%) 13 (62%) 3 ( H%) Bad . 9 ( 8%) 3 (33%) 3 (33%) 3 ( 33%) Total . 114 66 (58%) 38 (33%) 10 ( 8%) 45 to 60 years: Good . . 9 (37%) 7 (77%) 2 (22%) 0 (-) Moderate 8 (33%) 1 (12%) 5 (63%) 2 ( 25%) Bad . 7 (30%) 0 (-) 2 (28%) 5 ( 7i%) Total . 24 8 (33%) 9 (36%) 7 ( 30%) Over 60 years: Good 6 (54%) 4 (66%) 2 (33%) 0 (-) Moderate 2 (18%) 1 (50%) 1 (50%) 0 (-) Bad . . . 3 (27%) 1 (33%) 1 (33%) 1 ( 33%) Total . . 11 All over 15 years: 6 (54%) 4 (37%) 1 ( 9%) Good 99 (67%) 69 (69%) 26 (37%) 4 ( 4%) Moderate 3i (20%) 7 (21%) 19 (62%) 5 ( 17%) Bad . . . 19 (12%) 4 (17%) 6 (33%) 9 ( 50%) Total . 149 80 (53%) 51 (34%) 18 ( 12%) 34 TREATMENT OF FRACTURES Comments on Tables II, III, and IV. Table II gives the answer to the first part of Question i. It shows without any doubt that the surest way to secure a good functional result is to obtain anatomical reposition of the fragments in any fracture: a good anatomical result gives a good functional result in 85 per cent, of cases; if anatomical reposition is not secured there is at once a falling off in good functional results to 50 per cent. This table shows also the apparent difficulty of obtaining such reposition, or at least the rarity with which it is actually obtained (only in 57 per cent, of the whole series of cases). Tables III and IV show that it is easier to secure anatomical reposition by operative means than by non-operative, but also demonstrate that good function follows in a larger proportion of cases where anatomical reposition is secured without operation than when operation is done (88 per cent, compared to 77 per cent, of cases). But it should, of course, be borne in mind that the group of cases treated without operation includes practically all fractures with- out primary displacement of the fragments, and that operation has usually been adopted only where marked displacement of the fragments existed. However, it is most noteworthy that even by operative means anatomical reposition was secured in less than three-fourths of cases (72 per cent.). These tables also show that if anatomical reposition is not secured, but only approx- imate reduction is obtained (moderate anatomical results), very much better function follows non-operative than operative treat- ment (55 per cent, of good function compared to 21 per cent.). Even bad anatomical results under non-operative treatment give good functional results in very nearly as large a proportion of cases (20 per cent.) as is secured when only moderate anatom- ical results follow operative treatment (21 per cent.). It is evident that unless anatomical reposition of the fragments is obtained by operation, the slight improvement in the position of the fragments that is obtained short of perfection does not com- pensate for the additional injury to the soft parts entailed by the operation. REPORT OF 1915 35 Comments on Tables V, VI, and VII. Table V. In patients under fifteen years of age good functional results depend less upon good anatomical results than in older patients, and the bad functional results are almost negligible (3 per cent.). The older the patients the greater is the proportion of bad results, and the more certainly do such bad results follow failure to secure anatomical reposition of the fragments. The proportion of good functional results secured from moderate and bad anatomical results grows progressively less the older the patient. Table VI and VII. When operative treatment1 is compared with non-operative treatment, the facts observed in the analysis of Tables III and IV become still more apparent. While it is easier in almost all age periods to secure anatomical reposition by operation than without, yet the proportion of good functional results following such reposition is higher when it is obtained without operation, and if only moderate reduction is obtained the proportion of good functional results is very much higher when no operation is done. This brings one to the conclusion that unless the surgeon is reasonably certain of securing accurate anatomical reduction by operative means, he will do better to leave the fracture unreduced. Certainly under fifteen years of age, where only moderate reduction secures good function in as high as 85 per cent, of cases, there is very little excuse for operation as an habitual practice. These tables confirm the point emphasized by the Fractures Committee of the British Medical Association,2 that the older 1 The operative cases in these tables belong to Class A and Class B of the classification of the Fractures Committee of the British Medical Associa- tion. None of Class C are included. It has not been practicable to separate Classes A and B. Class A are operations undertaken immediately without any attempts at non-operative treatment. Class B are operations undertaken only after non-operative treatment has been tried and failed. (This Committee of the American Surgical Association has followed the example of the Committee of the British Medical Association in accepting without question the decision of the attendant as to whether or not the attempts at non-operative treatment were efficient.) Class C are operations undertaken for malunion, non-union, etc. 2 Brit. Med. Jour., 1912, ii, 1505. 36 TREATMENT OF FRACTURES the patient the more important it is to secure anatomical reposi- tion. But they do not indicate that more patients will secure good function if treated by operation than if no operation is done. The only exception to this rule appears to be in the case of patients more than sixty years old; but the number of such patients treated by operation (n only) is far too small in this series to be considered authoritative. If patients from fifteen to forty-five years of age are considered, it is evident that by operation a good anatomical result will be secured in a larger proportion of cases than by non-operative treatment (74 per cent, compared to 46 per cent.), but the total number of patients in this group who secure a good functional result is higher when no operation is done than when operation is employed (62 per cent, compared to 58 per cent.); and in the next age group (forty-five to sixty years) although a higher proportion of good anatomical results follows non-operative than operative treat- ment (42 per cent, compared to 37 per cent.), the same excess of total good functional results is to be credited to non-operative treatment as was seen in the previous age period (47 per cent, from non-operative treatment compared to 33 per cent, from operative treatment). It is worth while here, we think, to pause and study these operative cases in greater detail. Why did one out of every 10 cases treated by operation secure only a bad anatomical result, and why also was the functional result bad in as many as 10 per cent, of cases? Why was a good anatomical result obtained only in 72 per cent, of cases, and a good functional result only in 61 per cent, of cases? It has been pointed out already, in com- menting on Tables II, III, and IV, that in most of the operative cases the fragments were much displaced, and that this was the indication for operation; whereas in a large proportion of the cases treated without operation the fragments never were displaced, and really no reduction was required. In a certain proportion of cases where operation was employed, however, and where there was already marked displacement of the fragments, the surgeon was enabled by operation to secure a good anatomi- REPORT OF 1915 37 cal result; those cases in which he was not able to secure ana- tomical reduction by means of operation presumably were very difficult cases. But extenuate these results as we may, there is one fact from which we cannot get away: it is the question of infection. Out of 210 operations for closed fractures (all of them clean wounds, none of them primarily infected), no less than twelve wounds, or over 5 per cent, of the whole series, became infected during the operation. Out of 8 operations on the shaft of the humerus, 2, or 25 per cent, were infected; out of 100 operations on the shaft of the femur, 7, or 7 per cent., were infected; and out of 19 operations on the shaft of the tibia 2, or about 10 per cent., were infected. Such a record of infection in a series of operations for hernia should be considered scandalous; and it is scandalous in a series of operations for simple fractures. And it may be remarked that while all the good operative results were obtained by good surgeons, the infected cases are not the sole property of bad surgeons. The number of deaths following operations for simple frac- tures has not been recorded. Some deaths there were; but as many series of case records contained only the reports of end- results in patients who recovered, and did not report any fatal cases at all (either operative or non-operative), it would be unfair to calculate the mortality of fractures in general from the records at hand. In 2 cases where infection was caused by the opera- tion it proved so severe that amputation had to be done, one for fracture of the femur and one for fracture of the tibia. There were 2 deaths, of 1.3 per cent., among 147 operations for frac- tures reported by the Fractures Committee of the British Medical Association, all of these operations belonging to Class A (i. e., where immediate operation was undertaken without attempt at non-operative treatment). Neither of these deaths, however, was chargeable directly to the operation. Lambotte, according to Appendix C, of the same report, had 9 deaths (1.5 per cent.) among 567 fracture operations of all classes. The results differ according as the fracture occurs in the shaft of the long bones, or near the joints. (“Quo propior fractura capiti vel superiori vel inferiori est, eo pejor est.” Cels, viii, 10.) 38 TREATMENT OF FRACTURES TABLE VIII.—575 FRACTURES OF THE SHAFTS OF LONG BONES Anatomical result. Good Moderate . Bad . Total. 207 (49%) 147 (35%) 63 (15%) Good. 183 (88%) 93 (63%) 17 (26%) Functional result. Moderate. 23 (H%) 44 (30%) 15 (24%) Bad. I (0.5) 10 ( 7%) 31 (50%) Total 417 293 (70%) 82 (20%) 42 (10% II. OPERATIVE Good . . . Moderate . Bad . 112 (72%) 27 (17%) 19 (12%) 89 (79%) 8 (29%) 4 (21%) 20 (18%) 15 (55%) 5 (26%) 3 ( 3%) 4 d5%) 10 (53%) Total 158 101 (64%) 40 (25%) 17 (n%) III. ALL CASES Good Moderate . Bad . ■ 319 (55%) 174 (30%) ■ 82 (14%) 272 (86%) IOI (59%) 21 (26%) 43 (i3%) 59 (33%) 20 (24%) 4 ( 1%) 14 ( 8%) 4i (50%) Total 575 394 (68%) 122 (21%) 59 (10%) I. NON-OPERATIVE TABLE IX. 254 FRACTURES NEAR JOINTS I. NON-OPERATIVE Anatomical result. Good Moderate . Bad . Total. 112 (55%) 66 (33%) 24 (11%) Good. 97 (86%) 24 (42%) 1 ( 4%) Functional result. Moderate. 10 ( 9%) 30 (38%) 4 (16%) Bad. 5 ( 4%) 12 (20%) 19 (79%) Total , 202 122 (60%) 44 (22%) 36 (18%) II. OPERATIVE Good Moderate . Bad . • 38 (73%) ■ 12 (23%) ■ 2 ( 4%) 26 (68%) I ( 8%) 0 ( -) 10 (26%) 10 (83%) 1 (50%) 2 ( 5%) 1 ( 8%) 1 (50%) Total • 52 27 (52%) 21 (40%) 4 ( 8%) III. ALL CASES Good Moderate . Bad . • 150 (59%) • 78 (30%) . 26 (10%) 123 (82%) 25 (32%) I ( 4%) 20 (13%) 40 (51%) 5 (19%) 7 ( 4%) 13 (16%) 20 (77%) Total • 254 149 (58%) 65 (25%) 40 (16%) REPORT OF 1915 39 TABLE X.—HUMERUS Anatomical Functional Total Good Moderate Bad Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Shoulder Good .... Moderate . Bad .... IO 4 I 9 5 1 9 3 6 1 1 1 2 4 1 1 1 Total .... 15 15 12 7 2 6 1 2 Per cent. . 100 100 80 47 13 40 7 13 Shaft Good .... Moderate . Bad .... 9 9 1 6 1 1 9 6 1 1 2 4 1 1 1 1 Total .... 19 8 16 1 2 5 1 2 Per cent. . 100 100 84 13 10 62 6 25 Elbow Good .... Moderate . Bad .... 43 11 2 10 3 43 8 1 7 3 1 2 2 1 1 Total .... 56 13 52 7 4 4 2 Per cent. . 100 100 93 54 7 31 15 Entire Humerus Grand total . 90 36 80 15 8 15 2 6 Per cent. . 100 100 90 42 8 42 2 16 Operations in black face figures. TABLE XI.—RADIUS AND ULNA Anatomical Functional Total Good Moderate Bad Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Shaft Good .... Moderate . Bad .... 32 15 6 18 5 1 32 12 4 17 2 1 4 1 1 2 1 Total .... S3 24 48 17 2 6 3 1 Per cent. . 100 IOO 90 7i 4 25 6 4 Wrist Good .... Moderate . Bad .... 7 3 2 3 0 0 6 3 2 1 1 2 Total .... 12 3 9 2 1 3 Per cent. . IOO IOO 75 66 33 25 Entire Forearm Grand total . 65 27 57 19 2 7 6 1 Per cent. . IOO IOO 88 70 3 26 9 4 Operations in black face figures. 40 TREATMENT OF FRACTURES Though it is evident from these tables (VIII and IX) that good functional results are most certain to follow good anatom- ical results, the most noteworthy fact demonstrated is that it is very much more important to secure anatomical reposition of the fragments in the case of joint fractures than in fractures in the shafts of the long hones. In the latter case (shaft fractures) bad function follows a bad anatomical result in only half the cases; whereas in the case of joint fractures a bad anatomical result insures a bad functional result in over three-fourths of cases (77 per cent.). In the shafts of the long bones, a moderate anatomical result secures good function in 59 per cent, of cases; but if the fracture is near a joint, good function follows a mod- erate anatomical result only in 32 per cent, of cases. TABLE XII.—FEMUR Anatomical Functional Total Good Moderate Bad Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Neck Good .... 16 5 10 2 4 3 2 0 Moderate . 36 1 5 0 21 1 10 0 Bad .... 11 0 0 0 2 0 9 0 Total .... 63 6 IS 2 27 4 21 0 Per cent. . 100 100 24 33 43 66 33 Trochanters Good .... 4 I 3 1 0 0 1 0 Moderate . 4 2 I 0 2 2 1 O Bad .... 0 1 0 0 0 1 0 0 Total .... 8 4 4 I 2 3 2 0 Per cent. . 100 100 50 25 25 75 25 Shaft Good .... 115 70 103 56 II 14 1 0 Moderate . IOI 15 62 7 35 6 4 2 Bad .... 48 15 12 3 13 3 23 9 Total .... 264 100 177 66 59 23 28 II Per cent. . 100 100 67 66 17 23 12 11 Condyles Good .... 1 4 I 1 0 3 0 0 Moderate . 3 0 2 0 0 0 1 0 Bad .... 0 0 0 0 0 0 0 0 Total .... 4 4 3 1 0 3 1 0 Per cent. . 100 100 75 25 75 25 Entire Grand total . 339 114 199 70 88 33 52 11 Per cent. . 100 100 58 61 26 29 15 9 Operations in black face figures. REPORT OF 1915 41 TABLE XIII.—TIBIA AND FIBULA Functional Total Good Moderate Bad Anatomical Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Shafts Good . 45 15 34 13 11 1 0 1 (also shaft of Moderate . 21 3 12 0 5 2 4 1 tibia alone 24 cases) Bad .... 7 1 0 0 1 1 6 0 Total .... 73 19 46 13 17 4 10 2 Per cent. . 100 100 66 65 25 23 9 12 Ankle Good .... 32 25 6 1 (all forms) Moderate . 5 2 3 0 Bad .... 7 0 0 7 Total .... 44 27 9 8 Per cent. . 100 62 20 18 Entire Leg Grand total . 117 73 26 18 Per cent. . 100 62 22 15 Operations in black face figures Comments on Tables X, XI, XII, and XIII. These tables show the anatomical and functional results in the more impor- tant groups of fractures. Table X includes, under the general heading “ shoulder, ” fractures of the surgical neck, anatomical neck and tuberosities of the humerus as well as separations of the upper epiphysis of this bone; there are so few cases in all (15) that a separate classification is not practicable. Likewise under the heading “elbow” are included all fractures of the lower end of the humerus. In Table XI under “wrist” are included Colies’s fractures, epiphyseal separations, etc. In Table XII there are included under “neck” both intracapsular and extracapsular fractures, impacted or unimpacted; as the exact site of the fracture was not indicated in a great many cases it was not possible to give a more accurate classification. Fractures through the trochanters, however, have been classified separ- 42 TREATMENT OF FRACTURES ately. All fractures of the shaft are grouped together; while those of the “condyles” include supracondylar fractures (only such as are within io cm. of the base of the condyles should be so named), epiphyseal separations, and fractures of one or other condyle into the knee-joint. In Table XIII fractures of the shaft of the tibia alone have been grouped together with fractures of the shafts of both tibia and fibula; and all forms of fractures at the ankle have been grouped together. Comments on Tables XIV and XV. In Tables XIV and XV the foregoing tables (X, XI, XII, XIII) are summarized and compared with the functional results in similar groups of cases reported by the British Fractures Committee. The non- operative cases are tabulated first, giving the total number of cases observed, and the total number of cases in which a good functional result was secured, regardless of the anatomical result. In the British report were tabulated a total of 1040 operations and these were classified as Class A, Class B, and Class C. (See footnote, p. 35.) It has not, however, been possible to classify the present series of operative cases on this plan, mainly owing to lack of details. The 210 operative cases which it has been possible to analyze represent exclusively Classes A and B, though the exact proportions are not known; it is certain, how- ever, that comparatively few of the operations belong in Class A. This point should be constantly borne in mind in making comparisons in the following tables, since the British figures refer exclusively to operations in Class A. Where no figures are given in Table XV, either no operations are recorded or at most only one operation in the special region of the bone investigated. REPORT OF 1915 43 TABLE XIV.—GOOD FUNCTIONAL RESULTS FOLLOWING NON-OPERATIVE TREATMENT Site. American Surgical Association. British Medical Association. Total. Good function. Total. Good function. Humerus, shoulder .... 15 12 (80%) 53 35 (66%) Humerus, shaft 19 16 (84%) 73 60 (82%) Humerus, elbow .... 56 52 (93%) 101 61 (60%) Total 90 80 (90%) 227 156 (68%) Radius and ulna, shafts S3 48 (90%) 76 42 (55%) Radius and ulna, wrist 12 9 (75%) 62 39 (63%) Total 65 57 (88%) 138 81 (58%) Upper extremity .... 155 137 (88%) 365 237 (65%) Femur, neck 63 15 (24%) 9i 24 (26%) Femur, shaft 264 177 (67%) 638 509 (79-8%) Femur, condyles .... 4 3 (75%) 21 12 (57%) Total 331 195 (59%) 750 545 (72%) Tibia and Fibula, shafts 73 46 (66%) 975 748 (76%) Ankle fractures 44 27 (62%) 255 125 (49%) Leg bones, total .... 117 73 (62%) 1230 873 (71%) Lower extremity .... 448 268 (60%) 1980 1418 (71%) TABLE XV.—GOOD FUNCTIONAL RESULTS FOLLOWING OPERATIVE TREATMENT Site. American Surgical Association. British Medical Association. Total. Good function. Total. Good function Humerus, shoulder .... 15 7 (47%) 10 8 ( 80%) Humerus, shaft 8 1 (13%) 6 5 ( 83%) Humerus, elbow .... 13 7 (54%) 16 11 (68.7%) Total 36 15 (42%) 32 24 ( 75%) Radius and ulna, shafts 24 17 (7i%) 15 11 ( 73%) Radius and ulna, wrist 3 2 (66%) 2 2 (100%) Forearm, total .... 27 19 (70%) 17 13 ( 76%) Upper extremity .... 63 34 (54%) 49 37 ( 75%) Femur, neck 6 2 (33%) Femur, shaft 100 66 (66%) 32 29 ( 90%) Femur, condyles .... 4 1 (25%) Total no 69 (62%) 32 29 ( 90%) Tibia and fibula, shafts 19 13 (65%) 39 3i ( 79%) Ankle fractures 4 2 ( 50%) Leg bones, total .... 19 13 (65%) 43 33 ( 76%) Lower extremity .... 129 82 (63%) 75 62 ( 82%) 44 treatment of fractures Question I (b). Does a Good Anatomical Result Lessen the Period of Disability? An attempt has been made to answer this question in Tables XVI, XVII, XVIII, XIX, XX, XXI, and XXII. It is much to be regretted that the period of disability is known in so few cases (532), and that these are so scattered among the various sites of fracture that to obtain any satisfactory figures it has been necessary to group the cases in rather an artificial manner. It has seemed, on the whole, more accurate to rely on the figures which give the proportion of patients who recover their function (whether good, moderate, or bad) within a given period (Tables XVII, XVIII, XIX, XX), rather than on the average period of disability for all cases in a given region. The latter calcula- tion is necessarily inaccurate in most instances, as the period of disability often is recorded merely as “over one year,” “over two years,” etc. As a working rule, however, it may be con- sidered that patients with fractures of the upper extremity who are still incapacitated after more than twenty-four weeks (approximately six months) will be more or less permanently incapacitated, and that a period of twelve months may be applied similarly to fractures of the lower extremity. According to this reckoning the following table has been constructed: TABLE XVI.—AVERAGE PERIOD OF DISABILITY Average Cases Average period of disability, terminated under 24 period of disability, Site of fracture. All cases. weeks. weeks. weeks. Humerus, shoulder . . . 18 xi.5 17 IO.9 Humerus, shaft . • • 19 14.0 16 12.0 Humerus, elbow • • 23 9.0 22 8.2 Radius and ulna, shafts . 26 10.8 25 10.3 Average Cases Average period of terminated period of disability, under 12 disability, Site of fracture. All cases. months. months. months. Femur, neck • • 51 8.1 32 6-5 Femur, shaft . 196 7-1 168 6.3 Tibia or tibia and fibula, shafts . . . . . . 66 4-9 6l 4-25 Ankle • • 29 4-9 28 4.28 TABLE XVII—PERIOD OF DISABILITY IN FRACTURES OF THE UPPER EXTREMITY Anatomical result. Total. Under 6 weeks. Period of disability. Under 12 Under 24 weeks. weeks. Over 24 weeks. Good . • 58 35 (60.0%) 15 (26.0%) 6 (10%) 2 ( 3%) Moderate . . 20 8 (40.0%) 6 (30.0%) 2 (10%) 4 (20%) Bad . . 8 I (12.5%) 5 (62.5%) 2 (25%) 0 (0) REPORT OF 1915 45 Anatomical results Period of Disability. Total Under 6 weeks. Under 12 weeks. Under 24 weeks. Over 24 weeks. Humerus 60 cases Good 4i Shoulder Shaft Elbow 6 4 12 Shoulder Shaft Elbow 4 3 5 Shoulder Shaft Elbow 320 Shoulder Shaft Elbow 1 1 0 Per cent. 43 40 70 29 30 30 21 20 7 10 Moderate 16 322 032 010 021 Per cent. 100 25 40 38 40 12 25 20 Bad 3 000 ill 000 0 0 0 Per cent. 100 100 100 Total 60 29 20 6 S Per cent. 48 33 10 9 Forearm (shafts of either or of both bones) 26 cases Good 17 13 3 1 Per cent. 76 18 6 Moderate 4 1 1 1 1 Per cent. 25 25 25 25 Bad 5 1 2 2 Per cent. 20 40 40 Total 26 IS 6 4 1 Per cent. 58 23 IS 4 TABLE XVIII.—DOES GOOD ANATOMICAL RESULT LESSEN PERIOD OF DISABILITY? 46 TREATMENT OF FRACTURES Table XVII, which is elaborated in Table XVIII, seems to show that the period of disability depends very little upon the anatomical result, except for patients who recover function within six weeks. But the fallacy is evidently due to the small total number of cases observed. TABLE XIX.—PERIOD OF DISABILITY IN FRACTURES OF THE FEMUR Anatomical result. Total. Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. Neck: 3 (20%) Good 16 6 (35%) 4 (25%) 0 (-) 3 (20%) Moderate 27 6 (22%) 7 (26%) 1 ( 4%) 4 (15%) 9 (33%) Bad . 8 0 (-) 2 (25%) 1 (12.5%) 0 (-) 5 (62.5%) Shaft: 23 (22%) 3 ( 3%) Good 104 46 (44%) 27 (26%) 5 ( 5%) Moderate 52 14 (27%) 15 (29%) 6 (11%) 10 (19%) 7 (13%) Bad . 40 7 (17%) 9 (22%) 3 (7-5%) 3 (7-5%) 18 (45%) Table XIX, which gives the period of disability in fractures of the neck and shaft of the femur, is condensed in Table XX, which also includes a summary of fractures of the leg. The larger the number of cases examined the more trustworthy are the inferences drawn from the analysis. Thus Table XX indi- cates that if good anatomical results are obtained, 69 per cent, of fractures of the femur in general will recover function within six months, as compared with 53 per cent, if the anatomical result is only moderate, and only 38 per cent, if the anatomical result is bad. In the case of the leg bones the importance of a good anatomical result is even more striking; when a good anatomical result is obtained, no less than 92 per cent, of patients recover their function within six months; if only moderate anatomical results are secured, 80 per cent, will recover their function within this time; and if a bad anatomical result is present, only 25 per cent, of patients secure a return of function within six months. REPORT OE 1915 47 Femur (all forms) Anatomical results. Period of disability. Total. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. Good 120 ( 48%) 52 (44%) 3i (25%) 5 ( 4%) 26 (22%) 6 ( 5%) Moderate 79 ( 32%) 20 (25%) 22 (28%) 7 ( 9%) 14 (18%) 16 (20%) Bad 48 ( 20%) 7 (i5%) 11 (23%) 4 ( 8%) 3 ( 6%) 23 (48%) Total 247 (100%) 79 (32%) 64 (26%) 16 ( 6%) 43 (i7%) 45 (19%) Leg (all forms) Good 75 ( 75%) 52 (69%) 17 (23%) 4 ( 5%) 0 .. 2 ( 3%) Moderate 20 ( 20%) 8 (40%) 8 (40%) 1 ( 5%) 1 ( 5%) 2 (10%) Bad 4 ( 5%) 0 .. 1 (25%) 2 (50%) 0 .. 1 (25%) Total 99 (100%) 60 (60%) 26 (26%) 7 ( 7%) 1 ( 1%) 5 ( 5%) TABLE XX.—DOES GOOD ANATOMICAL RESULT LESSEN PERIOD OF DISABILITY? 48 TREATMENT OF FRACTURES Anatomical results. Total. Period of disability and functional results. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. Good. Mod. Bad. ,Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Under 15 Good 4 4 0 0 years Moderate X 0 0 1 Bad 0 0 0 0 15 to 45 Good 3 1 1 1 years Moderate 6 4 X 1 Bad I 1 45 to 60 Good 4 X 2 1 years Moderate 8 X 1 1 3 2 Bad 4 1 3 Over Good S X 2 1 1 60 years Moderate 12 S 1 1 2 I 2 Bad 3 1 1 1 All ages Good 16 5 1 0 4 0 0 0 0 0 0 3 0 0 2 1 Moderate 27 1 4 X 0 6 1 0 1 0 1 2 X 0 4 5 Bad 8 0 0 0 0 X X 0 0 1 0 0 0 0 0 5 TABLE XXI.—FEMUR, NECK. 51 CASES. REPORT OF 1915 49 Period of disability and functional results. results. Total. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Under Good 54 32 2 5 2 1 12 15 years Moderate 15 9 2 2 2 Bad 8 2 4 1 1 15 to 45 Good 34 7 12 3 2 1 8 1 years Moderate 23 3 7 2 5 1 1 4 Bad 14 5 3 2 1 1 2 45 to 60 Good 12 5 3 1 1 1 1 years Moderate 9 2 1 2 2 2 Bad 10 1 1 2 6 Over Good 4 2 1 I 60 years Moderate 5 I 1 2 1 Bad 8 1 1 6 All ages Good 104 44 2 0 22 5 0 4 1 0 22 1 0 0 3 0 Moderate 52 12 2 0 12 3 0 5 1 0 6 4 0 0 4 3 Bad 40 3 0 4 6 2 1 3 0 0 0 3 0 2 2 14 TABLE XXII.—FEMUR, SHAFT. 196 CASES. 50 TREATMENT OF FRACTURES Age. Number of cases. Period of disability. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. Under 15 years 77 Non-operative ... 61 (79%) Operative .... 16 (21%) 40 (66%) 11 (69%) 7 ( 12%) 3 ( 19%) i ( 6%) 13 (22%) 1 ( 6%) 1 (0.5%) 15 to 45 years 7i Non-operative ... 44 (62%) Operative .... 27 (38%) 4 ( 9%) 6 (22%) 14 ( 32%) 14 ( 52%) 8 (18%) 4 (15%) 15 (34%) 1 ( 4%) 3 ( 7%) 2 ( 7%) 45 to 60 years 3i 'Non-operative ... 24 (78%) Operative .... 7 (22%) 5 (21%) 1 (14%) 8 ( 33%) 1 ( 14%) I ( 4%) 3 (12%) 1 (14%) 7 (30%) 4 (57%) Over 60 years 17 'Non-operative . . .15 (88%) .Operative .... 2 (12%) 1 ( 7%) 2 (100%) 3 (20%) 11 (73%) All ages 196 fNon-operative . . . 144 (73%) .Operative .... 52 (27%) 49 (34%) 18 (35%) 30 ( 20%) 20 ( 38%) 9 ( 6%) 5 ( 9%) 34 (24%) 3 ( 6%) 22 (15%) 6 (12%) TABLE XXIV.- -FEMUR, SHAFT. OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT Age. Number of cases. Period of disability. Under 6 mos. Under 12 mos. Over 12 mos. Under 15 years 77 ' rNon-operative 61 (79%) .Operative 16 (21%) 47 ( 78%) 14 ( 88%) 13 (22%) 2 (12%) 1 (o.5%) 15 to 45 years 7i Non-operative 44 (62%) [Operative 27 (38%) 18 ( 41%) 20 ( 74%) 23 (52%) 5 (i9%) 3 ( 7%) 2 ( 7%) 45 to 60 years 3i fNon-operative 24 (78%) [Operative 7 (22%) 13 ( 54%) 2 ( 28%) 4 (16%) 1 (14%) 7 (30%) 4 (57%) Over 60 years 17 (Non-operative 15 (88%) [Operative 2 (12%) 1 ( 7%) 2 (100%) 3 (20%) 11 (73%) All ages 196 (Non-operative 144 (73%) [Operative 52 (27%) 79 ( 54%) 38 ( 73%) 43 (30%) 8 05%) 22 (15%) 6 (12%) TABLE XXIII.—FEMUR, SHAFT. OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT REPORT OF 1915 51 Table XXI and XXII contain analyses of fractures of the shaft and neck of the femur according to age, functional results, and period of disability. Question II. Does Operative Treatment Lessen the Period of Disability? It has been impossible, with the data at hand, to give a satis- factory answer to this question. The only region for which anywhere near a sufficient number of operative cases is avail- able is the shaft of the femur, and even here the total in which the period of disability is known is lamentably small, only 52 cases. These 52 cases, however, have been compared with the available number (144) of non-operative cases in Tables XXIII and XXIV. Table XXIV presents the figures in a slightly more condensed form. From this it appears that for patients under forty-five years of age or over sixty years of age operative treatment materially shortens the period of disability; but as already remarked the figures involved are entirely too small for any satisfactory solution to this question. TABLE XXV.—TABLES TO SHOW THE RESULTS OF FRACTURES OF THE RADIUS AND ULNA Radius and ulna. Anatomical results. Functional results. Total. Good. Moderate. Bad. Non-operative. Opera- tive. Non-operative. Opera- tive. Non-operative. Opera- tive. Non-operative. Opera- tive. Immediate. Deferred. Immediate. Deferred. Immediate. Deferred. Immediate. Deferred. Shaft . Good . 15 24 29 22 Moderate . 12 9 2 11 Bad 4 2 2 Total . 31 35 29 22 2 11 2 Per cent. . 47 53 57 43 16 85 100 TABLE XXVI.—TABLES TO SHOW THE RESULTS OF FRACTURES OF FEMUR IN THE VARIOUS AGE GROUPS Anatomical results. Functional results. Total. Good. Moderate. Bad. Femur. Group A. Opera- Opera- Opera- Opera- i to is 6 tive. 6 tive. > > years. u 6 U 6 aS u a* te 03 P< o *3 if 8 1—1 Q if 8 HH P if 8 HH Q if 8 HH Q Neck . Good . 3 3 3 3 Moderate . Bad Total . 3 3 3 3 Per cent. . IOO IOO 100 100 Shaft . Good . 67 24 86 29 Moderate . 28 4 11 6 Bad . . 4 8 2 1 Total . 99 36 86 29 11 6 2 1 Per cent. . 73 26 75 25 65 35 66 33 Condyle Good . 1 I Moderate . Bad Total . 1 1 Per cent. . 100 100 Grand total 103 3 36 90 3 29 11 6 2 1 Per cent. . 72 2 25 73 3 24 65 35 66 33 TABLE XXVII—TABLES TO SHOW THE RESULTS OF FRACTURES OF FEMUR IN THE VARIOUS AGE GROUPS Anatomical results. Functional results. Total. Good. Moderate. Bad. Femur. Group B. Opera- Opera- Opera- Opera- 15 to 45 6 > tive. tive. tive. 6 > tive. years. "c3 u . 3 U (D u 1' *3 "S 4-> c3 Pi 0 "3 > > bined. cd ►H 2 W CM O I £ o ch' W TABLE XXX.—COMPOUND FRACTUR REPORT OF 1915 57 Fracture. Age group, years. No. of cases. Upper ej Anatomical results. ctremity. Functional results. Died. Good. Mod- erate. Bad. Good. Mod- erate. Bad. Humerus i to 15 No cases Humerus 15 to 45 Shaft 6 5 1 6 Humerus 45 to 60 Shaft No cases Humerus 60 to 90 No cases Radius 1 to 15 No cases Radius 15 to 45 Shaft 1 1 1 Radius 45 to 60 Shaft 1 1 1 Radius 60 to 90 No cases Ulna 1 to 15 No cases Ulna 15 to 45 Shaft X One loss blood. Ulna 45 to 60 No cases Ulna 60 to 90 No cases Radius and ulna X to 15 Shaft 2 1 1 1 1 Radius and ulna 15 to 45 Shaft 4 4 4 Radius and ulna 45 to 60 Shaft 1 1 1 Radius and ulna 60 to 90 No cases TABLE XXXI.—COMPOUND FRACTURES; OPERATIVE CASES 58 TREATMENT OF FRACTURES Age group, years. Lower extremity. Fracture. No. of cases. Anatomical results. Functional results. Died. Good. Mod- erate. Bad. Good. Mod- erate. Bad. Femur Upper third Middle third x to 15 No cases 2 1 1 1 1 Lower third 7 4 2 4 2 One of shock. Femur Upper third IS to 45 3 3 3 Middle third 5 4 4 One from loss Lower third 17 12 2 3 14 3 of blood. Femur Upper third Middle third 45 to 60 No cases 3 1 1 Two of shock. Lower third 1 1 1 Femur Upper third Middle third Lower third Tibia Shaft 60 to 90 1 to 15 No cases No cases No cases 2 1 1 One of shock. Tibia Shaft IS to 45 18 13 3 12 4 Two of shock. Tibia Shaft 45 to 60 2 2 I I TABLE XXXI.—COMPOUND FRACTURES; OPERATIVE CASES.—Continued REPORT OF 1915 59 Age group, years. Lower extremity. Fracture. No. of cases. Anatomical results. Functional results. Died. Good. Mod- erate. Bad. Good. Mod- erate. Bad. Tibia Fibula 60 to 90 1 to is No cases Shaft Fibula IS to 45 1 1 1 Shaft Fibula 45 to 60 1 1 1 Shaft Fibula 60 to 90 1 1 X Shaft Tibia and fibula 1 to 15 1 1 1 Shaft Tibia and fibula 15 to 45 6 3 2 1 3 2 1 Shaft Tibia and fibula 45 to 60 38 20 12 3 19 10 6 Three of shock. Shaft Tibia and fibula 60 to 90 6 4 2 5 1 Total upper extremity, 16 cases = 80 per cent, good anatomical results. 93 per cent, good functional results. Total lower extremity, 104 cases = 64 per cent, good anatomical results. 69 per cent, good functional results. Ten deaths, almost 10 per cent, mortality, all due to shock or loss of blood. TABLE XXXI—COMPOUND FRACTURES; OPERATIVE CASES.—Continued 60 TREATMENT OF FRACTURES The non-operative cases grouped in the age periods show: (a) Compound Fracture of the Upper Extremity x to 15 years: 2 cases of compound fracture of humerus, o “ “ “ radius, o “ “ “ ulna, i “ “ “ both bones of forearm. Total 3 15 to 45 years: 1 cases of compound fracture of shaft of humerus. 1 “ “ “ “ radius. 2 “ “ “ “ ulna. 2 “ “ “ “ both bones of forearm. Total 6 45 to 60 years: 1 cases of compound fracture of shaft of humerus, o “ “ “ “ radius, o “ “ “ “ ulna, o “ “ “ “ both bones of forearm. Total 1 60 to 90 years: o cases of compound fracture of shaft of humerus, o “ “ “ “ radius, o “ “ “ “ ulna. 1 “ “ “ “ both bones of forearm. Total 1 (b) Compound Fracture of the Lower Extremity 1 to 15 years: 4 cases of compound fracture of shaft of femur. 1 “ “ “ “ tibia, o “ “ “ “ fibula. 8 “ “ “ “ both bones of leg. Total 13 15 to 45 years: 11 cases of compound fracture of shaft of femur. 20 “ “ “ “ tibia. 3 “ “ “ “ fibula. 51 “ “ “ “ both bones of leg. Total 85 REPORT OF 1915 61 45 to 60 years: 3 cases of compound fracture of shaft of femur, n “ “ “ “ tibia. 1 “ “ “ “ fibula. 16 “ “ “ “ both bones of leg. Total 31 “ 60 to 90 years: 2 cases of compound fracture of shaft of femur. 2 “ “ “ “ tibia. 2 “ “ “ “ fibula. 7 “ “ “ “ both bones of leg. Total 13 “ The operative cases grouped in the age periods show: (a) Compound Fractures of the Upper Extremity 1 to 15 years: o cases of compound fracture of humerus, o “ “ “ radius. 0 “ “ “ ulna. 1 “ “ “ both bones of forearm. Total 1 15 to 45 years: 6 cases of compound fracture of shaft of humerus. 1 “ “ “ “ radius. 1 “ “ “ “ ulna. 4 “ “ “ “ both bones of forearm. Total 12 “ 45 to 60 years: o cases of compound fracture of shaft of humerus. 1 “ “ “ “ radius, o “ “ “ « ulna. 1 “ “ “ “ both bones for forearm, Total 2 “ 60 and over: No cases. (b) Compound Fractures of the Lower Extremity 1 to 15 years: 9 cases of compound fracture of femur. 2 “ “ tibia. 1 “ “ “ fibula. 6 “ “ “ shaft of both bones of leg. Total 18 “ 62 TREATMENT OF FRACTURES 15 to 45 years: 25 cases of compound fracture of shaft of femur. 18 “ “ “ tibia. 1 “ “ “ “ fibula. 38 “ “ “ “ both bones of leg. Total 82 45 to 60 years: 4 cases of compound fracture of shaft of femur. 2 “ “ “ “ tibia. 1 “ “ “ “ fibula. 6 “ “ “ “ both bones of leg. Total 13 “ 60 and over: o cases of compound fracture of shaft of femur, o “ “ “ “ tibia. 1 “ “ “ “ fibula, o “ “ “ “ both bones of leg. Total 1 Note: Very few cases of compound fractures of the bones of the upper extremity occur in the one to fifteen-year period and these are rarely operated on. The lower extremity shows a moderate number of compound fractures during this period and the majority of them are operated on. The middle period, namely, fifteen to forty-five years, shows by far the most cases and the majority are operative cases. TABLE XXXII.—COMPARATIVE RESULTS OF OPERATIVE AND NON-OPERATIVE CASES OF COMPOUND FRACTURES. Cases. Operative cases. Cases. Non-operative cases. Good ana- tomical results. Good func- tional results. Good ana- tomical results. Good func- tional results. Humerus (shaft) 6 83% 100% Humerus (shaft) 4 100% 100% Radius (shaft) 2 100% 100% Radius (shaft) 1 100% 100% Ulna (shaft) I 100% 100% Ulna (shaft) 2 100% 100% Radius and ulna 6 83% 100% Radius and ulna 4 100% 50% Femur (shaft) 38 73% 76% Femur (shaft) 20 80% 70% Tibia (shaft) 22 59% 68% Tibia (shaft) 34 61% 64% Fibula (shaft) 4 50% 100% Fibula (shaft) 6 50% 16% Tibia and fibula 50 60% 60% Tibia and fibula 82 65% 68% Total 129 Total 153 REPORT OF 1915 63 Time after injury. 0 to 7 days. 8 to 14 days. 15 to 21 days. 22 to 28 days. 60 days. 90 days. 180 days. Humerus . 7i Cases operated 24 14 4 8 5 4 3 Time of treatment, unstated. Humerus . 46 Cases not operated Radius 22 Cases operated 4 3 2 5 4 1 2 Time of treatment, unstated. Radius IS Cases not operated Ulna . . . 13 Cases operated 5 2 0 4 0 2 0 Time of treatment, unstated. Ulna . . . 6 Cases not operated Radius and ulna 54 Cases operated 17 12 5 5 5 3 1 Radius and ulna 29 Cases not operated Time of treatment, unstated. Femur 143 Cases operated 43 26 4 14 21 9 23 12 early, 52 late. Femur 74 Cases operated Femur 360 Cases not operated Time of treatment, unstated. Femur 140 Cases not operated Time of treatment, unstated. Tibia . 18 Cases operated 9 1 2 0 3 2 0 Tibia . Fibula 20 2 Cases not operated Cases operated 1 1 Time of treatment, unstated. Fibula 29 Cases not operated Time of treatment, unstated. Tibia and fibula 47 Cases operated 16 2 3 2 8 4 8 Tibia and fibula Total 59 704 444 Cases not operated 119 61 20 38 46 25 37 Time of treatment, unstated. TABLE XXXIII.—INFLUENCE ON RESULT OF TIME ELAPSING BETWEEN INJURY AND EFFICIENT TREATMENT •_ 64 TREATMENT OF FRACTURES The above analysis shows the cases not operated on have a larger percentage of good anatomical results, but the percentage of the good functional results is decidedly higher in the patients operated on, except in compound fractures of both bones of the leg; here the reverse is true. An attempt to find out the average period of disability for com- pound fractures of the several bones in the various regions failed because the records rarely included this important item. Likewise the note as to whether the patient was able to return to his former job was so rarely made that this question failed. The reporter’s own cases, totaling 51, showed disability when the patient returned to work: from compound fractures of the bones of upper extremity, four months; compound fractures of femur, thirteen months; and compound fractures of leg, six months. No marked difference was noted as regards disability between the non-operative and operative cases. In the largest number of cases there was no statement as to the number of hours which elapsed between the hour the accident occurred and the hour the first treatment was applied. Time Elapsing between Injury and Efficient Treatment The following investigations (Tables XXXIII and XXXIV) refer to simple fractures. In a series of 140 femurs it was stated that 70 were treated within the first twelve hours; 9 between thirteen and twenty- four hours; 4 between twenty-five and forty-eight hours; 4 between forty-nine and seventy-two hours, and 5 after seventy- three hours. In 48 cases the time was not stated. It is thought that many of the unsatisfactory results following fractures are due to the fact that too many hours elapse between the time the fracture occurs and the time when the fracture is reduced and the first efficient splint is applied. In order to determine this it will be especially important to answer correctly questions 7 and 9 of the inquiry form for fractures (page 27). From a collection of 143 femurs which were operated on it was possible to analyze more or less accurately a series of 103 cases 65 REPORT OF 1915 and thus learn whether or not prompt attention markedly affected their results: 37 were children up to fifteen years. 11 were operated on within seven days and secured normal function; 13 within fourteen days with normal function; 5 within twenty-one days with normal function; whereas 8 who were operated on after the twenty-eighth day recovered only moderate function. Of the whole 37 patients, the results were 80 per cent, good function, 20 per cent, moderate function. 14 cases between sixteen and twenty-five years. 6 were operated on within seven days and secured normal function; whereas 8 were operated on later recovered only moderate function. Of the whole 14 patients, 43 per cent, secured good function, 57 per cent, moderate function. 29 cases between twenty-six and forty-five years. 10 operated on within fourteen days recovered normal function; 1 case oper- ated on within twenty-one days secured normal function; whereas 20 operated on later secured only moderate function in 18 and bad function in 2. Of the whole 29 patients, 37 per cent, secured good function, 62 per cent, moderate function, 1 per cent, bad function. 23 cases over forty-five years. 3 only secured good function and all were operated on within fourteen days. Six additional cases operated on within fourteen days secured only moderate function; 14 operated on later than fourteen days recovered only moderate function in 10 and bad function in 4. Of the whole 23 patients, 13 per cent, secured good function, 70 per cent, moderate function, 17 per cent, bad function. It can easily be seen from the above that normal function is recovered in a larger number of cases when operation is done promptly (within fourteen days) than when operation is post- poned until later; also, that the percentage of recovery of normal function diminishes as age advances. In the 103 cases good anatomical position was secured in 71 cases (about 70 per cent.), whereas good function was obtained in only 50 cases (about 50 per cent.). This corresponds with the facts that only 52 cases were operated on within fourteen days and 51 cases later than twenty-one days. 66 TREATMENT OF FRACTURES When operation is postponed longer than about fourteen days; the bones may still be brought into good position, but on account of injury or disuse of the muscles and soft parts for longer periods, good function has seldom been obtained. TABLE XXXIV.—INFLUENCE ON RESULT OF TIME ELAPSING BETWEEN INJURY AND OPERATION (FEMUR) Ages, years. Date of operation, days. Anatomical position. Functional result. 5 to 10 XX to 15 16 to 20 21 to 25 26 to 45 46 + 0 to 7 8 to 14 15 to 21 22 to 28 29 + Good. Moderate. Bad. Good. Moderate. Bad. 1 23 8 8 8 7 7 7 I i i 2 2 2 3 3 3 2 2 2 14 3 3 3 6 6 6 2 2 2 I I I 2 2 2 6 3 3 3 I i I I I I X i I 8 3 3 3 i I I i i I 2 2 2 I i I 29 6 6 6 4 4 4 I I I I I I I I I I X I I I I 4 4 4 8 8 8 2 2 2 23 2 2 2 I I I 3 3 3 I I I 2 2 2 X I I 3 3 3 i I I 6 6 6 i I I 2 2 2 103 cases 31 21 6 3 42 7i 30 2 50 46 7 REPORT OF 1916 COMMITTEE Dr. John B. Walker Dr. Thomas W. Huntington Dr. Edward Martin Dr. Astley P. C. Ashhurst Dr. W. L. Estes Chairman Synopsis. Form of record and schedule adopted by railroad companies and societies. According to the program and the directions contained in the Resolution adopted by the Association at its last annual meeting, the Committee on Fractures has this year only made preparation for its final report. As the Association recommended, the form of record and schedule of fractures adopted by the Association last year were presented to and adopted by the Surgical Section of the American Medical Association, were sent to all the principal railroads and industrial establishments of the East and Middle West, and the standard form of record was adopted by most of them. It was also formally adopted by the New York and New England Association of Railway Surgeons, by the National Conference on First Aid, by the Pennsylvania Railroad Surgical Association, by the Medical Society of the State of Pennsylvania, by the Medical Department of the United States Army, and by the United States Public Health Department. Besides these organizations, a number of industrial corporations and hospitals have taken the blanks as their models and have furnished their institutions with similar blanks. The Committee has sent out to date 7500 of these blank reports. The general adoption of these forms is encouraging, but it will do little good unless the records are faithfully kept, and unless these records, when properly completed after the patients have 68 TREATMENT OE FRACTURES returned to work, are sent to the committee for analysis and included in its final report to this Association. The Committee begs, therefore, every Fellow of this Associa- tion to use his influence and efforts constantly to see that these reports be kept faithfully and fully, and to have copies sent to the Committee when the records are completed. The Committee will endeavor from this time on to collect and collate these reports, and hopes next year to be able to make its final report. REPORT OF 1917 COMMITTEE Dr. John B. Walker Dr. Thomas W. Huntington Dr. Edward Martin Dr. Astley P. C. Ashhurst Dr. W. L. Estes Chairman Though the Committee sent out 6850 copies of the official blank for collecting data, and directly or through the assistance of the associate members throughout the United States and Canada enlisted the promised help of many hospitals and a large number of industrial establishments and railroads, the chair- man received only 79 reports from these establishments and railroads. The Surgeon-Generals of the Army and Public Service Depart- ment also adopted the form, and from these services 149 reports were received. The several members of the committee have collected from their own services and hospital connections something like 350 reports. Obviously these data are not sufficient upon which to base the conclusive standardization for which the committee is working. The Workmen’s Compensation Board of Pennsylvania has officially adopted the Association’s forms of report, and has agreed to give the committee the benefit of its collection. By persistent effort through another year hospital surgeons and hospital managements may be induced so to record their cases of fractures that your committee may receive sufficient data to make a final report, one of value and importance. The committee therefore reports progress, and leaves to the Association the determination as to whether or not the committee shall be continued. REPORT OF 1918 COMMITTEE Dr. John B. Walker Dr. Thomas W. Huntington Dr. Edward Martin Dr. Astley P. C. Ashhurst Dr. W. L. Estes Chairman It will be recalled that in its preliminary report in 1915 it was stated by the committee that it had set itself the task of trying to determine three points in regard to fractures of the long bones, namely: 1. To find out the average present-day result in both simple and compound fractures, as regards anatomical and functional results, in the several age groups and the average time of dis- ability. This latter period is determined to mean the average time the patient lost from work or from his ordinary duties. 2. The comparative value of (a) the conservative or closed methods, and (b) the operative or open methods. 3. The comparative value of immediate or delayed treatment in each group of cases. To carry out this plan it was necessary to obtain and to analyze a large number of well-kept and fully registered fracture records. The committee based its preliminary report on 1745 collected and investigated cases. The records of these cases, however, were so incomplete and unsatisfactory that for some of the points entirely too little data were obtained to form the basis for conclu- sions. In order to overcome this difficulty the committee recom- mended to this Association a standard form for the record and preservation of fracture data, requested that it be made the official form of the Association, and that it be adopted by all Fellows of this Association and by the hospitals with which they were connected. The Association adopted the form. It was also adopted by the surgical section of the American Medical Association, by several REPORT OF 1918 71 State medical societies, by the U. S. Army Medical Department, by the Compensation Board of Pennsylvania and by numerous hospitals and associations. The chairman sent out several thousand copies of these forms to the various associations, societies, departments, hospitals and individuals. The net results have been the reception of reports of 327 additional cases up to date. Of these, many were so incom- pletely filled out that they were useless. The committee feels, therefore, that with so few additional data it can offer to the Association very little more toward the standardization of the treatment and the average time of dis- ability of fractures of the several regions of the long bones in the several age periods than it did in the preliminary report. The little additional evidence, all of which has been worked out, except a few cases left over, by a Fellow who is in active military service, goes to confirm the conclusions of the prelimi- nary report. The committee finds: 1. The results are best in the age period under fifteen years. Conservative treatment is generally effectual during this period. 2. Good anatomical restitution of a fractured long bone always results in the best functional result and has the shortest period of disability. 3. While few open operations are reported under the fifteen- year age period, it seems to make little difference in the results, except in senile cases (where it is unfavorable), what the age period is when the operation is done. 4. The end-results of non-operative and operative treatment of compound fractures show very little difference in the anatomical result, but the functional results are better after operative treatment,1 except in compound fractures of the shafts of both bones of the leg; hete the reverse seems to be true. The age period, except in senile cases, has no marked effect on the result of the treatment. 1 The period of disability is, however, longer by three or four weeks. 72 TREATMENT OF FRACTURES 5. The average period of disability (that is, the time lost from work) in simple fractures is as follows: For fracture of the shaft of the humerus .... 14.0 weeks For fracture at the head and neck of the humerus . 11.5 “ For fracture at condyles of the humerus . . . . 9.0 “ For fracture of the shaft of both bones of the forearm 10.8 “ For fracture of the femur, all sites 6.2 months For fracture of the leg, all sites 4.9“ Note.—This determination must still be held as not quite conclusive on account of the comparatively few clear reports on this point. The chairman has verified these disability periods in something less than 100 of his own cases and finds them sub- stantially correct. Periods of disability were not recorded accurately in the majority of the reported cases and very seldom in compound fractures. For compound fractures the average period of disability is as follows: For fractures of the femur 13 months For fractures of the leg 6 “ For fractures of the upper extremity 4 “ 6. The humerus should show not more than 1 cm. shortening and no appreciable angulation. Musculospiral paralysis should not result. The forearm bones should show no appreciable shortening and pronation and supination should be unhindered. Function should always be good and no lasting pain result. Fracture of the shaft of the femur should not result in shorten- ing greater than 2 cm., nor in a fixed position of angulation or rotation which will affect the joints and require new habits of balancing or tilting of the pelvis; joint function should be good. No permanent disability of the affected member should result. Fracture of the shaft of the bones of the leg should result in no appreciable shortening and no angulation or rotation. Joint function should be preserved. REPORT OF 1918 73 7. There is no method or splint universally applicable, nor has any given splint or apparatus proved its superiority. All depends upon the discrimination of the surgeon and the manner in which the apparatus is applied and maintained. It is evident that traction methods are most frequently unskilfully employed. As a rule, too little weight is used. The gauge of the proper weight required is that necessary to overcome the shortening. This should be determined by careful daily measurement. Traction methods require, as a rule, counter- traction. Plaster casts and molded splints are especially indicated and useful after a fracture has been satisfactorily reduced. REPORT OF 1921 THE FINAL REPORT. By W. L. ESTES, M.D., Chairman BETHLEHEM, PA. The committee presents its final report. This report is the completion of the 1915 report and may be received as a combi- nation of the preliminary 1915 report with subsequent investi- gation and later data. The same general scheme of investigation as was indicated in the 1915 report has been followed, namely: 1. Only fractures of the long bones have been studied. 2. The same regions or divisions of the bones have been noted. 3. Simple and compound fractures have been separately classified, investigated and tabulated. The four main points of inquiry and investigation have been continued, namely: 1. What is the average present-day anatomical and functional results in both simple and compound fractures in the several age groups? 2. What is the average period of disability of (a) simple and (b) compound fractures of the several long bones? 3. What is the comparative value of (a) the non-operative or closed methods and (6) the operative or open methods? 4. What is the comparative success of immediate and delayed treatment in each group of cases? The blank form recommended by the committee has been slightly changed. It was formally adopted by this Association, recognized by the American College of Surgeons and has been in- troduced into many hospitals in the United States as the accepted blank for recording fracture data. Its continued and regular use 76 FINAL REPORT OF THE COMMITTEE ON FRACTURES in the hospitals will result in having available for future investi- gation adquate records of fractures, and we hope will induce surgeons to see to it that their fracture cases shall always be followed up and the final results accurately determined and noted. FRACTURE RECORD American Surgical Association General Results: good moderate bad Anatomical . Functional j 1. Bone 2. Site—Neck.. Upper Middle Lower 3d Condyle Involving joint-. 3. Name 4. Sex—M F 5- Age 6. Occupation 7. Time fracture occurred—Date Hour 8. Hospital entered—Date Hour 9. First treatment—Date. Hour 10. Cause of fracture n. Kind of fracture—Oblique Transverse Spiral Impacted Comminuted Simple Compound... Greenstick Subperiosteal 12. Was there serious injury to soft parts—Skin—Yes No... Muscles—Yes No Vessels—Yes No. - Nerves—Yes No 13. Reduction: How many hours elapsed after accident before reduction 14. Was anatomical reposition of fragments obtained—Yes No 15. Anesthetic used: Yes No Ether Gas.. 16. Fixation: Closed Method. Position—Hyperflexion full supination abduction Splints Plaster of Paris Traction—Buck Thomas Hodgen Balkan frame Tongs Amount of weight used FINAL REPORT OF 1921 77 17. Fixation: Open Method. Was non-operative treatment tried first How long after injury was operation performed... Was open reduction alone performed What form of internal fixation used—Steel plates Wire Nails Screws Bone transplants or implants Was it later necessary to remove fixation materials—Yes No Date 18. Shortening at first examination cm. When all apparatus removed cm. Date When discharged from hospital cm. Date At last observation cm. Date 19. Roentgen ray used—Yes No First finding—Date day before reduction; day after reduction Plate Fragments No. displaced, date. Not. Slightly. Markedly. Overriding. Rotation. Angulation. Before reduction After reduction | After union 20. How long confined in bed How long in hospital 21. How long did patient use crutches Cane 22. Results: Final examination made weeks months after injury. Union: Bony Fibrous Non-union 23. Disability: Absent Partial Complete Estimated by Shortening Angulation Swelling of soft parts Pain Nerve involvement Interference with joint function Endurance 24. Mortality—Main cause of death... Age of patient Shock Hemorrhage Other injuries Sepsis Exhaustion 25. Duration of absence from work weeks months 26/Is patient fully able to take his former job 27. jPresent wage-earning capacity compared with former 28. Compensation under insurance, legislative act or legal process obtained— Yes No Expected—Yes No The investigation on account of the difficulty in securing reports and the necessity of searching through many incomplete reports in order to find adequate data has proved onerous and trying. In order to lighten the labor and to obtain the best results the committee was divided and a certain part of the work assigned to each as follows: 78 FINAL REPORT OF THE COMMITTEE ON FRACTURES 1. To Dr. J. B. Walker was assigned the investigation and report of fractures of the A. E. F. during the war, with ultimate results. 2. To Dr. T. W. Huntington the fractures of the humerus in civil life. 3. To Dr. Edward Martin the fractures of the bones of the forearm in civil life. 4. To Dr. A. P. C. Ashhurst the fractures of the bones of the leg in civil life. 5. To Dr. W. L. Estes the fractures of the femur in civil life. Each head of a division will therefore make a report of his investigation of the fractures belonging to his division and should receive full credit for his work. The following-named Fellows served as the auxiliary committee and rendered valuable service in assisting, collecting and exami- ning cases. Divided into groups a certain number were assigned to each division and assisted in drafting and formulating the reports of the several divisions. Dr. Walker: Fractures in War. Assistants: Dr. Jones, Dr. Matas, Dr. Starr. Dr. Huntington: Fractures of the Humerus. Assistants: Dr. Jonas, Dr. Freeman, Dr. Terry. Dr. Martin: Fractures of the Bones of the Forearm. Assist- ants: Dr. Thompson, Dr. Ransohoff. Dr. Ashhurst: Fractures of the Bones of the Leg. Assistants: Dr. Speed, Dr. Gaub. Dr. Estes: Fractures of the Femur. Assistants: Dr. Graham, Dr. Vaughan. We gratefully acknowledge their valuable assistance in prepar- ing this report. First Division. Military fractures, 2083 cases. Second Division. Fractures of the humerus, 162 cases: non- operative, 117; operative, 45. Third Division. Fractures of the bones of the forearm, 271 cases: non-operative, 227; operative, 44. FINAL REPORT OF 1921 79 Fourth Division. Fractures of the leg bones, 926 cases: non- operative, 739; operative, 187. Fifth Division. Fractures of the femur, 654 cases: non-opera- tive, 471; operative, 183. Altogether the committee collected and studied over 8000 cases of military fractures and 2013 cases in civil life. Of these civil cases 1521 were simple fractures and 482 compound. The results of all these cases have been carefully investigated. Unfortunately the records of many of the cases were so incom- plete that they could not be used in their entirety. The cases have been tabulated under six principal heads, namely: 1. To show the results in the following age periods, viz.: (a) One to fifteen years; (b) fifteen to forty-five years; (c) forty-five to sixty years; (d) over sixty years. 2. To show the effect of good anatomical restitution in shorten- ing the period of disability and restoring full function. 3. To show comparative results in the treatment of simple fractures of the operative (open) method and the non-operative (closed) method in the several age groups. 4. To show the result of the operative and non-operative methods in the treatment of compound fractures, also considered as regards the several age groups. 5. To show the results of treatment of the fractures of the several long bones in the various regions in the several age groups, in order to determine the average period of recovery. 6. To show the comparative results of immediate and delayed treatment of the closed and open methods of treatment in the several age groups. The operative cases are considered as: 1. Immediate. 2. Delayed. All operations performed within fourteen days after injury are classed under immediate operations; those done after this period are classed as delayed operations. The results of operations for non-union and for deformities 80 FINAL REPORT OF THE COMMITTEE ON FRACTURES resulting from fractures are not included nor considered in the report at all. The committee finds: 1. The results are best in the age period under fifteen years. Conservative treatment is generally effectual during this period. 2. Good anatomical restitution of a fractured long bone results in the best functional result and has the shortest period of disability. 3. While comparatively few open operations are reported under the fifteen-year-age period it seems to make little differ- ence in the result, except in senile cases (where it is unfavorable), what the age period is when the operation is done. 4. The end-results of non-operative and operative treatment of compound fractures show very little difference in the anatomi- cal result, but the functional results are better after operative treatment, except in compound fractures of the shafts of both bones of the leg; here the reverse seems to be true. 5. The average period of disability (that is the time lost from work) in simple fractures is as follows: For fracture of the shaft of the humerus .... 14.0 weeks For fracture of the head and neck of the humerus . 11.5 “ For fracture of the condyles of the humerus . . . 9.0 “ For fracture of the shaft of both bones of the forearm 10.8 “ For fracture of the femur, all sites, adult cases . . 8.2 months For fracture of the femur, all sites, children ... 4.5 “ For fracture of the leg, all sites 4.7 “ (Periods of disability were not recorded accurately in many of the reported cases and very seldom in compound fractures.) Compound Fractures For fractures of the femur u.o months For fractures of the leg 7.0 “ For fractures of the upper extremity 4.0 “ 6. For good functional results the humerus should show not more than 1 cm. shortening and no appreciable angulation. No pain or paralysis should result. FINAL REPORT OF I92I 81 The forearm bones should show no shortening; function should always be good and no lasting pain result. Fracture of the shaft of the femur should not result in shorten- ing greater than 2 cm., nor in a fixed position of angulation or rotation. The function of all joints should be good. Fracture of the shaft of the bones of the leg should result in no appreciable shortening and no angulation or rotation. All function of the joints should be preserved. 7. There is no method or splint universally applicable; all depends upon the discrimination of the surgeon and the manner in which the apparatus is applied and maintained. The late war has brought into prominence the suspension- traction method for treating fractures. The Balkan frame or the Hodgen splint for suspension is used, and tongs or the Steinmann nail are used for traction directly on the distal frag- ment. The Thomas splint has proved of great value in the treatment of fractures of the shaft of the femur; it is recommended especially when hospital treatment cannot be obtained. Plaster casts and molded splints are indicated and are useful only after a fracture has been satisfactorily reduced. Recommendations, i. The committee recommends as a gen- eral principle that fractures be treated by a skilled surgeon. 2. Roentgen-ray pictures should be made by a competent radiographer and a fluoroscope should be used for diagnostic purposes and for guidance in applying the permanent dressing. At least two skiagrams should be taken, and they should be taken from opposite perpendicular directions. Skiagrams should also be taken after permanent dressings are applied, to prove proper reduction, and at the end of treatment to show the results of the union and for the purpose of a graphic record. 3. Fractures should be reduced immediately after the injury if it is possible to obtain and apply proper retaining apparatus or splints. The statistics show markedly better results when the treatment is begun at once. It is, however, not only useless but cruel to subject the patient to the pain of manipulation for reduction unless the surgeon has proper fixation apparatus at 82 FINAL REPORT OF THE COMMITTEE ON FRACTURES hand and the subject is where he may have a permanent dressing applied. 4. General anesthesia should be employed, as a rule, to facili- tate reduction and to prevent pain, unless the condition of the patient contraindicates it. 5. Neither the non-operative nor the operative method is to be recommended exclusively. Each has its indications and should be employed when required. Generally speaking the age period under fifteen years is the period in which non-operative methods are especially effectual. 6. The open method when adopted should be employed early. It may be used at any age period, except in senile cases, when- ever a skiagram shows a deformity or a position of the fragments which obviously cannot be reduced or when proper efforts at reduction and retention have proved unavailing. 7. Some form of rigid plate applied directly to the bone seems to be the best fixation method in operative cases. 8. Open operations for simple fractures should be undertaken only by experienced surgeons who are thoroughly equipped by training and who have proper instruments and apparatus to meet all the possible indications of the operation. 9. After fracture of the long bones of the lower extremity, some efficient form of caliper should be used when the patient begins to walk, and should be continued for some wreeks, in order to prevent yielding of the newly united fragments to the weight of the body and the production of bending and distortion at the seat of fracture. 10. The treatment of any fracture ought not to be considered complete until full restitution of function has been secured. For this purpose every hospital which treats fractures should be equipped with apparatus for mechanical, electrical and hydro- pathic treatment. The reconstructive treatment should be considered in every case an essential part of the general treat- ment. Also, in order to make the record of every case of major fracture complete a careful follow-up system should be adopted and sedulously followed. FINAL REPORT OF 1921 83 ii. The work of this committee has been greatly hampered by the inadequacy of the records submitted for its consideration. A large proportion of the cases had to be rejected entirely, and most of them were so incomplete as to make deductions based upon them misleading. The first step in the betterment of practice is the study of results achieved by present-day methods. An adequate study is impossible without complete records. FRACTURES IN MILITARY SERVICE. By JOHN B. WALKER, M.D. NEW YORK Among the 224,089 battle casualties in the A. E. F. there were 27,013 patients, with 18,639 fractures involving the long bones: 5063 occurred in the femur, 4254 in the humerus, 1066 in the fibula, 2679 in the tibia, 1945 tibia and fibula, 1527 in the radius, 1225 in the ulna, 801 radius and ulna, 79 not stated. The most serious cases were the gunshot fractures of the femur, and it was in just this class that there developed the greatest improvement in the treatment of fractures during the World War. Of the 5063 patients with this fracture, 1010 (20 per cent) died; while in the Civil War, of the 6738 fractured femurs, 3434 (50 per cent) died. Of the above 1010 deaths, 40 per cent died within the first seventy-two hours and 55 per cent within the first seven days. Treatment. Infection to some degree was present practi- cally always; generally it was severe and persistent. Osteomye- litis became the most serious complication. Those cases in which the primary operative work was thoroughly performed within the first twelve hours made by far the best recovery. In those cases which were operated on after twenty-four hours the percentage of infection and mortality was more than doubled. Amputation. 833 femurs were amputated and 218 (26 per cent) died. It is generally believed that the earlier the amputation the lower the mortality, but as yet it has been impossible to secure from the Surgeon-General’s office sufficiently accurate data upon this question, in the majority of cases the time of operation was not recorded. 85 walker: fractures in military service Splints. The Thomas splint was generally applied in the front lines and many fractured femurs received the additional benefit of suspension traction in the Balkan frame, for a time, in some one of the different hospitals through which they passed. Later, when ready for transportation to the United States, plaster casts were applied and many remained unchanged for a longer period than necessary, thus predisposing to joint stiffness. Consequently, the good or bad result obtained in many cases could not be attributed to any special method, as the fractures had been treated by so many various methods. While in many cases the Thomas splint was not used efficiently, as it did not fit well, and the so-called extension straps were rarely found tight enough, nevertheless it is universally con- ceded to have proven by far the best method of treatment. Suspension-traction, when accurately applied and efficiently maintained, produced really wonderful results, such as had not been generally believed possible before the World War, as Page, Pierson, Sinclair, Blake, Depage and Tuffier and others have demonstrated. Statistics. From the 5063 fractured femurs, 158 (3.12 per cent) returned to duty in the army. March 1, 1919, reports in the Surgeon-General’s office indi- cated that a prognosis could be made that 76 per cent of fractures of long bones would recover with satisfactory function. How widely this has varied is seen by the follow-up reports of the Bureau of War Risk over two years later, May 1, 1921, when it was found that 70 per cent of fractures were suffering a dis- ability of at least 20 per cent. Only 4 per cent have been reported, with a disability of less than 10 per cent. Femurs. Of 2306 cases recorded in the Bureau of War Risk June 1, 1921, 83 per cent are suffering with a disability of 20 per cent or more; 0.02 per cent have less than 10 per cent disability. Shortening is variable, but generally least when the Thomas or the Hodgen splint was well applied and suspended from the Balkan frame. It was reported that there was no shortening in 18 per cent. I think this is doubtful, and more careful measurements 86 walker: fractures in military service will show some shortening; 14 per cent had shortening of one- half to one inch; 72 per cent had shortening of one and a quarter inches or more. Bowing. Outward bowing and marked deformity has occurred in many cases after union had been thought to be firm. This has occurred more often in the United States patients than among the British, who customarily wear a walking caliper splint for a considerable period. Refracture has also occurred more frequently than is generally appreciated, and again more often with our patients than with the British. This accident, generally preventable, furnishes an additional reason for applying a walking caliper as soon as the patient leaves his bed to begin walking. Walking calipers have seldom been used by our patients. Duration in Hospital. Five per cent of cases were discharged under three hundred days, 24 per cent under four hundred days, and 76 per cent required hospital treatment for more than four hundred days. This last figure varies considerably from that of three hundred and eight days as estimated from the records in the Surgeon-General’s office—another illustration of the great difficulties in comparing records for the purpose of establishing standards for duration of disability. During 1917, 1918 and 1919 there occurred in the United States Army, either in the United States or in the A. E. F., accidental fractures other than battle fractures. Compound Fractures: 9449 cases required hospital treat- ment, with an average of sixty-nine days; 683 were femur fractures and required hospital treatment for an average of one hundred and five days. Simple Fractures: 43,497 cases required an average of forty days’ hospital treatment; 1531 were femur fractures, which required hospital treatment for an average of eighty-nine days. Duration of Disability. When one consults the British frac- ture report to learn the period of disability for fractures of the femur he finds it is two hundred and thirty-one days; the Ameri- can Fracture Committee gives two hundred and seventeen days; 87 walker: fractures in military service the New York State Compensation gives one hundred and sixty- nine days; the United States Employers’ Commission gives one hundred and fifty-two days; the United States Surgeon-General’s Office gives eighty-nine days. Compound Fractures of the Femur: Accidental, Surgeon- General’s Office, one hundred and five days; battle injuries, three hundred and eight days; Bureau of War Risk, over four hundred days. Non-union. Thus far there have been 906 cases reported: Humerus, 164; radius, 178; ulna, 120; radius and ulna, 71; femur, 155; tibia, 132; fibula, 9; tibia and fibula, 77. Bone grafts were used in 611 cases; Lane plates in 189; suture and wire in 52; kangaroo tendon or chromic gut in 54. Grafts were taken from the tibia in 358 cases, and in 98 cases a sliding graft was employed; in 25 cases pegs made from beef bone were used, and in 31 cases pieces of rib. Grafts: Autogenous, taken from the tibia, have proven the most efficient material for fractures of the long bones, on account of its characteristic strength. They are best made with the saw, and exact coaptation of the parts of the graft to respective parts of the host bone must be secured. Where many of these records are as yet too incomplete to give the final end-results, yet sufficient evidence has been secured to prove that bone- grafting is the most efficient method of treatment for non-union of fractures, and favorable results can be obtained in the largest percentage of cases. Conclusions. The earliest possible reduction of a fracture is imperative. The suspension-traction method secures the best results in fractures of the long bones, and especially in the femur. It is easily adjusted; wounds of the thigh can be readily exposed for dressings; both the wounds and the fracture can be properly treated together without disturbing the satisfactory reduction of the fracture that is preserving the immovableness of the fragments. “It secures relaxation of the deforming muscles and so permits the bone fragments to fall into their proper relation.” It permits mobilization of the joints of the part from the first 88 walker: fractures in military service moment of beginning treatment and thus secures prompt recovery with preservation of function. Fractures of the lower third with displacement are best treated by skeletal traction, with non-penetrating calipers above the knee, combined with early movement of the joints, hip, knee and ankle. One of the most important lessons learned is the great emphasis placed upon ultimate function in the individual rather than on restoration of the contour and anatomical structure of a part. The former idea that marked deformity and disability are inevitable in fractures must be abandoned. In the past, surgeons have failed to devote the care which these most serious cases demanded. Putting into actual practice the methods which were demonstrated the best, especially in the last year of the World War, convalescence will be shortened, compensation reduced and the injured returned to his former occupation with a saving of 25 to 50 per cent of the time now lost—an enormous saving to industry. Page and LeMeseurier secured excellent results in 125 cases of fracture of the femur with an average shortening of 0.37 inch. Pierson, in 68 cases, had no shortening in 29; 29 additional cases averaged 1.5 cm. shortening; mobility of the hip and the ankle were in almost all cases normal; in the knee, 55 had a range of flexion over 90 degree 10 had a range of between 60 degree and 90 degree and 3 ranged between 30 degree and 60 degree. Bohler had 54 cases, in which the average shortening did not exceed one-half inch. Erlacker and Zollinger reported equally good results. Methods of treatment should be standardized and then uni- versally employed. Conventional treatment is now inadequate. “There is no standard to which the advocate of efficiency may appeal; no incentive to energy, nor penalty for incompetence.” In the past inefficiency has been tolerated; hereafter the surgeon who applies inadequate methods will be held responsible for failure. Jones states, “The question of fracture of the femur is essentially one of preventable surgery,” dependent upon (1) 89 walker: fractures in military service efficient fixation of the fracture with as correct alignment as possible, and (2) early and frequent movements of the neighbor- ing joints. Recommendations. The general adoption of the standard forms of splints used in the A. E. F. General use of suspension-traction methods, employing the Hodgen or Thomas splints with the Balkan frame. Systematic and frequent x-ray examinations and mensuration to control the position of the fragments. Films should be taken as often as once every two weeks until firm union occurs. A portable x-ray outfit and a fracture table should be installed in every hospital where fractures are treated. Physiotherapeutic massage and electrical treatment should be employed in every case at the earliest date. Every femur case should wear a walking caliper when out of bed until union is solid. Standard fracture records should be used in every case, and the greatest improvement in the treatment of fractures will result. Wherever these have been used there fractures have received the best treatment. The importance of using follow-up reports cannot be exaggerated. Medical schools should give more clinical instruction in hospital wards in the actual detailed care of fractures. One of the most valuable lessons learned from the World War was clearly demonstrated in the British and the United States A. E. F. hospitals, that where fractures were concentrated under one control in special services there the best results followed. It is firmly believed that civil hospitals should be so reorganized that fractures can be concentrated in special fracture services asso- ciated with a well-equipped physiotherapeutic department and that thereafter great improvement will result. Wherever this plan has been developed it has proven wise, as in the Massachu- setts General, Montreal General and Bellevue hospitals. According to Hoffa, two-thirds of all accident claims are based upon the consequence of fractures. Increased efforts must be made to so treat fractures as to obtain good functional 90 walker: fractures in military service results in a larger number of cases. Economically it is the soundest business for the individual and for the state to get a perfect result in a young man. An imperfect cure makes a man face difficulties in finding employment and results in the perma- nent charge to the state of an unproductive, subsidized and discontented citizen. SIMPLE FRACTURES OF THE HUMERUS1 By THOMAS W. HUNTINGTON, M.D. SAN FRANCISCO, CALIF. Table I shows that 38 per cent, of the cases of fractures of the humerus were treated by the operative method. This is probably an indication that anatomical reduction of these fractures without the assistance of vision directly upon the fragments is very difficult in a large number of cases. Table III shows that 70 per cent, of the non-operative cases were followed by good anatomical results, and that when this was obtained 95 per cent, of the cases had good functional results and only a little over 1 per cent, had bad functional results. When only moderate anatomical results were obtained there followed barely 68 per cent, of good functional results. This emphasizes the importance and value of good anatomical results in all cases of fracture of the humerus. (See Table IX.) Table VIII indicates that fracture of the upper and lower extremities (the head and condyle) of the humerus required the greater number of operations, but even after operative treat- ment the anatomical results in these regions were not as good as by the non-operative treatment. The functional results were not nearly as good by the operative as by the non-operative treatment. In Table V only a very small group could be obtained for the study of the influence of age upon the functional results. While the actual percentages would show the senile age period, viz., over sixty years, had better functional results than the 1 to 15 year 1 The conclusions and data worked out by the Chairman. 92 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS period, the group is too small to disprove the general rule that children under fifteen years of age have better functional results after fractures than do those over fifteen years of age. The operative group in age periods is entirely too small for one to draw any definite conclusions. In Table IX is shown that good anatomical results are followed in 79 per cent, of the cases by the shortest disability. It is interesting to note that two cases, one an individual in the i to 15 age period and the other in the 45 to 60 period, notwithstanding a bad anatomical result, are rated among the cases of shortest disability. These anomalies are certainly exceptions, and apart from the fact that there are only two cases out of thirty-six, it is shown in Table X that the 45 to 60 age period cases had bad functional results and should doubtless be classed as permanently disabled. In a group of thirty-six cases the average disability of the age period 1 to 15 years is three months, average of all age periods over 1 to 15 years is eight months, but of these 52 per cent, were reported to have a disability under three months. Compound Fractures of the Humerus. In this group the number of cases is too small for any deductions. A little more than twice as many of the cases were treated by the operative as by the non-operative method. The tables suffice to show the various divisions of the study and the conclusions so far as they may be drawn from the small number of cases. Simple Fractures of the Humerus TABLE I Total. Non-operative. Operative. Humerus, shoulder . . . 42 26 16 Humerus, shaft . . . 42 3° 12 Humerus, elbow . . . 78 61 17 162 117 45 In the following tables the fraction percentages are not worked out: HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS 93 Anatomical result. Total. Good. Functional result. Moderate. Bad. Good • 116(71%) 97 (83%) 15 (12%) 4 ( 3%) Moderate . • 38 (23%) 21 (55%) 15 (39%) 2 ( 5%) Bad . • 8 ( 4%) 3 (37%) 2 (25%) 3 ( 37%) 162 (98%) 121 (74%) 32 (19%) 9 ( 5%) TABLE II Anatomical result. Total. Good. Functional result. Moderate. Bad. Good • 82 (70%) 78 (95%) 3 ( 3%) I( 1%) Moderate . • 29 (24%) 20 (68%) 8 (27%) i( 3%) Bad . • 6 ( 5%) 3 (50%) 2 (33%) 1 ( 16%) 117 (99%) 101 (86%) I3(n%) 3 ( 2%) TABLE III.—NON-OPERATIVE TABLE IV.—OPERATIVE Anatomical result. Total. Good. Functional result. Moderate. Bad. Good 34 (75%) 19 (55%) 12 (35%) • 3 ( 6%) Moderate . 9 (20%) i (n%) 7 (77%) i( n%) Bad . . . . 2 ( 4%) 0 0 2 (100%) 45 (99%) 20 (44%) 19 (42%) 6 ( 13%) TABLE V.-INFLUENCE OF AGE ON THE FUNCTIONAL RESULTS Anatomical result. I to 15 years: Good Moderate Bad . . . Total. 8 (72%) 2 (18%) 1 ( 9%) Good. 7 ( 87%) 1 ( 50%) 1 (100%) Functional result. Moderate. I ( 12%) 0 0 Bad. 0 I ( 50%) 0 11 (99%) 9 ( 81%) i( 9%) i( 9%) 15 to 45 years: Good . 10 (90%) 7 ( 70%) 3 ( 30%) 0 Moderate 1 ( 9%) 0 1 (100%) 0 Bad . o( 0%) 0 0 0 11 (99%) 7 ( 63%) 4 ( 36%) 0 45 to 60 years: Good 6 (75%) 4 ( 66%) 2 ( 33%) 0 Moderate 1 (12%) 1 (100%) 0 0 Bad . . . 1 (12%) 1 (100%) 0 0 8 (99%) 6 ( 75%) 2 (25%) 0 94 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS Over 60 years: Good Moderate Bad . . . 5 (83%) 1 (16%) 0 5 (100%) 0 0 0 1 (100%) 0 0 0 0 All over 15 years: 6 (99%) 5 ( 83%) 1 ( 16%) 0 Good . 21 (84%) 16(76%) 5 ( 23%) 0 Moderate 3 ( 8%) 1 (33%) 2 ( 66%) 0 Bad . 1 ( 4%) 0 0 1 (100%) 25 (96%) 17 (68%) 7 ( 28%) i( 4%) TABLE VI-INFLUENCE OF AGE ON NON-OPERATIVE TREATMENT Anatomical result. i to 15 years: Good . Moderate Bad . Total. 7 ( 70%) 2 ( 20%) 1 ( 10%) Good. 7 (100%) 2 (100%) I (100%) Functional result. Moderate. 0 0 0 Bad. 0 0 0 10 (100%) xo (100%) 0 0 15 to 45 years: Good 7 ( 87%) 6 ( 85%) I ( 14%) 0 Moderate 1 ( 12%) 0 I (100%) 0 Bad . 0 0 0 0 8 ( 99%) 6( 75%) 2 ( 25%) 0 45 to 60 years: Good . 4 ( 80%) 2 ( 50%) 2 ( 50%) 0 Moderate 1 ( 20%) 1 (100%) 0 0 Bad . 0 0 O 0 5 (100%) 3 ( 60%) 2 ( 40%) 0 Over 60 years: Good . 2 ( 66%) 2 (100%) 0 0 Moderate 1 ( 33%) 0 I (100%) 0 Bad . 0 0 0 0 3 ( 99%) 2 ( 66%) I ( 33%) 0 All over 15 years: Good . 13 ( 81%) 10 ( 76%) 3 ( 23%) O Moderate 3 ( 18%) 1 ( 33%) 2 ( 66%) O Bad . 0 0 0 0 16 ( 99%) 11 ( 68%) 5 ( 3i%) O HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS 95 TABLE VII.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical result. i to 15 years: Good . Moderate Bad . Total. I (100%) 0 0 Good. 0 0 0 Functional result. Moderate. I (100%) O O Bad. 0 0 0 x (100%) O I (100%) 0 15 to 45 years: Good . 3 (100%) 2 ( 66%) 1 ( 33%) 0 Moderate 0 0 0 O Bad . 0 0 0 0 3 (100%) 2 ( 66%) 1 ( 33%) 0 5 to 60 years: Good . 2 (100%) 2 (100%) 0 0 Moderate 0 0 0 0 Bad . . . 0 0 0 0 2 (100%) 2 (100%) 0 0 Over 60 years: Good 3 (100%) 2 ( 66%) 1 ( 33%) 0 Moderate i ( 25%) 0 1 (100%) 0 Bad . 0 0 0 0 4 (100%) 2 ( 50%) 2 ( 50%) 0 All over 15 years: Good . B ( 88%) 6 ( 75%) 2 ( 25%) 0 Moderate 1 ( n%) 0 1 (100%) 0 Bad . 0 0 0 0 9 ( 99%) 6 ( 66%) 3 ( 33%) 0 Anatomical result. Total. Good. Functional result. Moderate. Bad. Non-operative Shoulder: Good . 17 (65%) 16 ( 94%) O i( 5%) Moderate 6 (23%) 4 ( 66%) 2 ( 33%) 0 Bad . 3(H%) 1 ( 33%) 2 ( 66%) 0 26 (99%) 21 ( 81%) 4 ( 15%) i( 3%) Operative Shoulder: Good . . 10 (62%) 7 ( 70%) 2 ( 20%) 1 ( 10%) Moderate 5(31%) 1 ( 20%) 4 ( 80%) 0 Bad . . ■ i ( 6%) 0 0 1 (100%) 16 (99%) 8 ( 50%) 6 ( 37%) 2 ( 12%) TABLE VIII 96 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS Shaft: Good . • 18 (60%) 15 ( 83%) 3 ( 16%) 0 Moderate • h(36%) 7 ( 63%) 3 ( 27%) x( 9%) Bad . . • 1 ( 3%) 1 (100%) 0 0 30 (99%) 23 ( 76%) 6 ( 20%) x( 3%) Operative Shaft: Good . 10 (83%) 4 ( 40%) 5 ( 50%) 1 ( 10%) Moderate • 1 ( 8%) 0 1 (100%) 0 Bad . x ( 8%) 0 0 1 (100%) 12 (99%) 4 ( 33%) 6 ( 50%) 2 ( 16%) Non-operative Elbow: Good . ■ 47 (77%) 47 (100%) 0 0 Moderate ■ 12 (19%) 9 ( 75%) 3 ( 25%) 0 Bad . • 2 ( 3%) 1 ( 50%) 1 ( 50%) 0 61 (99%) 57 ( 93%) 4 ( 6%) 0 Operative Elbow: Good • 14(82%) 8 ( 57%) 5 ( 35%) 1 ( 7%) Moderate 3 (17%) 0 2 ( 66%) 1 ( 33%) Bad . 0 0 0 0 17 (99%) 8 ( 47%) 7 ( 4i%) 2 ( n%) Non-operative TABLE IX.—DOES GOOD ANATOMICAL RESULTS LESSEN PERIOD OF DISABILITY? Anatomical result. Period of disability. Total. Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. Humerus, all regions: Good 29 ( 81%) 23 ( 79%) 6 (20%) 0 0 0 Moderate 5 ( 13%) i( 20%) 4 (80%) 0 0 O Bad . . . 2( 5%) 2 (100%) o( 0%) 0 0 0 Total 36 (100%) 26 ( 72%) 10(27%) 0 0 0 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS 97 Anatomical result. Total. Period of disability and functional result. Under 3 months. Under 6 months. Under 9 months. Under 12 months. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. i to 15 years Good 8 7 0 0 0 1 0 0 0 0 0 0 0 Moderate .... 2 1 0 0 1 0 0 0 0 0 0 0 0 Bad 1 1 0 0 0 0 0 0 0 0 0 0 0 Total .... XI 9 0 0 1 1 0 0 0 0 0 0 0 15 to 45 years Good 10 5 1 0 2 0 0 0 1 0 0 1 0 Moderate .... X 0 0 0 0 I 0 0 0 0 0 0 0 Bad 0 0 0 0 0 0 0 0 0 0 0 0 0 Total .... II 5 1 0 2 1 0 0 1 0 0 1 0 45 to 60 years Good 6 3 0 0 1 1 0 0 1 0 0 0 0 Moderate .... I 0 0 0 0 0 0 1 0 0 0 0 0 Bad 1 0 0 1 0 0 0 0 0 0 0 0 0 Total .... 8 3 0 1 1 1 0 1 1 0 0 0 0 Over 60 years Good S 3 0 0 I 1 0 0 0 0 0 0 0 Moderate .... 1 0 0 0 0 1 0 0 0 0 0 0 0 Bad 0 0 0 0 0 0 0 0 0 0 0 0 0 Total .... 6 3 0 0 1 2 0 0 0 O 0 0 0 All ages Good 29 18 1 0 4 3 0 0 2 0 0 I 0 Moderate .... 5 1 0 0 1 2 O 1 0 0 0 0 0 Bad 2 I 0 1 0 0 0 0 0 0 0 0 0 Total .... 36 20 1 1 5 5 0 1 2 0 0 I 0 TABLE X.—HUMERUS*, ALL FORMS—36 CASES Average disability for all ages, 5.33 months. TABLE XI.—OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT (HUMERUS) Period of disability. Total. Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. i to 15 years: Non-operative . 10(90%) 9 (90%) 1 ( 10%) 0 0 0 Operative . i 0 x (100%) 0 0 0 IS to 45 years: Non-operative . 8 (72%) 5 (62%) 2 ( 25%) 1 (12%) 0 0 Operative . 3 (27%) 2 (66%) 0 0 0 0 45 to 6o years: Non-operative . 6 (75%) 3 (50%) 2 ( 33%) 1 (16%) 0 0 Operative . 2 (25%) 1 (50%) 1 ( 50%) 0 0 0 Over 6o years: Non-operative . 3 (50%) 1 (33%) 2 ( 66%) 0 0 0 Operative . 3 (50%) 2 (66%) 1 ( 33%) 0 0 0 All ages: Non-operative . 27 (75%) 18 (66%) 7 ( 25%) 2 ( 7%) 0 0 Operative . 9 (25%) 5 (55%) 3 ( 33%) 0 1 (n%) 0 The series is too small to draw absolute conclusions. It appears from the above, however, that operative treatment lengthens the period of disability. TABLE XII.—INFLUENCE ON RESULT OF TIME ELAPSING BETWEEN INJURY AND OPERATION (HUMERUS) No. of cases. Ages, years. Date of operation, days. Anatomical result. Functional result. i to 15 15 to 45 45 to 60 Over. 60 0 to 7 8 to 14 15 to 21 22 to 28 29 Good. Mod. Bad. 1 0 0 0 0 1 0 0 0 Good . . 1 0 1 0 Moderate . 0 0 0 0 Bad ... 0 0 0 0 3 0 0 1 0 I 0 1 Good . . 3 X 2 0 Moderate . 0 0 0 0 Bad ... 0 0 0 0 2 0 1 0 I 0 0 Good . . 2 2 0 0 Moderate . 0 0 0 0 Bad ... 0 0 0 0 3 1 1 I 0 0 Good . . 3 2 1 0 Moderate . 0 0 0 0 Bad ... 0 0 0 0 9 0 0 3 2 3 1 1 Good . . 9 5 4 0 Moderate . 0 0 0 0 Bad ... 0 0 0 0 9 5 4 0 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS 99 Compound Fractures of the Humerus TABLE I Total. Non-operative. Operative. Humerus, shoulder . • • 4 2 2 Humerus, shaft . • • 15 4 II Humerus, elbow . 0 0 0 19 6 13 Anatomical result. Total. Good. Functional result. Moderate. Bad. Good • 12 ( 63%) II ( 91%) i ( 8%) 0 Moderate . • 4 ( 21%) I ( 25%) 3 (75%) 0 Bad . • 3 ( 15%) 0 0 3 (100%) 19 ( 99%) 12 ( 63%) 4(21%) 3 ( 15%) TABLE II Anatomical result. Total. Good. Functional result. Moderate. Bad. Good 6 (100%) 6 (100%) 0 0 Moderate . 0 0 o 0 Bad . 0 o o o 6 (xoo%) 6 (ioo%) 0 O TABLE III.-NON-OPERATIVE TABLE IV.—OPERATIVE Anatomical result. Total. Good. Functional result. Moderate. Bad. Good • 6 ( 46%) 5 ( 83%) I (16%) O Moderate . 4 ( 30%) 1 ( 25%) 3 (75%) 0 Bad . • 3 ( 23%) 0 0 3 (100%) 13 ( 99%) 6 ( 46%) 4 (30%) 3 ( 23%) TABLE V.-INFLUENCE OF AGE ON THE FUNCTIONAL RESULT Anatomical result. Total. Good. Functional result. Moderate. Bad. i to 15 years: Good 3 ( 75%) 3 (100%) 0 0 Moderate 0 0 0 O Bad . . . I ( 25%) 0 O I (100%) 4 (100%) 3 ( 75%) O l( 25%) 100 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS 15 to 45 years: Good . Moderate Bad . 8 ( 57%) 4 ( 28%) 2 ( 14%) 6 ( 75%) 1 ( 25%) 0 2 (25%) 3 (75%) 0 0 0 2 (100%) 14 ( 99%) 7 ( 50%) 5 (35%) 2 ( 14%) 45 to 6o years: Good 1 (100%) 1 (100%) 0 0 Moderate 0 0 0 0 Bad . . . 0 0 0 0 I (100%) All over 6o years, no cases. 1 (100%) 0 0 All over 15 years: Good . 9 ( 60%) 7 ( 77%) 2 (22%) 0 Moderate 4 ( 25%) 1 ( 25%) 3 (75%) 0 Bad . 2 ( 13%) 0 0 2 (100%) 15 ( 98%) 8 ( 53%) 5 (33%) 2 ( 13%) TABLE VI.—INFLUENCE OF AGE ON THE FUNCTIONAL RESULTS (NON-OPERATIVE TREATMENT) Anatomical result. Total. Good. Functional result. Moderate. Bad. i to 15 years: Good . 3 (100%) 3 (100%) 0 0 Moderate O 0 0 O Bad . . . 0 0 0 0 3 (100%) 3 (100%) 0 0 15 to 45 years: Good 1 (100%) 1 (100%) 0 0 Moderate 0 0 O O Bad . 0 0 0 0 1 (100%) 1 (100%) 0 0 45 to 60 years: Good . 2 (100%) 2 (100%) 0 0 Moderate 0 0 0 O Bad . 0 0 0 0 2 (100%) All over 60 years, no cases. 2 (100%) 0 0 All over 15 years: Good 3 (100%) 3 (100%) 0 0 Moderate 0 0 0 0 Bad . 0 0 O 0 3 (100%) 3 (100%) 0 0 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS 101 TABLE VII.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical result. I to 15 years: Good . Moderate Bad . Total. O 0 I (100%) Good. O 0 0 Functional result. Moderate. 0 0 0 Bad. 0 O I (lOO%) I (100%) 0 0 I (100%) 15 to 45 years: Good • 7 ( 58%) 5 (7i%) 2 (28%) 0 Moderate • 3 ( 25%) 1 (33%) 2 (66%) O Bad . • 2 ( 16%) 0 0 2 (100%) 12 ( 99%) 6 (50%) 4 (33%) 2 ( 16%) 45 to 60 years, no cases. Over 60 years, no cases. TABLE VIII Anatomical result. Shoulder: Good Moderate Bad . . . Total. 2 ( 50%) 0 0 Good. Non-operative 2 (100%) 0 0 Functional result. Moderate. 0 6 0 Bad. 0 0 0 2 (100%) 2 (100%) 0 0 Operative Shoulder: Good 0 0 0 0 Moderate 0 0 0 0 Bad . 2 (100%) 0 0 2 2 (100%) 0 Non-operative 0 2 (100%) Shaft: Good 3 (100%) 3 (100%) 0 0 Moderate 0 0 (100%) 0 0 Bad . 0 0 0 0 3 (100%) 3 (100%) 0 0 102 HUNTINGTON: SIMPLE FRACTURES OF THE HUMERUS Shaft: Good ... 7 ( 58%) Moderate . 4 ( 33%) Bad . . . 1 ( 8%) 5( 7i%) 1 ( 25%) 0 2 (28%) 3 (75%) 0 0 0 1 (100%) 12 ( 99%) 6 ( 50%) 5(4i%) i( 8%) Elbow, non-operative, no cases. Elbow, operative, no cases. Operative TABLE IX.—COMPARATIVE RESULTS OF OPERATIVE AND NON-OPERATIVE CASES OF COMPOUND FRACTURES OF THE HUMERUS Cases. Operative cases. Cases. Non-operative cases. Good ana- tomical result. Good functional result. Good ana- tomical result. Good functional result. Humerus, shoulder . 2 0 0 2 100% 100% Humerus, shaft 3 100% 100% 12 58% 7i% Humerus, elbow 0 0 0 0 0 0 FRACTURES OF THE BONES OF THE FOREARM By EDWARD MARTIN, M.D. AND E. L. ELIASON, M.D. (By Invitation.) PHILADELPHIA, PA. The non-operative treatment of fractures of the shafts of the radius and ulna gave 83 per cent, good functional, 77 per cent, good anatomical and 1 per cent, bad results. Operative methods gave 83 per cent, good functional results, 50 per cent, good ana- tomical results, 17 per cent, bad functional results. (Table VII.) Non-operative treatment of fractures near joints gave 79 per cent, good functional and 77 per cent, good anatomical results. Operative treatment gave 72 per cent, good functional and 27 per cent, good anatomical results. (Table VIII.) Disability was not longer than six weeks in 45 per cent, of the 257 cases and in 57 per cent, of the cases with good anatomical results. (Table X.) The non-operative treatment of compound fractures gave 55 per cent, good functional results and the operative treatment gave 14 per cent, good functional results. The number of cases, 16, is too small for conclusions of value. (Table XI.) In so far as conclusions are justified by a study and classifica- cation of the reported cases of fracture of the forearm bones it would seem that: Non-operative treatment gave good functional results in 78 per cent, as compared to 68 per cent, operative, and showed only 2 per cent, bad functional results as compared to 13 per cent, bad functional results in the operative cases. 104 MARTIN, ELIASON: FRACTURES OF FOREARM The cases operated on were in the main those in which injury was most extensive and delay in adequate treatment most pronounced. (Table III.) Forearm fractures in the young (under fifteen years) gave the best results, both under conservative and operative treatment, if one small series (6 cases over sixty years of age) be excluded. (Tables IV, V, VI.) Internal Fixation. Of the 43 cases with data only 36 are recorded with sufficient detail to be of service. Bone plates were used in 17 cases; catgut or tendon in 7; screws in 5; bone inlays in 4; and wire in 2. In 5 cases in the series the internal fixation had to be removed later (three bone inlays and two bone plates). In 3 of the 5 cases, 7.9 per cent, of the total number, infection seemed to be the cause. Time of Operation. The earliest operation was within three hours; the latest was one hundred and twenty days. Only 4 cases were operated under forty-eight hours. Table XII shows that the best anatomical and functional results are obtained under early operation; that is, in the first and second weeks, each giving 50 per cent, good results. After the fourth week the results are over 50 per cent, bad for function. Total. Non-operative. Operative. Radius, head .... . . 6 3 3 Radius, shaft . . 41 38 3 Radius, Colies’s . . 100 95 5 Ulna, olecranon . • • 15 12 3 Ulna, shaft .... • • 32 28 4 Radius and ulna, shafts . . 76 50 26 Total .... . 270 226 44 TABLE I Note.—In reading the following tables there will be found some discrepancies which, however, are due to incomplete history records and insufficient data. The percentage figures are always taken as the first whole number and no fractions considered. TABLE II.—FRACTURES OF THE RADIUS AND ULNA Anatomical result. Functional result. Total. Good. Moderate. Bad. Non- oper- ative 1 Oper- ative Non- oper- ative Oper- ative Non- oper- ative Oper- ative Non- oper- ative Oper- ative. Radius, Shaft Good 33 2 33 2 0 0 0 0 Moderate . 5 0 2 0 3 0 0 0 Bad .... 0 0 0 0 0 0 0 0 Total 38 2 35 2 3 0 0 0 Per cent. 100 100 90 100 70 0 0 0 Radius, Good 70 2 65 2 5 0 0 0 Colles’s Moderate . 13 2 4 1 7 1 2 0 Bad .... 10 1 3 0 6 1 I Total 93 5 72 3 18 1 3 1 Per cent. 100 100 77 60 0 20 60 20 Ulna, Shaft Good 20 2 15 2 5 0 0 0 Moderate s 3 2 0 0 0 Bad .... 3 2 2 1 1 0 1 Total 28 4 20 2 8 1 0 X Per cent. 100 100 71 50 28 25 0 25 Radius and Good 26 12 24 10 2 2 0 0 Ulna, Moderate 13 8 6 2 7 6 0 0 Shafts Bad .... 7 6 0 1 5 1 2 4 Total 46 26 30 13 14 9 2 4 Per cent 100 100 65 50 30 34 4 15 Radius, Head Good 3 1 3 1 0 0 0 0 Moderate 0 2 0 1 0 1 0 0 Bad .... 0 0 0 0 0 0 0 0 Total 3 3 3 2 0 1 0 0 Per cent 100 100 100 66 0 33 0 0 Ulna, Good xo 0 10 0 0 0 0 0 Olecranon Moderate . 1 3 0 3 1 0 0 0 Bad .... 0 0 0 0 0 0 0 0 Total 11 3 10 3 1 0 0 0 Per cent 100 100 90 100 9 0 0 0 Grand total 210 43 170 25 44 12 5 6 Per cent. 100 100 78 68 20 27 2 13 Functional result. Anatomical Total. Good. Moderate. Bad result. Non- Non- Non- Non- opera- Opera- opera- Opera- opera- Opera- opera- Opera- tive. tive. tive. tive. tive. tive. tive. tive. Good . 162 19 ISO 17 12 2 0 0 Moderate . 37 IS IS 7 20 8 2 0 Bad 20 9 5 X 12 2 3 6 Total 219 43 170 25 44 12 S 6 Per cent. . 100 100 78 68 20 27 2 13 Note.—Only 4 cases were operated under forty-eight hours; 2 had good functional and anatomical results; 2 had bad functional and anatomical results. TABLE III.—FRACTURES OF THE RADIUS AND ULNA. TABLE IV.—INFLUENCE OF AGE ON THE FUNCTIONAL RESULT Anatomical result. Total. Good. Functional result. Moderate. Bad. Under 15 years: Good 78 74 3 I Moderate 18 13 5 0 Bad . 8 3 4 I — — — — Total . 104 90 (86%) 12(11%) 2 (19%) 15 to 45 years: Good 9i 85 4 2 Moderate 12 3 8 I Bad . 11 2 4 5 — — — — Total . 114 90 (78%) 16(14%) 8 ( 7%) 45 to 60 years: Good 15 12 3 0 Moderate 8 5 3 0 Bad . 7 1 3 3 — — — — Total . 30 18 (60%) 9 (30%) 3 (10%) Over 60 years: Good 7 6 1 0 Moderate 6 0 6 0 Bad . 3 1 2 0 — — — — Total . 16 7 (43%) 9 (56%) 0 All over 15 years: Good 113 103 9 2 Moderate 26 8 7 4 Bad ... . 21 4 9 8 — — — — Total . . . 160 115 (72%) 25 (15%) 14 ( 8%) MARTIN, ELIASON: FRACTURES OF FOREARM 107 TABLE V.-INFLUENCE OF AGE ON NON-OPERATIVE TREATMENT Anatomical result. Total. Good. Functional result. Moderate. Bad. Under 15 years: Good 68 64 3 I Moderate 16 13 3 0 Bad . 4 2 1 I — — — — Total . 88 79 (89%) 7 ( 7%) 2 (2%) 15 to 45 years: Good 81 77 4 O Moderate 7 1 5 I Bad . 7 2 4 I — — — — Total . 95 80 (84%) 13 (13%) 2 (2%) 45 to 60 years: Good 15 12 3 O Moderate 8 5 3 O Bad ... . 5 1 3 X — — — — Total . 28 18 (64%) 9 (62%) I (3%) Over 60 years: Good 6 6 0 0 Moderate 6 . 0 6 0 Bad ... . 3 1 2 0 — — — — Total . 15 7 (46%) 8(52%) 0 All over 15 years: Good 102 95 8 0 Moderate 22 6 4 I Bad ... . 15 4 9 2 Total . 139 105 (75%) 21 (15%) 3(2%) TABLE VI.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical result. Total. Good. Functional result. Moderate. Bad. Under 15 years: Good . 10 10 0 0 Moderate . 2 0 2 O Bad . . . 4 I 2 0 — — — — Total . . l6 ii (68%) 4 (25%) 0 108 MARTIN, ELIASON: FRACTURES OF FOREARM 15 to 45 years: Good 10 8 0 2 Moderate 5 2 3 0 Bad .... 4 0 0 4 — — — — Total . 19 10 (52%) 3 (i5%) 6( 31%) 45 to 6o years: Good .... 0 0 0 0 Moderate 0 0 0 0 Bad ... . 2 0 0 2 — — — — Total . 2 0 0 2 (100%) Above 6o years: Good .... 1 0 1 0 Moderate ' . 0 0 0 0 Bad .... 0 0 0 0 — — — — Total . 1 0 1 (100%) 0 All over 15 years: Good 11 8 1 2 Moderate 5 2 3 0 Bad .... 6 0 0 6 — — — — Total . 22 10 (45%) 4 ( 18%) 8 ( 37%) TABLE VII.—FRACTURES OF SHAFTS OF THE LONG BONES Non-operative Anatomical result. Total. Good. Functional result. Moderate. Bad. Good • 79 72 7 O Moderate . • 23 II 12 0 Bad .... 10 2 6 2 — — — — Total . . 112 85 (83%) 25 (24%) 2 ( 1%) This series does not contain Colles’s, olecranon or radial head fractures. Operative Good 16 14 2 0 Moderate . 8 2 6 0 Bad . 8 1 2 5 Total . • 32 17 (53%) 10(31%) 5 (17%) MARTIN, ELIASON: FRACTURES OF FOREARM 109 TABLE VIII.—FRACTURES NEAR JOINTS Anatomical result. Total. Non-operative Good. Functional result. Moderate. Bad. Good • 83 78 5 O Moderate . . 14 4 8 2 Bad . . . . . 10 3 6 I — — — Total . . . 107 85 (79%) 19 (17%) 3 (2%) Good 3 Operative 3 0 0 Moderate . 7 5 2 0 Bad . . . . 1 0 O 1 — — — — Total . 11 8(72%) 2 (18%) 1 (9%) TABLE IX Good Functional Results Following Non-operative Treatment Site. Total. Good function. Radius and ulna, shafts .... . 112 85 Radius and ulna, extremities . . 107 85 Total 170 (78%) Good Functional Results Following Operative Treatment Radius and ulna, shafts .... • • 32 17 Radius and ulna, extremities. . . II 8 Total • • 43 25 (68%) TABLE X.—PERIOD OF DISABILITY IN FRACTURES OF THE UPPER EXTREMITY Anatomical result. Total. Under 6 weeks. Under 12 weeks. Under 24 weeks. Over 24 weeks. Good . • 174 IOO 55 12 7 Moderate • 50 l6 23 6 5 Bad . • 33 12 10 6 5 Total • 257 128 (45%) 88 (33%) 24 (9%) 17 (8%) 110 MARTIN, ELIASON: FRACTURES OF FOREARM Note.—This table shows that good anatomical results were associated with disability under six weeks in 45 per cent, of cases. Disability here had been taken to apply to time elapsing before return to work. TABLE XI.—COMPOUND FRACTURE OF THE FOREARM GROUPED IN ONE SERIES BECAUSE OF SMALL NUMBER Anatomical result. Functional result. Total. Good. Moderate. Bad. Died. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Non- oper- ative. Oper- ative. Good .... 4 i 4 i 0 O o o 0 Moderate 2 3 0 0 2 3 0 0 0 Bad .... 3' 3 i 0 O i 3 i 2 Total 9 . 7 5 i 2 4 3 i 2 Per cent . 0 0 S3 14 22 57 33 14 0 Deaths: i from tetanus; i from shock and other injuries. Other deaths in the records were not attributable to the forearm condition. TABLE XII.—TIME OF OPERATION ON FRACTURED FOREARM Anatomical result. Total. Good. Functional result. Moderate. Bad. I to 7 days: Good 7 6 I 0 Moderate 3 0 3 0 Bad . 2 0 0 2 — — — — Total . 12 (100%) 6 (50%) 4(33%) 2 (16%) 7 to 14 days: Good 5 4 1 0 Moderate 2 0 2 O Bad . 1 0 0 I — — — — Total . 8 (100%) 4 (50%) 3 (37%) I (12%) MARTIN, ELIASON: FRACTURES OF FOREARM 111 14 to 21 days: Good 1 1 0 0 Moderate 3 0 3 0 Bad .... 1 0 0 1 — — — — Total . 5 (100%) 1 (20%) 3 (60%) 1 (20%) 21 to 28 days: Good Moderate ' No cases reported. Bad ... . Total . Over 28 days: Good 3 3 0 0 Moderate 1 0 1 0 Bad ... . 5 0 0 5 — — — — Total . 9 (100%) 3 (33%) I (n%) 5 (55%) FRACTURES OF THE TIBIA AND FIBULA By ASTLEY P. C. ASHHURST, M.D. PHILADELPHIA The statistics presented herewith are based on the figures given in the report of this committee for the year 1915 with the addition of the cases since collected, making a total of 926 cases of fractures of the tibia and fibula which have been reported in sufficient detail to permit of study. These cases are thus divided. Simple fractures, 625 (non-operative, 555; operative, 70). Compound fractures, 301 (non-operative, 184; operative, 117). Total, 926 (non-operative, 739; operative, 187). The thanks of the committee are extended to their collabora- tors, Dr. Otto C. Gaub, of Pittsburgh; Dr. Daniel F. Jones, of Boston; Dr. Kellogg Speed, of Chicago, as well as to Dr. Edward B. Hodge, of Philadelphia, for reports of cases; and especially to Dr. Irvine M. Boykin and Dr. Edward T. Crossan for collect- ing a very large number of end-results from the Episcopal Hospital of Philadelphia; also to Miss M. C. Lamor for tabulating the cases of fractures of the tibia and fibula. The results are slightly better, in the more recently collected cases, than they were in those forming the subject of investiga- tion in 1915; but in these latter, as well as in the earlier cases, these results are not ideal. They show that the treatment of fractures of the leg bones is still capable of much improvement. The accompanying tables analyze separately all the simple fractures (Tables I to XIII inclusive) and subsequently (Tables XIV to XXI inclusive) the compound fractures. ashhurst: fractures of the tibia and fibula 113 Simple Fractures of the Leg Bones. These statistics (Tables I to XIII inclusive) relate only to recent, closed fractures. Included in the analysis are the following 625 individual cases of fracture: Simple Fractures of the Leg Bones, 1915 and 1921 TABLE I Total. Non-operative. Operative. Fibula, shaft .... . . 46 46 Tibia, shaft . .114 92 22 Tibia and fibula, shafts . . 232 192 40 Tibia and fibula, ankle . 109 IOI 8 Tibia, ankle • • 36 36 Fibula, ankle .... . . 88 88 625 555 70 TABLE II Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 476 ( 76%) 408 (86%) 60(12%) 8 ( 2%) Moderate . 109 ( 18%) 57 (51%) 40 (39%) 12 (10%) Bad 40 ( 6%) 3 ( 8%) 14 (35%) 23 (57%) 625 (lOO%) 468 (75%) II4(l8%) 43 ( 7%) TABLE III.—NON-OPERATIVE Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 428 ( 77%) 372 (87%) 49 (H%) 7 ( 2%) Moderate . 94 ( 17%) 49 (52%) 36 (38%) 9(10%) Bad . . . 33 ( 6%) 1 ( 3%) 12 (36%) 20 (61%) 555 (100%) 422 (76%) 97 (17%) 36 ( 7%) TABLE IV.—OPERATIVE Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . . 48 ( 69%) 36(75%) II (23%) I ( 2%) Moderate . 15 ( 21%) 8 (53%) 4(27%) 3 (20%) Bad 7 ( 10%) 2 (28%) 2(28%) 3 (44%> 70 (100%) 46 (66%) 17 (24%) 7 (10%) 114 ashhurst: fractures of the tibia and fibula As in our previous report a much larger number of case records was examined, but many had to be rejected partly or entirely because of lack of data. This insufficiency in regard to certain details accounts for the fewer number of cases analyzed in some tables than in others. We have tried to maintain the standard as set forth under the heading of Definitions on page 12 of our 1915 report. But in many of the reports received the examining surgeons appear to Anatomical result. Total. Under 15 years: Good . . 51 ( 88%) Moderate . 6 ( 10%) Bad . . . 1 ( 2%) RESULT Good. 49 (96%) 3 (50%) Functional result. Moderate. I( 2%) 3 ( 50%) 1 (100%) Bad. I ( 2%) 58 (100%) 52 (89%) 5 ( 9%) I ( 2%) 15 to 45 years: Good 244 ( 80%) 217 (89%) 25 (10%) 2 ( 1%) Moderate . 48 ( 16%) 28 (58%) 18(38%) 2 ( 4%) Bad . 11 ( 4%) 2 (l8%) 6(55%) 3(27%) 303 (100%) 247 (82%) 49 (16%) 7 ( 2%) 45 to 60 years: Good 70 ( 67%) 56 (80%) 11 (16%) 3 ( 4%) Moderate . 23 ( 22%) II (48%) 8(35%) 4(17%) Bad . 12 ( 11%) 5 (42%) 7 (58%) 105 (100%) 67 (64%) 24 (23%) 14(13%) Over 60 years: Good 17 ( 77%) 12 (71%) 4(23%) 1 ( 6%) Moderate . 3 ( H%) I (33-3%) 1 (33-3%) 1 (33-4%) Bad . 2 ( 9%) 2(100%) 22 (100%) 13 (59%) 5 (23%) 4 (18%) All over 15 years: Good 33i ( 77%) 285 (86%) 40(12%) 6( 2%) Moderate . 74 ( 17%) 40 (55%) 27 (36%) 7 ( 9%) Bad . 25 ( 6%) 2 ( 8%) 11 (44%) 12 (48%) 430 (100%) 327 (76%) 78 (18%) 25 ( 6%) TABLE V.-INFLUENCE OF AGE ON THE FUNCTIONAL ashhurst: fractures of the tibia and fibula 115 have been less strict than the committee, and therefore the statistical tables probably show better results than actually are obtained in practice. For instance, some reports received have classed as “good” anatomical results cases in which shortening of as much as 3 cm. was recorded; and as “good” functional results cases in which pain in damp weather persisted or where there was evident, but not disabling, limitation of motion and TABLE VI.-INFLUENCE OF AGE ON NON-OPERATIVE TREATMENT Anatomical result. Total. Good. Functional result. Moderate. Bad. Under 15 years: Good 47 ( 90%) 46 (98%) I( 2%) Moderate . 4 ( 8%) 2 (50%) 2 ( 50%) Bad . i( 2%) I (100%) 52 (100%) 48 (92%) 00 rf- 15 to 45 years: Good 218 ( 81%) 199 (91%) 17 ( 8%) 2 ( 1%) Moderate . 4i (16%) 23 (57%) 17 (41%) I ( 2%) Bad . 9 ( 3%) I (H%) 5 (56%) 3 (33%) 268 (100%) 223 (83%) 39(15%) 6( 2%) 45 to 60 years: Good 66 ( 70%) 54 (81%) 9(i4%) 3 ( 5%) Moderate . 20 ( 21%) 9 (45%) 8 (40%) 3(i5%) Bad . . . 9 ( 9%) 5 (56%) 4 (44%) 95 (100%) 63 (66%) 22 (23%) 10(11%) Over 60 years: Good 17 ( 77%) 12 (70%) 4 (24%) 1 ( 6%) Moderate . 3 ( H%) 1 (33-3%) 1 (33-3%) 1 (33-4%) Bad . 2 ( 9%) 2 (100%) 22 (100%) 13 (59%) 5 (23%) 4 ( 18%) All over 15 years: Good 301 ( 78%) 267 (88%) 30 (10%) 6 ( 2%) Moderate . 64 ( 17%) 33 (50%) 27 (42%) 5 ( 8%) Bad . 20 ( 5%) 1 ( 5%) 10 (50%) 9 (45%) 385 (100%) 299 (78%) 66 (17%) 20 ( 5%) 116 ashhurst: fractures of the tibia and fibula where disability was “partial,” not entirely “absent.” Our definitions showred that such results should have been classed as “moderate” or “bad” in anatomy and function according to the degree of deformity and disability; and though an effort was made to correct very glaring inaccuracies of this kind in the reports received, it is probable a number have been passed undetected. Table II shows the functional result in all the cases reported; and it certainly is not creditable that only 75 per cent of the whole number of patients recovered good function. Table III TABLE VII.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical result. Under 15 years: Good Moderate . Bad . . . Total. 4 ( 67%) 2 ( 33%) Good. 3 ( 75%) 1 (100%) Functional result. Moderate. I (100%) Bad. I ( 25%) 6 (100%) 4 ( 66%) I (17%) I ( 17%) 15 to 45 years: Good 26 ( 74%) 18 ( 69%) 8(31%) Moderate . 7 ( 20%) 5 ( 72%) I (14%) I ( H%) Bad . . . 2 ( 6%) 1 ( 50%) I (50%) 35 (100%) 24 ( 68%) 10 (29%) i ( 3%) 45 to 60 years: Good 4 ( 40%) 2 ( 50%) 2 (50%) Moderate . 3 ( 30%) 2 ( 67%) 1 ( 33%) Bad . 3 ( 30%) 3 (100%) 10 (100%) 4 ( 40%) 2 (20%) 4 ( 40%) Over 60 years: Good .... .... Moderate .... Bad . .... .... .... All over 15 years: Good 30 ( 67%) 20 ( 67%) 10 (33%) Moderate . 10 ( 22%) 7 ( 70%) I (10%) 2 ( 20%) Bad . 5 ( n%) I ( 20%) I (20%) 3 ( 60%) 45 (100%) 27 ( 62%) 12(27%) 5 ( n%) ASIIHURST: FRACTURES OF THE TIBIA AND FIBULA 117 and Table IV show the functional results in non-operative and operative cases respectively. It is especially worthy of note that in each case the greatest number of patients who secure good function are those in whom the anatomical result is good (87 TABLE VIII.—FRACTURES OF THE TIBIA AND THE FIBULA Anatomical results. Functional results. Total. Good. Moderate. Bad. Non- opera- tive. Opera- tive. Non- opera- tive. Opera- tive. Non- opera- tive. Opera- tive. Non- opera- tive. Opera- tive. Sha fts (als 0 Shaft of the Tibia al one) Good . 206 4i 181 33 21 6 4 2 (70%) (67%) (88%) (81%) (10%) (14%) ( 2%) ( 5%) Moderate . 69 IS 4i 8 23 4 5 3 (23%) (24%) (59%) (54%) (33%) (26%) ( 8%) (20%) Bad 22 6 1 1 II 2 10 3 (79%) ( 9%) ( 5%) (17%) (50%) (33%) (45%) (50%) Total 297 62 223 42 55 12 19 8 Per cent . (100%) (100%) (75%) (68%) (19%) (19%) (6%) (13%) A NKLE ( All For ms) Good . 185 8 156 3 26 5 3 (82%) (100%) (84%) (38%) (14%) (62%) ( 2%) Moderate . 26 8 14 4 (12%) . . * (31%) (54%) (15%) Bad ... 13 1 12) ( 6%) ( 8%) (92% Total 224 8 164 3 4i 5 19 Per cent (100%) (100%) (73%) (38%) (18%) (62%) (9%) TABLE IX.—AVERAGE PERIOD OF DISABILITY Average Cases Average AH eases. period of disability terminated under 12 period of disability Site of fracture. (months). (months). (months) Tibia or tibia and fibula, shafts . 4-7 316 4.2 Ankle 4.0 218 35 556* 534 * 35 extra cases not included in Table VIII are included in Table IX. 118 ASHHURST: FRACTURES OF THE TIBIA AND FIBULA per cent in non-operative cases, 75 per cent in operative cases); and conversely, that the worse the anatomical result the worse is function sure to be. Hence it is cause for regret that in the entire series a good anatomical result was secured only in 76 TABLE X —DOES GOOD ANATOMICAL RESULT LESSEN THE PERIOD OF DISABILITY? FRACTURES OF THE LEG BONES (ALL FORMS) Anatomical Under Under Under Under Over result. Total. 3 months. 6 months. 9 months. 1 year. 1 year. Good 335 (79%) 177 (53%) 118(35%) 30 ( 9%) 6 (2%) 4 ( 1%) Moderate 69 (16%) 15 (22%) 33 (47%) 15 (22%) 2 (3%) 4 ( 6%) Bad . 20 ( 5%) 3 (15%) 9 (45%) 3 (15%) 1 (5%) 4 (20%) O O M Tf’ CS ''t 195 (46%) 160 (38%) 48 (H%) 9 (2%) 12 ( 3%) TABLE XI.—GOOD FUNCTIONAL RESULTS FOLLOWING OPERATIVE AND NON-OPERATIVE TREATMENT (SIMPLE FRACTURES) Site. American Surgical Association, 1921. British Medical Association, 1912. Total. Good function. Total. Good function. Tibia and fibula, shafts 338 239 (70%) 1014 779 (76%) Ankle fractures 232 188 (81%) 259 127 (49%) Total leg fractures 570 437 (76%) 1273 906 (71%) TABLE XII.-GOOD FUNCTIONAL RESULTS FOLLOWING NON-OPERATIVE TREATMENT (SIMPLE FRACTURES) Site. American Surgical Association, 1921. British Medical Association, 1912. Total. Good function. Total. Good function. Tibia and fibula, shafts 297 206 (70%) 975 748 (76%) Ankle fractures 224 185 (82%) 255 125 (49%) Total leg fractures 521 39i (75%) 1230 873 (7i%) ASHHURST: FRACTURES OF THE TIBIA AND FIBULA 119 TABLE XIII.—GOOD FUNCTIONAL RESULTS FOLLOWING OPERATIVE TREATMENT (SIMPLE FRACTURES) Site. American Surgical Association, 1921. British Medical Association, 1912. Total. Good function. Total. Good function. Tibia and fibula, shafts 4i 33 (82%) 39 3i (79%) Ankle fractures 8 3 (37%) 4 2 (50%) Total leg fractures .... 49 36 (73%) 43 33 (76%) TABLE XIV.—COMPOUND FRACTURES Total. Non-operative. Operative. Fibula, shaft ... 13 9 4 Tibia, shaft .... • • • 73 43 30 Tibia and fibula, shafts . 206 125 8l Tibia and fibula, ankle ... 6 5 I Tibia, ankle .... . . . 2 1 X Fibula, ankle 1 301 184 117 TABLE XV.—COMPOUND FRACTURES Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 167 ( 58%) 156(93%) 8 ( 5%) 3 ( 2%) Moderate . 83 ( 29%) 21 (25%) 54(65%) 8(10%) Bad 39 ( 13%) 3(8%) 7 (18%) 29 (74%) 289 (100%) 180 (62%) 69 (24%) 40(14%) TABLE XVI.—NON-OPERATIVE CASES (COMPOUND FRACTURES) Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . 109 ( 61%) 102 (93%) 6 ( 6%) I( I%> Moderate . 51 ( 29%) 15 (29%) 33 (65%) 3 ( 6%) Bad . . . 18 ( 10%) i ( 6%) . 3(17%) 14(77%) 178 (100%) 118(67%) 42 (23%) 18(10%) 120 ashhurst: fractures of the tibia and fibula per cent of cases (77 per cent of non-operative and only 69 per cent of operative cases). Should not surgeons be able to secure accurate anatomical reposition of the fragments (“good anatomy”) in more than two-thirds of the cases they subject to open reduction? The influence of age on the functional result is shown in Tables V, VI and VII. These figures emphasize the fact so clearly demonstrated in our earlier tables that in patients under fifteen years of age good function is obtainable with most certainty, and that the older the patient the less certain is good function to be secured. They indicate, moreover, that in patients under fifteen years of age good function is secured in 92 per cent of cases without resort to operation. In regard to operative treatment of simple fractures of the leg hones these tables appear to show that it has proved less easy TABLE XVII.—OPERATIVE CASES (COMPOUND FRACTURES) Anatomical result. Total. Good. Functional result. Moderate. Bad. Good . . . 58 ( 52%) 54 (94%) 2 ( 3%) 2 ( 3%) Moderate . 32 ( 29%) 6(19%) 21 (65%) 5 (16%) Bad 21 ( 19%) 2 (10%) 4(19%) 15(71%) III (100%) 62 (56%) 27 (24%) 22 (20%) TABLE XVIII.—INFLUENCE OF AGE ON THE FUNCTIONAL RESULT (COMPOUND FRACTURES) Anatomical result. Under 15 years: Good Moderate . Bad . . . Total. 17 ( 55%) 9 ( 29%) 5 ( 16%) Good. 15 (88%) 2 (22%) 1 (20%) Functional result. Moderate. I ( 6%) 7 (78%) Bad. I ( 6%) 4 (80%) Over 15 years: 31 (100%) 18 (58%) 8 (26%) 5 (16%) Good . . 150 ( 58%) 141 (94%) 7 ( 5%) 2 ( 1%) Moderate . 74 ( 29%) 19 (26%) 47 (63%) 8(n%) Bad . 34 ( 13%) 2 ( 6%) 7 (21%) 25 (73%) 258 (100%) 162 (62%) 61 (24%) 35(14%) ashhurst: fractures of the tibia and fibula 121 to secure anatomical reposition of the fragments by operation at any age period (40 to 74 per cent of good anatomical results) than when no operation is done (70 to 90 per cent of good ana- tomical results); but it must not be overlooked that in the cases treated without operation are included all the subperi- osteal and incomplete fractures as well as all those with only trifling displacement in which no reduction of the fragments is required; while in the operative series, almost only, are those fractures with great displacement (overriding, angulation, rota- tion) in which reduction by non-operative means has usually been tried and has failed before operation was undertaken. TABLE XIX.—COMPOUND FRACTURES OF THE TIBIA AND THE FIBULA Functional results. Total. Good. Moderate. Bad. Anatomical results. Non- opera- tive. Opera- tive. Non- opera- tive. Operas tive. Non- opera- tive. Opera- tive. Non- opera- tive. Opera- tive. S HAFTS ( also Sha ft of th e Tibia alone) Good . 105 58 99 54 6 2 2 (63%) (53%) (94%) (94%) ( 6%) ( 3%) ( 3%) Moderate . 46 30 15 6 29 19 2 5 (27%) (28%) (33%) (20%) (63%) (63%) ( 4%) (17%) Bad . . . 17 21 I 2 3 4 13 15 (10%) (19%) ( 6%) (10%) (18%) (19%) (76%) (71%) Total . 168 109 115 62 38 25 15 22 Per cent (100%) (100%) (69%) (57%) (22%) (23%) ( 9%) (20%) A NKLE ( All For ms) Good . 2 I 1 (29%) (50%) (50%) Moderate . 4 2 3 2 X (57%) (100%) (75%) (100%) (25%) Bad 1 1 ( 4%) (100%) Total . 7 2 I 3 2 3 Per cent (100%) (100%) (14%) (43%) (100%) (43%) 122 ASHHURST: FRACTURES OF THE TIBIA AND FIBULA One death is recorded from sepsis, five and a half months after open operation and fixation of the tibia by a steel plate. In Table VIII the anatomical and functional results are analyzed according as the fractures involved the shafts of the leg bones or affected the ankle. Our 1915 statistics clearly showed how much more serious was the prognosis in joint fractures. And in the present table we note that whereas in the case of the shafts of the leg bones bad function follows bad anatomy only in 45 per cent of cases (non-operative), yet in the case of ankle fractures bad anatomical results ensure bad function in 92 per cent of cases. In the shafts of the leg bones a moderate anatomical result secures good function in 58 per cent of cases, whereas in the case of ankle fractures a moderate anatomical result secures good function in less than a third of the cases (31 per cent). The average period of disability in our combined figures (1915 and 1921) shows a slight improvement; in 1915 we found the average period of disability for both shaft and ankle fractures was nearly five months (four and nine-tenths); in the combined statistics, based on 556 cases, this is reduced to four and seven- TABLE XX.—AVERAGE PERIOD OF DISABILITY (COMPOUND FRACTURES) Average Cases Average period of terminated period of disability under 12 disability Site of fracture. All cases. (months). (months). (months). Tibia or tibia and fibula, shafts 82 7.0 66 5-4 Ankle 8 5-7 8 5-7 90 74 TABLE XXI.—DOES GOOD ANATOMICAL RESULT LESSEN THE PERIOD OF DISABILITY? COMPOUND FRACTURES OF THE LEG BONES (ALL FORMS) Anatomical Under Under Under Under Over result. Total. 3 months. 6 months. 9 months. 1 year. 1 year. Good . 39 ( 43%) 8 (20%) 21 (54%) 5 (13%) I ( 3%) 4(iO%) Moderate 37 ( 41%) 3 ( 8%) 15 (39%) 11 (30%) I ( 4%) 7 (19%) Bad . 14 ( 16%) .... 5 (36%) 2 (14%) 2 (14%) 5 (36%) 90(100%) II (13%) 41 (45%) 18 (20%) 4 ( 4%) 16(18%) ashhurst: fractures of the tibia and fibula 123 tenths months for fractures of the shafts of the leg bones and to four months only in the case of ankle fractures. Or if only those cases are included in which the period of disability was less than twelve months the figures show an average of four and one-fifth months for the shaft fractures and only three and a half months for the ankle fractures. These later investigations confirm our former conclusions that patients with fractures of the lower extremity whose period of disability exceeds twelve months usually are permanently crippled. Table X indicates very positively that a good anatomical result lessens the period of disability: 88 per cent of patients with good anatomical results have a period of diability of less than six months; whereas only 69 per cent of those with a mod- erate anatomical result are able to resume their usual occupations within that space of time. Comparative Results Shown in American and British Statistics. In Tables XI, XII and XIII are analyzed in parallel columns the results now recorded by the Fracture Committee of the American Surgical Association and those published in 1912 by the Fracture Commission of the British Medical Association. It will be seen that though the latter figures are based on more than twice as many case reports as the American figures, yet that the gross results are sensibly the same, with a small margin to the credit of the American statistics (76 per cent good results compared to 71 per cent good results of the British cases). While the total number of cases of operative treatment is rather too small to make the results very significant (especially in the case of ankle fractures) the great difference in the proportion of good results secured in the non-operative treatment of ankle fractures certainly is worthy of comment. The British statistics show that only 49 per cent of their patients with ankle fractures secured good function, while 82 per cent of American patients recovered without disability; and these figures are the more noteworthy because the number of end-results recorded is very nearly the same in each case (255 British and 224 American). It is possible 124 ashhurst: fractures of the tibia and fibula that our methods of treatment are more efficient now than those employed by the British a decade ago, and that the interest in fractures aroused in this country by the previous report of this committee is beginning to tell on the end-results; but it seems more likely that in this country more accurate diagnosis has been secured through the more general use of the roentgen ray during the past nine years, and that on this account the American figures include more cases of fracture without dis- placement than do the British statistics. Compound Fractures of the Leg Bones. Our tables include 301 cases: 184 non-operative and 117 operative. Good anatomical results were secured only in 58 per cent of cases and good function only in 62 per cent; but of the 167 patients in whom anatomical reposition of the fragments was secured (or in whom no displacement existed) no less than 93 per cent recovered without disability. And, as in the case of simple fractures of the leg bones, it is worthy of comment that even with operative treatment only half the cases (58 out of hi patients) secured good anatomical results and only a little more than half (56 per cent) secured good function; but that in 54 out of 58 patients, or in 94 per cent of those in whom the surgeon succeeded in obtaining anatomical reposition of the fragments, recovery without any disability is recorded. And the impor- tance of securing accurate anatomical reposition of the frag- ments is even more apparent in the cases of compound fractures than was the case in simple fractures. In the latter even a moderate anatomical result will allow good function to result in more than half the cases; but in compound fractures only one-quarter of the patients will secure good function unless accurate reduction is secured. The average period of disability for patients with compound fractures of the shafts of the leg bones is seven months and for those of the ankle five and seven-tenths months. If good anatomical results are obtained, 74 per cent of patients can return to work in less than six months, compared with not more than 47 per cent of patients if only moderate anatomical results are secured. ashhurst: fractures of the tibia and fibula 125 Conclusions. These investigations emphasize anew the importance of securing anatomical reposition of the fragments not only to secure ultimate good function, but even more to lessen the period of disability. The means of securing reduc- tion naturally vary; in comparatively few cases can gross dis- placements of the leg bones be corrected by manipulation alone, even with the patient under the influence of a general anesthetic; and such manipulations may do more damage to the soft parts than open operation with direct exposure of the fracture. This objection applies even to reduction by mechanical traction if the latter is employed for rapid reduction. On the other hand continuous traction (without the use of an anesthetic except for the primary application of the apparatus) prolonged over a period of several days frequently will secure reduction of over- riding and angulation in cases in which attempts at rapid reduc- tion end in failure. Such continuous traction is to be continued after reduction has been secured until the process of union is so far advanced as to prevent recurrence of deformity. This period varies from ten days to three weeks. For such gradual reduction the reporter believes that for fractures of the leg skeletal traction by means of the Codivilla or the Steinmann nail is more readily applied and more efficient in the hands of the operating surgeon than is traction secured by means of a Sinclair skate or other indirect apparatus. Skeletal traction is especially indicated in cases of comminuted fractures, simple or compound, in which open fixation of so many fragments would prove diffi- cult or dangerous. In irreducible fractures (whether simple or compound), with two or three fragments only, fixation by a steel plate after open reduction is preferred; but for fractures whose obliquity exceeds twice the diameter of the bone, fixation by encircling bands or wires is more efficient. Ankle fractures, even more imperatively than fractures of the shafts of the leg bones, require accurate anatomical reduction. The value of the flexed position of the limb in permitting reduc- tion of the fragments (originally advocated by Pott) is not sufficiently appreciated at the present day; nor is the aid to 126 ashhurst: fractures of the tibia and fibula be derived from tenotomy of the tendon of Achilles. In cases in which one or two well-directed attempts under anesthesia fail to secure reduction of the fracture, open reduction should be done, and in most cases direct fixation of the exposed fragments is requisite. Finally, the investigations of this committee merely point the way for further improvements in our means of treating fractures of the leg bones. No surgeon having such fractures under his care should rest satisfied until he can publish a series of end-results which in the aggregate will be superior to those recorded in this report, for these are merely the average. FRACTURES OF THE FEMUR By W. L. ESTES, M.D. BETHLEHEM, PA. On account of irregularity in the notes and the absence of much important data a large number of the cases sent in for this report could not be used. Other report sheets were not full; it has required much time and labor to cull from them some of the information the committee set out to ascertain. There were 584 cases of simple and 70 cases of compound fractures of the femur reported; they were followed up and the final results were ascertained. These cases are used and analyzed and form the basis of the tables. The effort has been made to have the tables full enough and so diversified that the figures themselves will tell the various points one would like to know, especially in regard to the average result of the treatment of fractures of the femur during the last five years. Unfortunately one of the essential points, namely, method of treatment, has rarely been noted with sufficient accuracy to be made of any great use, except that it is always noted whether a case was treated by the non-operative or closed method or by the operative or open method. The cases were divided as follows: Fractures of the neck of the femur . . 100 Fractures through the trochanters 19 Fractures of the shaft 457 Fractures of the condyles 8 Total . v 584 128 ESTES: FRACTURES OF THE FEMUR There were 448 cases treated by the non-operative method and 136 by the operative method (23.28 per cent of the cases). Indirect violence in civil life causes 80.6 per cent of all fractures of the femur. The region involved most frequently in the age period: One to fifteen years is the middle third. Fifteen to forty-five years is also the middle third. Forty-five to sixty years is the neck. Sixty years and over is also the neck. Transverse fractures are much more frequent than oblique or other forms of fractures. Spiral and longitudinal fractures of the femur are rare. The average shortening before reduction was attempted in fractures of the shaft of the femur is 3.5 cm. The average shortening after reduction is 1.5 cm. Shortening after a fracture of the shaft of the femur as much as 2 cm. means the fragments are not apposed end to end; there must be some overlapping. It should be remembered, however, that uninjured femora are frequently of unequal lengths; they not unusually vary as much as 1 cm. Shortening determined by the ordinary methods of measuring extremities is misleading and unreliable. Properly taken skiagrams are much more reliable indices of good anatomi- cal results than shortening. The two methods should both be used to determine the condition. Many cases have demonstrated that as much as 2 cm. shortening by measurements does not prevent good functional results. On the other hand it has been shown that by traction methods the injured extremity may be extended even beyond the measured length of the uninjured member, and yet the fluoroscope will show inaccurate align- ment of the fragments. Union in such a position could never rightly be called a good anatomical result. In a series of over 200 cases in which measurements showed no or very little shortening, roentgen-ray examination showed only 2 per cent of accurate anatomical results. Treatment. It is interesting to note that since the war American surgeons have practically discarded the old Buck’s ESTES: FRACTURES OF THE FEMUR 129 traction method and are using for the purpose of extension some form of suspension with traction. A Balkan frame or some modification of this apparatus is the popular one now. Also traction directly on the distal fragment by means of the Steinmann nail, or by some form of tongs, is much more frequently employed than formerly. The apparatus which proved invaluable in the military service, and which stands out now as the most useful of splints for treating fractures of the femur and humerus, is the Thomas splint. Easily adapted to varying conditions, and efficient in the majority of cases, the Thomas splint is the apparatus which the general practitioner and the surgeon who must treat a fractured shaft of the femur outside a hospital may use with efficiency, and if properly handled, with confident expectation of a good functional result. Some very late data, obtained from one of the leading hospi- tals in the United States, are available fortunately for comparison in regard to the improved results of treatment of fractures of the femur. The series of cases is only 57, but is sufficient to bring out some salient points. There were 16 fractures of the neck and 41 fractures of the shaft. The Thomas splint was used in 24 of the cases of fracture of the shaft, sometimes with and sometimes without a Balkan frame. The Balkan frame with suspension-traction was used in 6 cases, and the other 11 cases were variously treated. No Buck extension, however, was used. For comparison the following figures showing the result of the older and newer methods will be interesting and instructive. In the much larger series of cases treated by the older methods the results were as follows: Non-Operative Cases i to 15 years Recovered under 6 months. 83 per cent Recovered over 6 months. 17 per cent 15 to 45 “ . . . . . . 46 U 54 45 to 60 “ ... • • • 53 U 47 Over 60 “ ... ... 14 u 86 “ 130 ESTES: FRACTURES OF THE FEMUR New Treatment Recovered under Recovered over 6 months. 6 months. i to 15 years .... . 100.0 per cent 15 to 45 “ .... . 28.5 “ 71.5 per cent Over 60 “ (no cases). It is evident that the result in childhood has been a quicker recovery by the methods of suspension and traction. This may be explained perhaps by the difference in rating “ability to work.” In this day of compensation laws the period of disability for adult cases may be reckoned a little longer than formerly. Taken, however, solely as a matter of statistics the newer methods do not produce earlier recovery in the class of men whose usefulness counts most in industrial life. These ratings, be it understood, are for the periods of disability, and in this report period of disability is taken to mean the time from the instant of injury to that of the returning to work. No surgeon reporting fractures of the femur has noted the use of some efficient form of caliper after union of the fragments when the patient begins to walk about. Calipers should be used for some weeks in order to prevent bending or other distortion at the seat of fracture as soon as the vertical position and weight-bearing is permitted. Results of Fracture of the Femur. These results are rated as anatomical and functional, and good, moderate and bad. A good anatomical result is taken to mean firm bony union of the well-apposed fragments in the proper axis of the limb. A good functional result is taken to mean no persistent stiff- ness of joints or resulting skeletal deformity, and unimpaired ability to do active work or exercise without pain or discomfort. Table III shows the results of 447 non-operative cases. It will be observed that out of this number there were 180 (42 per cent) good anatomical results, but of these 180 good anatomical results only 157 (87 per cent) proved good functional results: 18 (10 per cent) were moderate and 5 (3 per cent) were positively bad results. Omitting the analysis of the moderate anatomical ESTES: FRACTURES OF THE FEMUR 131 results, and going directly to the bad, it will be seen that out of 65 positively bad anatomical results there followed 14 good and 15 moderate functional results, or 44.6 per cent of these bad anatomical results were followed by useful function. The operative cases in Table IV show this point also, but to a less degree. The results of a fractured femur may be rated in two ways: 1. Scientifically. 2. Industrially. 1. Scientific rating takes in (a) the restoration of anatomical integrity and (b) restoration of full function of the part. 2. Industrial rating concerns itself solely with restoration of good function. That these two ratings must necessarily be the same is con- clusively disproved by practically all the tables. Reference to Tables III and IV, however, will show the point conclusively. It is shown by Table III that of 447 cases of fracture of the femur treated by non-operative methods, 180, or 40 per cent, had good anatomical results; 180, or 40 per cent, had moderate anatomical results, and of these 360 cases, 254, or 70.5 per cent, were restored to usefulness, viz.: 157 had good functional results; 58, or 13 per cent, had bad functional results, and 22, or 4.9 per cent, died. This means that surgeons of the United States and Canada by average non-operative treatment obtain good functional results in 62 per cent of their cases of fracture of the femur in all regions and in all age periods; 23 per cent have moderate functional results—these may be considered as not fully restored but able to do some useful work. The death-rate of this series is a little too high to be representative. This is explained by the fact that these records were culled from over 1000 records altogether and used because the data were full enough to give most of the desired information on the blanks. To check this death-rate another series of over 700 cases was analyzed and the death- rate was found to be 3.69 per cent. This is too low evidently. The true death-rate is probably the mean of these two series 132 ESTES: FRACTURES OF THE FEMUR of cases, viz.: about 4 per cent. All these deaths occurred in aged people. To ascertain the region which when fractured is followed by most deaths an analysis of 131 cases was made as follows: Case3. Deaths Fractures of the neck of the femur . . . • 31 12 Fractures through the trochanters • 7 7 Fractures of the upper one-third of shaft . 18 2 Fractures of the middle one-third of shaft . . 61 2 Fractures of the lower one-third of shaft . 14 0 Total • 131 23 One must conclude, therefore, that fractures of the upper segments of the femur with the usual concomitant injuries are for aged people very serious injuries indeed. The causes of death were stated as follows: Cases. Decubitus and sepsis 3 Gangrene and sepsis I Shock and exhaustion 16 Pneumonia 2 Pulmonary embolism I Operative Treatment. There were 137 operative cases out of a total of 584 cases; 23.28 per cent of the cases of fractures of all regions of the femur were treated by the operative method. Only 15 of the operative cases were fractures involving the extremities of the bone. There were 7 operations for fractures of the neck. There were 4 operations for fractures through the trochanters. There were 4 operations for fractures of the condyles. There were 121 operations for fractures of the shaft. Analysis of the cases shows exactly twice as many operations were done for fractures of the middle third of the shaft as for both the upper and lower third together. Fixation of the bone fragments by some manner of rigid plate was usually the method employed in these cases. Only one death is reported in the series of 136 operative cases; this fatal result was on account of sepsis. ESTES: FRACTURES OF THE FEMUR 133 Table IV gives the results in the operative cases. It is shown that though the anatomical results are rated good in 68 per cent of the cases as against 40 per cent in the non-operative method, good functional result is only 77 per cent as compared with 87 per cent of the non-operative cases. Further analysis given in the later tables shows comparatively few cases in the age period one to fifteen years were treated by the operative method; the operative cases were chiefly adult cases. Besides, these cases were operated, in nearly every instance, only because non-opera- tive methods were unsuccessful in obtaining reduction. They were difficult and sometimes complicated cases. It could not reasonably be expected, therefore, that the ultimate result functionally should be as good as the uncomplicated non-opera- tive cases. The interesting point is, however, that of the 94 cases which has good anatomical results, only 73, or 77 per cent, of them obtained good functional results. The moderate functional result ratio is a little higher than the non-operative methods, namely, 23 per cent against 10 per cent. These figures mean that though better anatomical results may be obtained by operative methods, functional results are not as good. Table XIV shows the average period of disability after opera- tive methods also is a little longer. Only one death is recorded in this series of 137 operative cases; this occurred from infection. In another series of 146 cases, 2 deaths were reported. Even this is too low as indicative of the results obtained by the average surgeon. The true death- rate following operative treatment of fracture of the femur is about 6 per cent. One must bear in mind that very few children and no senile cases were operated upon. Individuals in adult life, and pre- sumably in good physical condition, were those treated by the operative method. Good operative recoveries in such cases are to be expected. One marvels, however, that only 1 case of infection was reported in this series of 137 cases. It is noteworthy that in non-operative cases the functional 134 ESTES: FRACTURES OF THE FEMUR results from the moderate anatomical results is much better than in operative cases. In order to obtain good results in operative cases it is very important that good anatomical resti- tution be obtained. It is shown in Table XV that operative cases have better results when the operation is done soon after the fracture. The series of 125 cases analyzed seem, however, to show that when the operation is done not later than eight to fourteen days after the injury the results are as good as when the opera- tion is done the first week. The period of disability is, however, longer after the later operations. Period of Disability. The period of disability should be worked out separately for the age period one to fifteen years and for the years of adult life. In the first place, for purposes of reference and for industrial insurance companies, including compensation boards, the average time of disability for individuals in the working periods of their lives is the one desired to be established. In the second place the time of disability for children cannot be reckoned in the same manner as that for adults. As was stated before, the time of disability in this report is taken to mean the period from the instant of injury to the time the injured person is actually able to return to his former occupation or to some business requiring equal activity and endurance. Children, as a rule, have no occupation and they are able to go about on their feet and appear restored to full activity at a much earlier period than adults. Therefore, separate classification is made in reckoning periods of disability for the age period one to fifteen years and for all ages beyond fifteen years. For fractures of the entire femur (including all regions) the time of disability in non-operative cases in the period one to fifteen years is four and one-half months; for all other ages it is eight and one-fifth months. The operative cases show a little longer time of disability, namely, nine months, for adult cases. For compound fractures of all regions of the femur the average period of disability is eleven months. TABULATED REPORT ON FRACTURES OF THE FEMUR TABLE I.—SUMMARY OF ALL CASES Total. Non-operative. Operative. Femur, neck . . IOO 93 7 Femur, trochanter . • • 19 15 4 Femur, shaft . • • 457 335 122 Femur, condyles . . . 8 4 4 584 447 137 TABLE II Anatomical result. Total. .Good Functional result. Moderate. Bad. Good Moderate . Bad . • 274 (47%) • 205 (35%) • 82 (14%) 228 (83%) IOI (49%) 17(21%) 41 (15%) 85 (42%) 22 (26%) 5 ( 2%) 19 ( 9%) 43 (53%) Died 561 (96%) • 23 ( 4%) 346(61%) 148 (27%) 67 (12%) 584 (100%) TABLE III.—NON-OPERATIVE CASES Anatomical result. Good Moderate . Bad . Total. . 180 (42%) . 180(42%) • 65 (I5%) Good. 157 (87%) 97 (54%) 14(21%) Functional result. Moderate. 18 (10%) 66 (36%) 15 (23%) Bad. 5 ( 3%) 17 ( 9%) 36 (55%) Died 425 (99%) . 22 (4.9%) 268 (62%) 99 (23%) 58 (13%) 447 TABLE IV.-OPERATIVE CASES Anatomical result. Good Moderate . Bad . Total. • 94 (69%) • 25 (18%) 17(12%) Good. 73 (77%) 8(32%) 3 (17%) Functional result. Moderate. 21 (23%) 15 (60%) 4 (24%) Bad. 0 2 ( 8%) 10 (59%) Died 136 (99%) 1 (0.6%) 84(61%) 40 (29%) 12 (10%) 137 136 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE V.-INFLUENCE OF AGE ON THE FUNCTIONAL RESULT Anatomical result. Total. Good. Functional result. Moderate. Bad. TOTAL NON-OPERATIVE AND OPERATIVE CASES I to 15 years: Good . 35 ( 68%) 32 ( 91%) 3 ( 8%) O Moderate 14 ( 27%) 10 ( 71%) 4 (28%) 0 Bad . 2 ( 3%) 2 (100%) 0 0 51 (100%) 44 ( 86%) 7 (13%) O Deaths . 15 to 45 years: 0 Good . 15 ( 50%) 14 ( 93%) 1 ( 6%) 0 Moderate 14 ( 46%) 9 ( 64%) 4 (28%) I( 7%) Bad . . . i( 3%) 0 0 1 (100%) 30 ( 99%) 23 ( 77%) 5 (16%) 2 ( 6%) Deaths . 45 to 60 years: 0 Good . 6 ( 35%) 6 (100%) 0 0 Moderate 10 ( 58%) 4 ( 40%) 6 (60%) 0 Bad . i( 5% 0 0 1 (100%) 17 ( 98%) 10 ( 58%) 6 (36%) 1 ( 6%) Deaths1 . 5 ( 22%) 22 Over 60 years: Good . 2 ( 20%) 0 1 (50%) 1 ( 50%) Moderate 5 ( 50%) 1 ( 20%) 4 (80%) 0 Bad . . . \ 3 ( 30%) 0 0 3 (100%) 10(100%) 1 ( 10%) 5 (50%) 4 ( 40%) Deaths2 . 18 ( 64%) 28 All over 15 years: Good . 23 ( 40%) 20 ( 87%) 2 ( 8%) i( 4%) Moderate 29 ( 50%) 14 ( 48%) 14 (48%) i( 4%) Bad . 5 ( 8%) 0 0 5 (100%) 57 ( 98%) 34 ( 59%) 16 (28%) 7 ( 12%) Deaths . 23 ( 28%) 80 1 3 shock, x gangrene, i pneumonia. ! Shock and sepsis. ESTES! REPORT ON PRACTURES OE THE TEMUR 137 TABLE VI.—INFLUENCE OF AGE ON NON-OPERATIVE TREATMENT Anatomical result. Total. Good. Functional result. Moderate. Bad. I to 15 years: Good . Moderate Bad . 26 ( 66%) 11 ( 28%) 2 ( 5%) 24 ( 92%) 9 ( 81%) 2 (100%) 1 ( 3%) 2 (18%) 0 i( 3%) 0 0 39 ( 99%) 35 ( 90%) 3 ( 8%) i( 2%) Deaths . 0 15 to 45 years: Good . Moderate Bad . 11 ( 46%) 12 ( 50%) i( 4%) 9 ( 81%) 11 ( 91%) 0 2 (19%) 1 ( 8%) 0 0 0 1 (100%) 24 (100%) 20 ( 83%) 3(12%) i( 4%) Deaths . 0 45 to 60 years: Good Moderate Bad . 5 ( 33%) 9 ( 60%) i( 6%) 5 (100%) 5 ( 55%) 0 0 4 (44%) 0 0 0 1 (100%) Deaths . . 15 ( 99%) 4 ( 21%) 10 ( 66%) 4 (26%) i( 6%) 19 Over 60 years: Good . Moderate Bad . . . 2 ( 25%) 4 ( 50%) 2 ( 25%) 0 1 ( 25%) 0 1 (50%) 3 (75%) 0 1 ( 50%) 0 2 (100%) Deaths . 8 (100%) 18 ( 69%) 1 ( 12%) 4 (50%) 3 ( 38%) 26 All over 15 years: Good . Moderate Bad . 18 ( 38%) 25 ( 53%) 4 ( 8%) 14 ( 78%) 17 ( 68%) 0 3 (16%) 8 (32%) 0 i( 6%) 0 4 (100%) Deaths . 47 ( 99%) 22 ( 31%) 31 ( 65%) 11 (23%) 5 ( 10%) 69 138 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE VII.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical Functional result. result. Total. Good. Moderate. Bad. I to 15 years: Good . 9 ( 75%) 8 ( 90%) I ( 10%) 0 Moderate 3 ( 25%) i ( 33%) 2 ( 66%) O Bad . 0 0 0 0 12 (100%) 9 ( 75%) 3 ( 25%) 0 Deaths . 0 15 to 45 years: Good 4 ( 66%) 4 (100%) 0 O Moderate 2 ( 33%) 0 2 (100%) O Bad . 0 0 0 O 6 ( 99%) 4 (66%) 2 (33%) Deaths . 0 45 to 60 years: Good 1 ( 50%) 1 (100%) 0 0 Moderate 1 ( 50%) 0 1 (100%) 0 Bad . 0 0 0 O 2 (100%) 1 ( 50%) 1 ( 50%) 0 Deaths (sepsis) 1 (33%) 3 • Over 60 years: Good . 0 0 0 0 Moderate 1 ( 50%) 0 1 (100%) 0 Bad . 1 ( 50%) 0 0 I (100%) 2 (100%) 0 1 ( 50%) I ( 50%) Deaths . 0 All over 15 years: Good 5 ( 40%) 5 (100%) 0 0 Moderate 4 ( 50%) 0 4 (100%) 0 Bad . 1 ( 10%) 0 0 I (100%) 10 (100%) 5 ( 50%) 4 ( 40%) I ( 10%) Deaths, sepsis i( 9%) 11 TABLE VIII.—SUMMARY OF FRACTURES OF THE SHAFT OF THE FEMUR, INCLUDING ALL REGIONS Anatomical result. Total. Functional result. Good. Moderate. Bad. NON-OPERATIVE Good . 152 ( 46%) 138 (90%) 13 ( 8%) I (0.2%) Moderate . ■ 129 ( 38%) 82 (63%) 42 (33%) 5 ( 4%) Bad . . . 51 ( 16%) 14(27%) 13 (25%) 24 (48%) 332 (100%) 234 (70%) 68 (20%) 30 (10%) OPERATIVE Good • 84 ( 69%) 69 (82%) 15 (18%) 0 Moderate . ■ • 21 ( 17%) 10 (48%) 9 (43%) 2 ( 9%) Bad . ■ . I6( 14%) 3 (i9%) 3 (19%) 10(62%) 121 (100%) 82 (67%) 27 (22%) 12 (10%) ALL CASES Good ■ • 236 ( 52%) 207 (87%) 28 (11%) 1 (0.2%) Moderate • • 150 ( 34%) 92 (6l%) 5i (34%) 7 ( 5%) Bad . . . . 67 ( 14%) 17 (25%) 16(24%) 34 (50%) 453 (100%) 316 (69%) 95 (20%) 42 (10%) Deaths: Non-operative, 3 (1 sepsis, 1 gangrene , 1 decubitus and sepsis). Operative, 1 (sepsis). TABLE IX—SUMMARY OF FRACTURES OF THE NECK OF THE FEMUR Anatomical result. Good Moderate . Bad . . . Total. • 23 ( 28%) • 44 ( 54%) . 14 ( 18%) Functional result. Good. Moderate. NON-OPERATIVE 14 (60%) 6 (26%) 9 (20%) 25 (57%) 2 (14%) 9 (64%) Bad. 3 (H%) 10(23%) 3 (22%) 81 (100%) 25 (30%) 40 (50%) 16(19%) OPERATIVE Good . 5(7i%) 2 (40%) 3 ( 60%) 0 Moderate . • 2 ( 29%) 0 2 (100%) 0 Bad . . . 0 0 0 0 7 (100%) 2 (29%) 5 (7i%) 0 ALL CASES Good • 28 ( 52%) 16(57%) 9 (33%) 3 (I0%) Moderate . . 46 ( 32%) 9 (19%) 27 (58%) 10 (23%) Bad . . . . 14 ( 16%) 2 (14%) 9 (64%) 3 (22%) 88(100%) 27 (30%) 45 (5i%) 16(19%) Deaths: Non-operative, 12 (shock and old age). Deaths: Operative, 0. 140 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE X.-SHOWING COMPARISON BETWEEN NON-OPERATIVE AND OPERATIVE CASES Functional result. Total. Good. Moderate. Bad. Anatomical result. Non- Non- Non- Non- oper- Oper- oper- Oper- oper- Oper- oper- Oper- ative. ative. ative. ative. ative. ative. ative. ative. Neck Good 23 5 14 2 6 3 3 0 Moderate 44 2 9 0 25 2 10 0 Bad .... 14 0 2 0 9 0 3 0 Died . 12 Total 93 7 25 2 40 5 16 0 Per cent. 100 100 30 28 50 7i 19 0 Trochanters Good 4 1 3 1 0 0 1 0 Moderate 4 2 1 0 2 2 1 0 Bad .... 0 1 0 0 0 1 0 0 Died . 7 Total 15 4 4 1 2 3 2 0 Per cent. 100 100 50 25 25 75 25 0 Shaft Good 152 84 138 69 13 15 1 0 Moderate . 129 21 82 10 42 9 5 2 Bad . . . . 5i 16 14 3 13 3 24 10 Died . 3 1 Total 335 122 234 82 68 27 30 12 Per cent. 100 100 70 67 20 22 9 9 Condyles Good 1 4 1 1 0 3 0 0 Moderate . 3 0 2 0 0 0 1 0 Bad .... 0 0 0 0 0 0 0 0 Total 4 4 3 1 0 3 1 0 Per cent. 100 100 75 25 0 75 25 0 Entire Grand total 425 136 266 86 no 38 49 12 Deaths . 22 I Per cent. 100 100 62 63 24 28 11 8 Table XI shows that 37 per cent, of the good anatomical results, 27 per cent, of the moderate anatomical results and 19 per cent, of the bad anatomical results have a disability of less ESTES: REPORT ON FRACTURES OF THE FEMUR 141 than six months. It is evident, therefore, that good anatomical results very markedly lessen the period of disability. Anatomical result. Total. Period of disability. Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. Femur (all regions) Good Moderate .... Bad 178 (50%) 122 (34%) 55 (16%) 82 (46%) 32 (25%) 9 (16%) 51 (28%) 36 (30%) 12 (22%) 9 ( 6%) 17 d4%) 4 ( 7%) 28 (15%) 17 (i4%) 3 ( 6%) 8 ( 5%) 20(16%) 27 (49%) 355 (100%) 123 (35%) 99 (27%) 30 ( 8%) 48 (14%) 55 (16%) TABLE XT -DOES GOOD ANATOMICAL RESULT LESSEN THE PERIOD OF DISABILITY? Average period of disability for adults, 8.2 months. Average period of disability for children under fifteen years, 4.5 months. 142 ESTES: REPORT ON FRACTURES OF THE FEMUR Period of disability and functional results. Anatomical Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. results. Total. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. i to 15 Good 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 years Moderate 2 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 Bad 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 IS to 45 Good 4 1 0 0 1 0 0 0 0 0 I 1 0 0 0 0 years Good 7 0 0 0 1 0 0 0 0 0 0 0 1 0 0 I Bad i 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 45 to 6o Good 7 2 0 0 1 0 0 1 0 0 0 2 0 0 1 0 years Moderate 13 3 0 0 0 X 0 0 1 0 I 1 0 0 4 2 Bad 5 0 0 0 0 0 0 0 0 1 0 0 0 0 0 4 Over 6o Good 7 0 X 0 2 1 0 0 0 0 0 0 0 0 1 2 years Moderate 15 0 0 0 0 6 1 0 1 0 0 3 0 0 2 2 Bad 5 0 0 0 0 1 1 0 0 0 0 0 0 0 0 3 All ages Good 22 7 1 0 4 1 0 I 0 0 1 3 0 0 2 2 Moderate 37 3 4 1 2 7 I 0 2 0 I 4 1 0 6 5 Bad 11 0 0 0 0 i 1 0 0 I 0 0 0 0 0 8 TABLE XII.—FEMUR, NECK ESTES: REPORT ON FRACTURES OF THE FEMUR 143 Period of disability and functional result. Anatomical Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. result. Total. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. i to 15 Good 89 54 2 0 12 3 0 3 0 0 13 0 0 2 0 0 years Moderate 28 14 4 0 6 0 0 0 0 0 3 0 0 0 1 0 Bad 10 4 0 4 0 0 1 0 0 0 0 0 0 1 0 0 15 to 45 Good 47 9 0 0 19 3 0 3 1 0 10 0 0 1 1 0 years Moderate 37 3 0 0 11 2 0 9 4 1 I 6 0 0 O 0 Bad 15 0 0 0 5 O 0 3 0 0 0 2 0 1 I 3 45 to 60 Good 15 6 0 0 5 0 0 1 0 0 1 1 0 0 1 0 years Moderate 14 O 0 0 4 4 0 0 0 0 2 0 0 0 2 2 Bad 10 I 0 0 1 2 0 0 0 0 0 0 0 0 0 6 Over 60 Good 4 0 0 0 2 0 0 0 0 0 1 0 0 0 1 0 years Moderate 7 I 0 0 I 0 0 0 0 0 1 1 0 0 2 1 Bad 9 0 0 0 0 0 1 0 0 0 0 1 0 0 1 6 All ages Good 155 69 2 0 3» 6 0 7 1 0 25 1 0 3 3 0 Moderate 86 18 4 0 22 6 0 9 4 1 7 7 0 0 5 3 Bad 44 5 0 4 6 2 2 3 0 0 0 3 0 2 2 15 Average period of disability for adult cases, 8.2 months. Average period of disability for children one to fifteen years, 4.5 months. TABLE XIII.—FEMUR, SHAFT 144 ESTES: REPORT ON FRACTURES OF THE FEMUR Age. Number of cases. Period of disability. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. i to 15 years 127 Non-operative Operative .... 99 (78%) 28(22%) 66 (67%) 17 (62%) 16(16%) 4d4%) 3 (10%) 16 (16%) 1 ( 4%) 1 ( 1%) 3 (10%) 15 to 45 years 99 Non-operative _ Operative .... 66 (67%) 33 (33%) 6 ( 9%) 6 (18%) 24 (37%) 16 (48%) 16 (24%) 5 (i5%) 16 (24%) 4 (13%) 4 ( 6%) 2 ( 6%) 45 to 60 years 39 ' Non-operative k Operative .... 31 (79%) 8 (21%) 7 (23%) 2 (25%) 10(30%) 1 (12%) 4(i3%) 0 3 (n%) 1 (12%) 7 (23%) 4 (50%) Over 60 years 20 r Non-operative k Operative .... 16 (80%) 4(20%) 1 ( 7%) 0 x ( 7%) 3 (75%) 0 0 3 (18%) 1 (25%) 11 (68%) 0 All ages 285 f Non-operative \ Operative .... 212 (75%) 73 (25%) 80(38%) 25 (35%) 51 (24%) 24 (33%) 20 ( 9%) 8 (11%) 38 (18%) 7 ( 9%) 23 (10%) 9(12%) TABLE XIV.—FEMUR, SHAFT. OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT Deaths: Non-operative, 4; operative, o. Average period of disability for non-operative adult cases, 8.2 months. Average period of disability for operative adult cases, 9.0 months. ESTES: REPORT ON FRACTURES OF THE FEMUR 145 TABLE XV.—INFLUENCE ON RESULT OF TIME ELAPSING BETWEEN INJURY AND OPERATION (FEMUR) Ages, years. Date of operation, days. Anatomical position. Functional result. i to IS IS to 45 45 and over. 0 to 7 8 to 14 15 to 21 22 to 28 Good. Mod. Bad. 48 17 Good ... 16 Moderate . 1 Bad ... 0 16 1 0 16 Good . . .15 Moderate . 1 Bad ... 0 15 1 0 7 Good ... 7 Moderate . 0 Bad ... 0 7 0 0 8 Good ... 0 Moderate . 8 Bad ... 0 0 8 0 So 18 Good ... 17 Moderate . 1 Bad ... 0 17 I 0 3 Good ... 2 Moderate . 1 Bad ... 0 2 1 0 29 Good ... 1 Moderate . 26 Bad ... 2 1 26 2 27 11 Good ... 5 Moderate . 16 Bad ... 0 5 6 0 16 Good ... 0 Moderate . 12 Bad ... 4 0 12 4 125 c ases 17 45 10 53 Good ... 63 Moderate . 56 Bad ... 6 63 56 6 146 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE XVI.—SUMMARY OF SIMPLE FRACTURES OF THE FEMUR IN THE SEVERAL REGIONS Femur. Number of cases. Non-operative. Operative Neck • 31 30 I Upper third . 18 13 5 Middle third . 6l 47 14 Lower third • H 11 3 Through trochanter . • 7 7 0 — — — 131 108 23 Deaths—Neck .... 12 12 0 Upper third 2 1 1 Middle third . 2 2 0 Lower third 0 0 0 Through trochanter • 7 7 0 23 22 1 Tables XVI to XXIV are the result of a study of 131 fractures of the femur to show the number of cases and comparative results of non-operative and operative treatment of fractures in the several regions of the femur. Non-operative cases, 108; operative cases, 23. The middle third shows by far the largest number of cases. That the neck is fractured very rarely except in senile individuals the tables show conclusively. Fractures of the femur are more frequent in the age period 1 to 15 years in all regions except the neck and trochanter. In this series of cases, except in very old individuals, good anatomical results in cases of fracture, in all regions, were followed by 100 per cent, good functional results in non-operative cases except in the lower third. The period of disability is a little less in non-operative cases. One must remember, however, that the operative method is used when the non-operative is not practicable or does not suffice to reduce or retain the fracture. Operative cases are therefore essentially more difficult cases and the condition for rapid union are not as good; however, the operation makes a ESTES: REPORT ON FRACTURES OF THE FEMUR 147 simple fracture a compound one. The trauma of the soft tissues, and especially the forcible manipulation of the fragments, undoubtedly retards bony union. Except two the deaths all occurred in senile cases and from fractures of the upper segments of the bone. This emphasizes the fact that fractures of the femur anywhere above the middle third are very serious injuries for aged patients. TABLE XVII—COMPARATIVE RESULTS OF OPERATIVE AND NON-OPERATIVE TREATMENT OF SIMPLE FRACTURES OF THE FEMUR IN THE SEVERAL REGIONS Anatomical Functional result. result. Total. Good. Moderate. Bad. Neck: NON-OPERATIVE Good . 7 ( 23%) 4 ( 57%) 2 ( 28%) I ( H%) Moderate . 8 ( 26%) 4 ( 50%) 4 ( 50%) O Bad . • 3 ( 10%) 0 0 3 (100%) Deaths . . 12 ( 40%) 30 ( 99%) 8 ( 50%) 6 ( 25%) 4 ( 23%) Neck: OPERATIVE Good . 0 0 I (100%) 0 Moderate 1 (100%) 0 0 0 Bad . 0 0 0 0 Deaths . 0 1 (100%) O 1 (100%) 0 TABLE XVIII Anatomical Functional result. result. Total. Good. Moderate. Bad. Upper Third: NON-OPERATIVE Good 6 ( 46%) 5 ( 82%) I (17%) 0 Moderate 6 ( 46%) 5 ( 82%) I (17%) 0 Bad . 0 0 0 0 Deaths . i( 8%) 13 (100%) 10 ( 83%) 2 (l6%) 0 Upper Third: OPERATIVE Good . 3 ( 60%) 2 ( 66%) I (33%) 0 Moderate 1 ( 20%) I (100%) 0 0 Bad . 0 0 0 0 Deaths . 1 ( 20%) 5 (100%) 3 ( 75%) I (25%) 0 148 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE XIX Functional result. Bad. result. Total. Good. Moderate. Middle Third: NON-OPERATIVE Good . 25 ( 53%) 25 (lOO%) 0 O Moderate 18 ( 38%) 12 ( 66%) 5 (27%) I ( 6%) Bad . 2 ( 4%) 2 (100%) 0 0 Deaths . 2 ( 4%) 47 ( 99%) 39 ( 86%) 5 (12%) 1 (25%) Middle Third: OPERATIVE Good 9 ( 64%) 9 (100%) 0 0 Moderate 5 ( 35%) 2 ( 40%) 3 (60%) 0 Bad . 0 0 0 0 Deaths . 0 14 ( 99%) II ( 78%) 3 (22%) 0 TABLE XX Functional result. result. Total. Good. Moderate. Bad. Lower Third: NON-OPERATIVE Good . . 6 ( 54%) 5 ( 82%) I (17%) O Moderate 4 ( 36%) 3 ( 75%) I (25%) 0 Bad . I ( 10%) 0 0 I (100%) Deaths . 0 II (100%) 8 ( 72%) 2 (18%) i( 9%) Lower Third: OPERATIVE Good 2 ( 66%) 2 (100%) 0 0 Moderate 0 0 0 0 Bad . 1 ( 33%) O 0 1 (100%) Deaths . 0 3 ( 99%) 2 ( 66%) 0 1 ( 33%) TABLE XXL—INFLUENCE OF AGE PERIOD IN THE DIFFERENT REGIONS Anatomical Functional result. result. Total. Good. Moderate. Bad. Neck: NON-OPERATIVE i to 15 years: Good . . 0 0 0 0 Moderate . 1 (100%) I (100%) O 0 Deaths . 0 0 0 0 1 (100%) I (100%) 0 0 Neck: NON-OPERATIVE 15 to 45 years: Good . . 2 (100%) 2 (100%) 0 O Moderate . 0 0 0 0 Bad . . 0 0 0 0 Deaths . 0 2 (100%) 2 (100%) 0 0 Neck: OPERATIVE 15 to 45 years: No cases reported. Neck: NON-OPERATIVE 45 to 60 years: Good . . 3 ( 30%) 3 (100%) 0 0 Moderate . 4 ( 40%) 2 ( 80%) 2 (50%) 0 Bad . 1 ( xo%) 0 0 I (100%) Deaths . 2 ( 20%) O 0 0 10 (100%) 5 ( 63%) 2 (25%) 1 ( 12%) Deaths: 2 pneumonia. Neck: OPERATIVE 45 to 60 years: Good . . 0 O O 0 Moderate . 1 (100%) O I (100%) 0 Bad . . 0 O 0 0 Deaths . 0 1 (100%) O I (100%) 0 Neck: NON-OPERATIVE Over 60 years: Good . . 2 ( 12%) 0 I ( 50%) I (50%) Moderate . 3(17%) 0 3 (100%) 0 Bad . . 2 ( 12%) O 0 2 (100%) Deaths1 . 10 ( 58%) 17 ( 99%) 0 4 ( 56%) 3 ( 43%) Neck: OPERATIVE Over 60 years: No cases reported. 1 Deaths from old age and shock. 150 ESTES: REPORT ON ERACTURES OF THE FEMUR TABLE XXII. Anatomical result. Upper Third: i to 15 years: Good . Moderate . Bad Deaths Functional result. Total. Good. Moderate. NON-OPERATIVE 5(71%) 5(ioo%) 0 2 ( 28%) I ( 50%) I ( 50%) OOO O Bad. 0 0 0 7 (.99%) 6 ( 85%) I ( H%) 0 Anatomical Functional result. result. Total. Good. Moderate. Bad. OPERATIVE Upper Third: 1 to 15 years: Good . O 0 0 0 Moderate . I (100%) 0 I (100%) O Bad . . 0 0 O 0 Deaths 0 I (100%) O I (100%) 0 NON-OPERATIVE Upper Third: 15 to 45 years: Good . 1 ( 33%) I (100%) 0 0 Moderate . 2 ( 66%) 2 (100%) 0 0 Bad 0 O 0 0 Deaths 0 3 ( 99%) 3 (100%) 0 0 OPERATIVE Upper Third: 15 to 45 years: Good . 2 (100%) 2 (100%) 0 0 Moderate . 0 0 0 0 Bad . . 0 0 0 0 Deaths 0 2 (100%) 2 (100%) 0 O ESTES: REPORT ON FRACTURES OF THE FEMUR 151 Upper Third: 45 to 60 years: Good . Moderate . Bad Deaths1 0 i ( 50%) 0 i ( 50%) NON-OPERATIVE 0 I (100%) 0 0 0 0 0 0 0 2 (100%) I (100%) O 0 OPERATIVE Upper Third: 45 to 60 years: Good . I (100%) I (100%) 0 0 Moderate . 0 O 0 0 Bad . . o 0 0 0 Deaths o I (100%) I (100%) 0 0 NON-OPERATIVE Upper Third: Over 60 years: Good . 0 O 0 0 Moderate . I ( 50%) I (100%) o 0 Bad . . 0 0 0 0 Deaths2 I I ( 50%) I (ioo%) 0 0 OPERATIVE Upper Third: Over 60 years: No cases reported. 1 Sepsis, i. 2 Diabetes. 152 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE XXIII Anatomical result. Middle Third: i to 15 years: Good . Moderate . Bad Deaths1 Total. Good. NON-OPERATIVE 19(61%) 19(100%) 8(26%) 5(51%) 2 ( 6%) 2 (lOO%) 2( 6%) Functional result. Moderate. 0 3 ( 38%) 0 Bad. 0 0 0 31 ( 99%) 26 ( 89%) 3 ( n%) O 1 1 gangrene, 1 sepsis. OPERATIVE Middle Third: 1 to 15 years: Good . 8 ( 60%) 8 (100%) 0 0 Moderate . 2 ( 40%) I ( 50%) 1 ( 50%) 0 Bad 0 O 0 0 Deaths 0 10(100%) 9 ( 90%) 1 ( 10%) 0 NON-OPERATIVE Middle Third: 15 to 45 years: Good . 5 ( 38%) 5 (100%) 0 0 Moderate . 8 ( 61%) 5 ( 62%) 2 ( 25%) I (13%) Bad 0 0 0 0 Deaths 0 13 ( 99%) xo ( 76%) 2 ( 15%) I ( 8%) OPERATIVE Middle Third: 15 to 45 years: Good . 1 ( 20%) I (100%) 0 0 Moderate . 2 ( 40%) 0 2 (100%) 0 Bad . . 0 0 0 0 Deaths1 2 ( 40%) 5 (100%) 1 ( 33%) 2 ( 66%) 0 1 1 gangrene, 1 shock. ESTES: REPORT ON FRACTURES OF THE FEMUR 153 Middle Third: 45 to 60 years: NON-OPERATIVE Good . I ( 20%) I (100%) 0 o Moderate . 2 ( 40%) 0 2(100%) 0 Bad . . Deaths1 0 2 ( 40%) 0 0 0 Middle Third: 45 to 60 years: 5 (ioo%) I ( 33%) OPERATIVE 2 ( 66%) 0 Good . o 0 0 0 Moderate . 0 O 0 0 Bad o 0 0 0 Deaths 0 O 0 0 Middle Third: Over 60 years: Middle Third: Over 60 years: 0 0 NON-OPERATIVE No cases reported. OPERATIVE 0 0 Good . 0 O 0 0 Moderate . I (100%) 0 I (100%) 0 Bad o 0 0 0 I (100%) 0 I (100%) 0 154 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE XXIV Anatomical result. Lower Third: i to 15 years: Good . Moderate . Bad Deaths Total. 2 (100%) 0 0 0 Good. NON-OPERATIVE I ( 50%) 0 0 Functional result. Moderate. I (50%) 0 0 Bad. 0 0 0 Lower Third: 1 to 15 years: Good . . Moderate . Bad Deaths 2 (100%) I (100%) O 0 0 I ( 50%) OPERATIVE I (lOO%) 0 O I (50%) 0 0 0 0 0 0 0 I (100%) I (lOO%) 0 0 NON-OPERATIVE Lower Third: 15 to 45 years: Good . 3 ( 50%) 3 (100%) 0 0 Moderate . 2 ( 33%) I ( 50%) I (50%) 0 Bad 1 ( 17%) O 0 I (100%) Deaths 0 0 0 0 6 (100%) 4 ( 66%) OPERATIVE I (16%) I (16%) Lower Third: 15 to 45 years: Good . 1 (100%) I (100%) 0 0 Moderate . 0 0 0 0 Bad 0 0 0 0 Deaths 0 1 (100%) I (100%) 0 0 ESTES: REPORT ON FRACTURES OF THE FEMUR 155 Lower Third: 45 to 60 years: Good . Moderate . Bad Deaths 1 ( 33%) 2 ( 66%) 0 0 NON-OPERATIVE I (100%) I ( 50%) 0 0 0 I (50%) 0 0 0 0 0 0 3 ( 99%) 2 ( 66%) I (33%) 0 OPERATIVE Lower Third: 45 to 60 years: No cases reported. TABLE XXV Anatomica result. Total. Good. Functional result. Moderate. Bad. NON-OPERATIVE Lower Third: Over 60 years: No cases reported. OPERATIVE Lower Third: Over 60 years: Good . . o o O 0 Moderate . o O O O Bad . . i (100%) I (100%) 0 O Deaths . o o 0 O I (100%) I (100%) 0 0 Time Elapsing between Injury and Efficient Treatment. In a series of 248 cases of fracture of the femur, 107 were treated within the first twelve hours; 31 between thirteen and twenty- four hours; 20 between twenty-five and forty-eight hours; 14 between forty-nine and seventy-two hours; 13 after seventy- three hours. In 63 cases the time was not stated. From a collection of 165 cases of fracture of the femur which were operated on it was possible to analyze more or less accu- rately a series of 125 cases and thus learn whether or not prompt attention markedly affected their results: 48 were children up to fifteen years; 17 were operated on within seven days, 16 156 ESTES: REPORT ON FRACTURES OF THE FEMUR secured normal function and i moderate function; 16 were oper- ated on within fourteen days, 15 secured normal function and 1 moderate function; 7 were operated on within twenty-one days and secured normal function; 8 were operated on after twenty- eight days and secured moderate function. Of the whole 48 patients the results were 80 per cent, good function and 20 per cent, moderate function. There were 50 cases between fifteen and forty-five years: 18 were operated on within fourteen days, 17 secured normal function and 1 moderate function; 3 were operated on within twenty-one days, 2 secured normal function and 1 moderate function; whereas 29 were operated on later and secured only normal function in 1, 26 moderate, and 2 bad function. Of the whole number, 50 patients, 40 per cent, secured normal function, 56 per cent, secured moderate function, and 4 per cent, secured bad function. There were 27 cases over forty-five years of age: 5 only secured normal function and all were operated on within four- teen days; 6 additional cases operated on within fourteen days secured only moderate function; whereas 16 cases were oper- ated on later than fourteen days and secured only moderate function in 12 cases and bad function in 4 cases. Of the whole number, 27 patients, 18 per cent, secured normal function, 67 per cent, moderate function, and 15 per cent, bad function. TABLE XXVI.—SUMMARY OF ALL CASES OF COMPOUND FRACTURES OF THE FEMUR Anatomical result. Total. Non-operative. Operative. Neck . . I I 0 Upper third .... . . 10 6 4 Middle third .... 7 13 Lower third .... ■ • 39 10 29 — — — 70 24 46 ESTES: REPORT ON FRACTURES OF THE FEMUR 157 TABLE XXVJI Anatomical result. Total. Good. Functional result. Moderate. Bad. Good Moderate . Bad . • 42 ( 66%) . 10 ( 16%) • 11(18%) 38 (90%) 7 (70%) 0 4(10%) 3 (30%) 9 (82%) 0 0 2 ( 18%) Deaths . 63 (100%) • 7 45 (7i%) 16 (25%) 2 ( 4%) 70 TABLE XXVIII Anatomical result. Total. Good. Functional result. Moderate. Bad. Good Moderate . Bad . • I6( 76%) . 4 ( 20%) . I ( 4%) NON-OPERATIVE 15 (93%) 2 (50%) O 1 ( 7%) 2 (50%) 0 0 0 I (100%) Deaths . 21 • 3 17(81%) 3 (H%) i( 5%) 24 TABLE XXIX Anatomical result Total.. Good. Functional result. Moderate. Bad. Good Moderate . Bad . . 26 ( 62%) • 6(14%) . 10 ( 24%) OPERATIVE 25 (97%) 5 (83%) 0 i ( 3%) 1 (17%) 2 (20%) 0 0 8 ( 80%) Deaths . 42 (100%) • 4 30 (73%) 4 ( 9%) 8 ( 18%) 46 158 ESTES: REPORT ON FRACTURES OF THE FEMUR TABLE XXX.—INFLUENCE OF AGE ON THE FUNCTIONAL RESULT Anatomical Functional result. result. Total. Good. Moderate. Bad. I to 15 years: Good 8 ( 66%) 8 (100%) 0 O Moderate i( 8%) I (100%) 0 O Bad . . . 3 ( 25%) 0 3 (100%) O 12 ( 99%) 9 ( 75%) 3 ( 25%) 0 Deaths, 3 (shock). 15 to 45 years: Good 32 ( 73%) 3i ( 97%) i( 3%) 0 Moderate 8 ( 18%) 5 ( 62%) 2 ( 25%) I ( 13%) Bad . . . 4 ( 9%) 0 0 4(100%) 44 (100%) 361, 82%) 3 ( 7%) 5 ( n%) Deaths, 1 (loss of blood). 45 to 60 years: Good 2 ( 33%) 2 (100%) 0 0 Moderate 1 ( 16%) 0 1 (100%) 0 Bad . . . 3 ( 50%) 0 1 ( 33%) 2 ( 66%) 6 ( 99%) 2 ( 33%) 2 ( 33%) 2 ( 66%) Deaths, 2 (shock). Over 60 years: Good 1 (100%) 1 (100%) 0 0 Moderatef . 0 0 0 0 Bad . 0 0 0 0 1 (100%) 1 (100%) 0 0 Deaths, 1 (shock). Total deaths, 7 (6 shock, 1 loss of blood). TABLE XXXI.—INFLUENCE OF AGE ON NON-OPERATIVE TREATMENT Anatomical result. Total. Good. Functional result. Moderate. Bad. I to 15 years: Good 2 ( 66%) 2 (100%) 0 0 Moderate i ( 33%) I (lOO%) O 0 Bad . 0 O O 0 3 ( 90%) 3 (100%) 0 O Deaths, 2 (shock). ESTES: REPORT ON FRACTURES OF THE FEMUR 159 15 to 45 years: Good Moderate Bad . . . 11 ( 78%) 3 ( 22%) 0 11 (100%) 0 0 0 2 (66%) 0 0 1 ( 33%) 0 14 (100%) 11 ( 78%) 2 (14%) 00 45 to 6o years: Good 2 ( 66%) 2 (100%) 0 0 Moderate 0 0 0 0 Bad . 1 ( 33%) 0 0 I (100%) 3 (100%) 2 ( 66%) 0 1 ( 33%) Over 6o years: Good 1 (100%) 1 (100%) 0 0 Moderate 0 0 0 0 Bad . . . 0 0 0 0 I (ioo%) I (100%) Deaths, i (shock). Total deaths, 3 (shock). 0 0 TABLE XXXII.—INFLUENCE OF AGE ON OPERATIVE TREATMENT Anatomical Functional result. result. Total. Good. Moderate. Bad. I to 15 years: Good . 6 (66%) 6(100%) 0 0 Moderate 0 0 O 0 Bad . . 3 (33%) 0 3 (100%) 0 9 ( 99%) 6 ( 66%) 3 ( 33%) 0 Deaths, 1 (shock). 15 to 45 years: Good ■ 21 (70%) 20 ( 95%) i( 5%) 0 Moderate • 5 (16%) 3 ( 60%) 2 ( 40%) 0 Bad . . • 4d4%) 0 0 4 (100%) 30 (100%) 23 ( 76%) 3 ( 10%) 4 ( H%) Deaths, 1 (loss of blood). 45 to 60 years: Good 0 0 0 0 Moderate 1 (33%) 0 1 (100%) 0 Bad . . ■ 2 (66%) 0 1 ( 50%) x ( 50%) 3 (99%) 0 2 ( 66%) 1 ( 33%) Deaths, 2 (shock). Over 60 years: No cases reported. Total deaths, 4 (3 shock, 1 loss of blood.) TABLE XXXIII.—COMPOUND FRACTURES OF THE FEMUR (SHAFT) Anatomical result. Total. Good. Functional result. Moderate. Bad. NON-OPERATIVE Good Moderate . Bad . • 15 ( 75%) • 4 ( 20%) ■ 1 ( 5%) 15 (lOO%) 2 ( 50%) O 0 2 (50%) O O 0 I (10%) Deaths, 3 20 (100%) 17 ( 85%) 2 (10%) i ( 5%) Good . . Moderate . Bad . . . . 26 ( 62%) • 6 ( 14%) • 10 ( 24%) OPERATIVE 25 ( 97%) 5 ( 83%) 0 1 ( 3%) X (17%) 2 (20%) 0 0 8 (80%) Deaths, 4. 42 (100%) 30 ( 73%) 4 ( 9%) 8(18%) TABLE XXXIV.—COMPOUND FRACTURES OF THE FEMUR (NECK) Anatomical result. Total. Good. Functional result. Moderate. Bad. NON-OPERATIVE Good ... I (100%) I (100%) 0 0 Moderate . . o 0 0 0 Bad .... o 0 0 0 I (100%) I (100%) 0 0 OPERATIVE No cases reported. TABLE XXXV.-DOES GOOD ANATOMICAL RESULT LESSEN THE PERIOD OF DISABILITY Anatomical result. Total. Period of disability. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. Femur (all forms): Good 3 ( 25%) 1 (33%) 1 (33%) 1 (33%) 0 0 Moderate 7 ( 58%) 0 2 (28%) 4(57%) 0 i (i5%) Bad .... 2 ( 17%) 0 0 1 (50%) 0 i (50%) 12 (100%) x ( 8%) 3 (25%) 6 (SO%) 0 2 (16%) Compound Fractures of the Femur Note.—Table XXXV represents the only cases reported the last year with periods of disability noted. These combined with those of the 19x5 report, namely, 51 cases, would give 63 cases, an average disability of 11.5 months. The one case with a noted disability under three months was a child eight years of age. For adult cases, therefore, the average disability proves to be 11.8 months. ESTES: REPORT ON FRACTURES OF THE FEMUR 161 Period of disability and functional result. * Anatomical Under 3 months. Under 6 months. Under 9 months. Under 12 months. Over 12 months. result. Total. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. Good. Mod. Bad. i to is Good i 1 0 0 0 0 0 0 0 0 years Moderate i 0 0 0 1 0 0 0 0 0 Bad o 0 0 0 0 0 0 0 0 0 15 to 45 Good 2 0 0 0 1 0 0 0 1 0 years Moderate 5 0 0 0 1 0 0 3 I 0 Bad 1 0 0 0 0 0 0 0 0 1 45 to 60 Good 0 0 0 0 0 0 0 0 0 0 years Moderate 1 0 0 0 0 0 0 0 0 0 0 0 0 0 I 0 Bad 1 0 0 0 0 0 0 0 0 0 0 0 0 0 I 0 Over 60 years No cases. TABLE XXXVI—COMPOUND FRACTURES OF THE FEMUR, ALL FORMS 162 ESTES: REPORT ON FRACTURES OF THE FEMUR Age. Number of cases. Period of disability. Under 3 mos. Under 6 mos. Under 9 mos. Under 12 mos. Over 12 mos. i to 15 years 2 f Non-operative . . 1 ( 50%) \ Operative . . . . 1 ( 50%) 0 1 (100%) 1 (100%) 0 0 0 0 0 0 0 15 to 45 years g f Non-operative . . 3 ( 37%) \ Operative . . . . 5(61%) 0 0 2 ( 66%) 0 1 ( 33%) 5 (100%) 0 0 0 45 to 60 years 2 f Non-operative . . 0 l Operative .... 2 (100%) 0 0 0 0 0 0 0 0 0 2 (100%) Over 60 years No cases. All ages . 12 / Non-operative . . 4(33%) \ Operative . . . . 8 ( 66%) 0 1 ( 12%) 3 ( 75%) 0 1 ( 25%) 5 ( 61%) 0 0 0 2 ( 25%) a lit • r6CT °n7- SCS reP°rte(J the last year and represents the latest after-the-war treatment. It is too small a number to have conclusive value, but is suggestive of what may be expected in regard to periods of disability The two cases which went over twelve months had each of them twenty months’disability. u saointy. me two cases wmch TABLE XXXVII.—OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT Compound Fractures of the Femur ESTES: REPORT ON FRACTURES OF THE FEMUR 163 TABLE XXXVIII.—COMPARATIVE RESULTS OF OPERATIVE AND NON-OPERATIVE CASES Compound Fractures of the Femur Fracture. Operative cases. Non-operative cases. Cases. Good anatomical result. Good functional result. Cases. Good. anatomical result. Good functional result. Femur Shaft 46 57% 65% 23 66% 69%