This book is written primarily for the resident casualty surgeon. In Britain this resident appointment is usually held by young men whose practical experience, for obvious reasons, cannot match their theoretical knowledge. It is possible for such casualty officers to be fully conversant with modern textbooks of fracture treatment and yet be unable with any degree of certainty to reduce many of the simple fractures. I believe that this follows from the fact that in many large textbooks the space devoted to the detailed description of technique in the treatment of the common fractures is disproportionately small. An important step, on which might depend the whole success of a reduction, can be overlooked if it is concealed within one sentence. The full significance of many sentences in standard textbooks is often only realised on reading them again at a later date, when one has learned to reduce fractures by practical experience.

I have therefore in this small volume endeavoured to describe in detail what I consider to be the essential steps in the closed reduction of the common fractures, and at a length proportionate to the importance of the matter. No attempt has been made to write a comprehensive textbook but, by emphasising various mechanical features common to the reduction of certain fractures (which might almost be regarded as principles) it is hoped that the student may learn to apply these to the successful reduction of rare fractures whenever he encounters them.

This monograph was written fifty years ago by John Charnley when he was in his late thirties. Always a highly-practical orthopaedic surgeon with great clarity of thought, he combined his vast experience of fracture treatment gleaned from industrial Manchester and service in World War II to produce this work which is full of basic commonsense. It should be compulsory reading for all those involved in learning the art of fracture management and all students of orthopaedic surgery.

Open reduction of fractures and internal fixation is commonplace and successful in many cases in the 1990% but is not the total answer to fracture treatment. In many parts of the world, initial treatent, and frequently the final treatment, is by closed methods, and this book has become the bible for many isolated and lonely junior orthopaedic surgeons in remote areas.

The basic principles described are a benchmark and, like the Charnley hip, a gold standard from which to start if progress is to be made in the future.

The John Charnley Trust has decided to reprint this Golden Jubilee edition of The Closed Treatment of Common Fractures for the next generation of orthopaedic surgeons in training, to coincide with the Millennium.

It is now universally agreed that pertrochanteric fractures of the femur are best treated by internal fixation whenever this is feasible. Because many of the patients with pertrochanteric fractures are in an advanced state of senility, sometimes complicated by mild dementia and incontinence, the non-operative treatment of these fractures presents formidable nursing difficulties.

Not all pertrochanteric fractures of the femur are suitable for internal fixation by the blade plate, and attempted operation may cause such comminution in some cases that to persist with difficult surgery is not to be advised and the case is better returned to the ward for treatment on traction. There will always be a place for the non-operative treatment of the pertrochanteric fracture, and it is necessary therefore to decide what technical matters are of importance with regard to the comfort of the patient and the convenience of the nursing staff.

RUSSELL TRACTION

It is obvious that some form of balanced traction is the only rational method of non-operative treatment, because a plaster hip-spica is quite out of the question in patients of this degree of senility. The most generally used type of traction is that popularly known as Russell traction. In its original form Russell devised this system for the treatment of fractures of the shaft of the femur and he evolved the rather complicated system of pulleys in order to correlate the traction force necessary to maintain length with the upward lifting force necessary to correct backward angulation at the fracture.

Many failures in conservative treatment can be traced to inadequate plaster technique. A good manipulative reduction is often allowed to slip during the clumsy application of plaster. The surgeon who aspires to skill in the conservative method must subject himself to a long apprenticeship in ‘plastercraft.’ Skill is not to be learned from books but only by continuous repetition for at least one year, and the casualty officer who regards the application of plasters as a menial task to be delegated to juniors or to the nursing staff will be well advised to transfer his attention to another specialty. Until the surgeon's hands have acquired an automatic rhythm, being able to pass and mould the turns of bandages quickly, regularly, and subconsciously, his mind is not free to devote its entire concentration to the tissues of the fracture.

PADDED AND UNPADDED PLASTERS

Plaster casts can be divided into three types: (i) ‘badly padded’ plaster, (2) unpadded plaster, and (3) padded plaster.

‘Badly Padded’ Plaster

It was against the background of the badly padded plaster that Böhler inveighed with such effect, and it was Böhler's teaching which established the use of the unpadded plaster, applied directly to the skin without any soft material intervening. So powerful were his convictions that even now the word padding is still regarded in many circles as something unmentionable or as something for which to apologise.

A fracture of the shaft of the humerus is perhaps the easiest of major long bones to treat by conservative methods. The humerus is a bone which generally unites quickly. If some shortening results it is of no significance. If some angular deformity persists it is usually concealed by muscle covering. If angular deformity persists it is concealed in the flexed position of the elbow and becomes revealed only when the elbow is fully extended (a position in which the elbow is rarely viewed in ordinary postures of the body). These are facts which must be remembered when any elaborate or operative method for treating this bone is under consideration.

Sling or Collar and Cuff

It is surprising how few people realise the fundamental difference in the mechanics of a sling and a ‘collar and cuff.’ Few realise that the two are diametrically opposite in their mechanical action on the humerus, shoulder, and shoulder girdle.

A sling elevates the point of the elbow and thus applies a vertical compression force in the length of the humerus and on the shoulder joint. It must not therefore be used when treating a fracture of the humerus because it will cause overriding and lateral angulation.

A collar and cuff allows the weight of the elbow to generate a traction force on the shoulder and it tends therefore to elongate the humerus.

When treating fractures of the humerus a collar and cuff must be used. When treating fractures of the clavicle and dislocation of the acromio-clavicular joint, where it is necessary to elevate the shoulder, a sling is required.

The finger fracture which of all others demands most expert mechanical treatment is that of the proximal phalanx. The reputation of a surgeon may stand as much in jeopardy from this injury as from any fracture of the femur.

In the subsequent paragraphs a method is described which I believe to be of value, though it involves a rather heretical doctrine. It is important, therefore, that the spirit of this method should be fully understood because it contains a potential danger if the doctrine is misapplied.

ANATOMY OF THE FRACTURE

Fractures of the proximal phalanx are often compound, because they are so commonly the result of industrial injuries. The characteristic deformity is an angulation concave to the dorsum, and for the purpose of reduction the soft-tissue ‘hinge’ is to be regarded as being on the dorsal aspect of the fracture.

Mechanics of Treatment

The reduction of these fractures as a rule offers no great difficulty; the real difficulty lies in the application of a retentive apparatus which will hold securely the reduction so easily obtained by the surgeon's fingers.

Manipulative reduction is obtained by first applying traction and hyperextension; then, with the thumb applied as a fulcrum to the volar aspect of the fracture, the traction is followed by a movement of flexion, following which the traction is released (Fig. 120). After release of the traction the reduction can be held by a simple three-point arrangement of forces designed to maintain the finger flexed over a fulcrum.

In this chapter we are only concerned with the treatment of fractures of the shafts of the radius and ulna in their middle thirds. There are many difficulties in treating the radius and ulna by closed manipulation; closed methods can give excellent results, but the element of luck is rather prominent, and for this reason I am in favour of operative treatment. Some of the difficulties which damp enthusiasm for closed reduction are illustrated in the following sequence of catastrophes:

1. An excellent reduction may be secured by skilful manipulation.

2. The patient may suffer severe pain, with swollen fingers, because a closefitting plaster is obviously necessary; this causes the surgeon considerable anxiety, and may necessitate splitting of the plaster, thus causing further suffering to the patient unless a second anaesthetic is used.

3. When the swelling subsides there is a strong possibility of the initial reduction collapsing.

4. A second manipulation (sometimes the third anaesthetic) may therefore be necessary after fourteen to twenty-one days.

5. This may be followed by further pain and further swelling of the fingers.

6. An excellent reduction obtained initially is rarely ever retrieved by the second manipulation.

7. Delayed union of one or other bone may occur.

8. Limited pronation and supination may result after four to six months of plaster fixation.

9. External deformity may be so great as to be visible even to the patient.

10. […]

How often we see plaster of Paris applied merely because X-ray examination has revealed a small crack or undisplaced fracture! On many such occasions the surgeon would probably have treated a case without plaster had he used his clinical sense alone; he would then have been treating the injury according to his estimate of the damage inflicted on the soft parts. It is a platitude to say that soft-part injuries can be more serious than mere cracks in bone. One of the commonest instances in which the clinical assessment of an injury by soft-part damage is more important than the radiological is seen in severe ankle sprains where simple X-ray reveals ‘no bone injury.’ If an ankle presents very gross swelling, with extensive ecchymosis and solid induration due to the tension of the swelling, it is highly likely that there has been a rupture of the tibiofibular syndesmosis or of the external lateral ligament, and late displacement of the talus or recurrent subluxation of the ankle will occur if too early function without plaster is permitted. On the other hand, patients are frequently prevented from returning to work by plasters which are not essential but which are forced on them by surgeons who think only in terms of routine procedures and do not adjust their method to the demands of the individual problem.

It frequently happens that a surgeon is obliged to X-ray limbs for the medicolegal implication of an injury; but the result of this examination need not make him change his clinical judgment too lightly (p. 85, Fractures of the Scaphoid).

Descriptions of operative technique are to be found in most modern textbooks of fracture treatment, and often in great detail; by comparison the details of manipulative technique are usually indicated in only the vaguest of general outlines. This is not surprising if manipulative treatment is regarded as an art rather than as a science, because an art is essentially something which defies description and is therefore to be learned only by practice and apprenticeship.

In this chapter an attempt is made to reveal the scientific basis of manipulative methods. Unless the teacher of manipulative technique is able to create a mental picture of a manipulation, the student may waste months of experience and much valuable material before he eventually discovers what others may long have known but have failed to communicate. These mental pictures should not be decried by an experienced operator if the interpretations here offered seem to him open to question; the student must adapt these pictures to suit impressions gained from his own practical experience and they will thus form a useful basis on which to build.

The Soft Tissues associated with a Fracture

When the student inspects the radiograph of a badly displaced fracture, such as that of a Pott's fracture of the ankle, he may well despair at the thought of manipulative reduction. Manual reduction of a case such as that illustrated in Fig. 38 would appear not unlike the assembling of a jig-saw puzzle in the dark. The solution of the difficulty emerges, and the precision of reduction is realised, only when the supreme importance of the soft tissues is appreciated.

The bad results of open reduction and internal fixation of fractures are most commonly seen in fractures of the shaft of the tibia. There are several reasons for this: the tibia is the commonest major long bone to be fractured; it is very commonly a compound fracture; it is a fracture which is easily exposed and therefore tempts inexperienced operators; it is a subcutaneous fracture and after plating is especially prone to defective wound healing accompanied by what in some quarters is euphemistically termed ‘drainage’

We have still a long way to go before the best method of treating a fracture of the shaft of the tibia can be stated with finality. I feel sure that a closed method will eventually prevail, but we need mechanical aids to improve our control of the bone fragments. It is possible time will show that an intramedullary rod, introduced through the tibial tubercle, without exposing the fracture site, will be enough to enhance alignment as an adjuvant to closed methods. Used in this simple way the intramedullary rod will not be responsible for immobilisation; it will merely control alignment and prevent slipping of the reduced fracture.

Most surgeons who practise internal fixation of tibial fractures do so with the idea that accurate coaptation of the fragments, combined with rigid fixation, enhances the ability of the fracture to unite. I have attempted to show in Chapter I that this mechanical approach to fracture healing is out of touch with biological reality.

It is a fortunate thing that excellent functional results usually follow the common Colles' fracture, because disappointing anatomical results occasionally develop even in the most skilful hands. Though in general it is fair to class this injury as a minor fracture, this is not always the case, because the group includes a substantial number of comminuted fractures which would demand elaborate mechanical treatment if perfect anatomical restoration were to be the most important aspect of the problem.

From the student's point of view it is confusing that this common fracture is satisfactorily treated by a method which transgresses two of the basic principles of fracture treatment because, as will be shown later, the dorsal plaster slab is mechanically unsound as a method of fixation, and the position of flexion of the wrist is contrary to the general rule of splintage in the optimal position for function. Here, however, is an example of a method which is sanctioned by results and by convenience rather than theory, and these are very important practical matters in a busy clinic.

ANATOMY OF THE FRACTURE

The triple displacement of a Colles' fracture, i.e., dorsal shift, dorsal tilt, and radial shift of the distal fragment, constitutes the classical ‘dinner-fork’ deformity known to every student. Less obvious, but more important as regards treatment, are the ruptured soft parts which accompany this displacement.

In this third edition I have persisted in my attempt to write a book on the conservative treatment of fractures which at one and the same time would be a vade-mecum for the junior man and an interesting treatise for the experienced surgeon. It might be considered that these two objectives are incompatible, and that it would have been better to have written a simple textbook for the junior and to have reserved my ponderings on the nature of fracture repair for a separate monograph. In the training of young surgeons I believe that the attempt to foster the habit of making clinical observations and questioning accepted beliefs ought to start from the earliest moment. There is still a great deal of fundamental information concerning the healing of fractures waiting to be deduced, by the process of logic and close reasoning, from clinical facts collected in the operating theatre and out-patient department.

There is a tendency to imagine that serious research nowadays can only come out of a laboratory, and that contributions from the pure act of thinking on clinical facts ended with the great clinicians of the past. The old clinicians had their faculties for observation by sight and touch heightened by the absence of X-rays and laboratory tests. But though the clinical acumen of the old observers was greater than ours, it was frequently offset by a strain of credulity, which is apparent in a different form among clinicians to-day.

It is over thirty years since Arbuthnot Lane published his Operative Treatment of Fractures; but we still cannot compare conservative and operative principles from the viewpoint of basic science because the fundamental nature of fracture repair still eludes us. The best we can do is to compare the results of clinical practice; but there are so many variables (comminution, sepsis, mechanical details of the operation, blood supply, level of fracture, different observers, etc.) that a series of one or two hundred cases, which is a large series for any one operator, is soon reduced to statistical insignificance. Attempts to control the conditions of the fracture by using experimental animals have yielded nothing of importance compared with what we have learned ‘the hard way’ by developing operative techniques on the human subject.

The followers of Lane and Sherman believed that the failures of internal fixation would ultimately be eliminated by improved technique. We now know that internal splints are exposed to truly enormous forces and are subject to the phenomenon of failure by fatigue. Improvements in the design of plates and screws have reduced, but not eliminated, the mechanical failures which were common when techniques derived from the woodworker were used. The change to using electrolytically inert metals has only slightly diminished our problems, though there is no excuse for returning to the brass screws and reactive steel plates with which Lane himself achieved sufficient success to establish the method.

The precision with which it is possible to reduce a Pott's fracture by manipulation becomes a source of pleasure once the surgeon understands the mechanics of this reduction. My own satisfaction is increased when I recall the uncertainty of my own early attempts to reduce this fracture-dislocation and how I was once dependent on the X-ray as on a ‘lucky dip.’

The problem in treating a Pott's fracture is not so much how to reduce the fracture but how to make sure that it will stay reduced. I shall endeavour to indicate when I think it is dangerous to persist with closed reduction and when operative aid should be invoked.

Operative treatment of the Pott's fracture is not a procedure to be encouraged as a routine, because there are special complications of operative treatment quite as serious as the defects of closed treatment. In the ordinary Pott's fracture the functional and anatomical results of a skilful closed reduction should be perfect. Even if a small posterior marginal fragment remains displaced, the ankle possesses a latitude for recovery of function which is often astonishing. The open reduction of this fracture-dislocation can be a matter of considerable technical difficulty; to secure adequate exposure in the cramped space available may impair the blood supply of a detached fragment. If for any reason open reduction should be attempted, nothing less than a ‘hair-line’ restoration should be regarded as justifying it; incomplete reduction after open operation must be regarded as an error of judgment. If open reduction is considered imperative, then the minimum of metallic ‘hardware’ should be used.

The reduction of a supracondylar fracture of the humerus can become a comparatively simple feat if it is undertaken without delay and if the surgeon who has the first opportunity of treating it has a clear mental picture of its mechanism. The first reduction is the one most likely to succeed; after subsequent attempts the elbow becomes so indurated that the swelling may obstruct even the most expert manipulator.

ANATOMY OF THE FRACTURE

In the supracondylar fracture of the humerus the fracture line passes more or less transversely through the metaphysis at a variable distance from the epiphyseal line. When the fracture line is extremely close to the epiphyseal line it sometimes appears in the X-ray almost as an epiphyseal separation, but in every case a thin shell of the diaphysis is adherent to the distal fragment.

There are three elements in the displacement of the distal fragment of the supracondylar fracture: (i) posterior displacement, (2) lateral (or medial) displacement, and (3) rotary displacement.

In the manipulative reduction to be described, the rotary deformity will more or less correct itself under the influence of the tense fascial structures in the course of the preliminary phase of reduction by traction. An error of 10 degrees of rotation will not affect the functional or cosmetic result, though it will give rise to interesting appearances in the radiograph which need special comment (see below).

Opinions vary considerably on the frequency of late symptoms following unsatisfactory reductions of a Bennett's fracture. Casualty officers do not usually find it an easy fracture to reduce, and because it is also quite a common injury, one can presume that numerous cases must be treated inexpertly every year; but even so, the number of cases presenting themselves with symptoms of traumatic arthritis is remarkably few. However, this is no reason why a high standard of manipulative reduction should not be expected. The reduction of this fracture presents no great mechanical difficulty but it demands from the surgeon a fine sense of touch, and for this reason the injury could well be used as a ‘passing-out’ test for the student of closed reduction.

ANATOMY OF THE FRACTURE

As its alternative name implies, the ‘stave’ fracture is often sustained in a bout of fisticuffs. An ill-delivered blow transmits force in the line of the thumb while in flexion, thereby shearing off the anterior part of the base of the metacarpal, and so allowing the bone to escape from the joint in a dorsal direction. The volar ligament of the carpo-metacarpal joint remains intact and this is responsible for holding the wedge-shaped fragment of the metacarpal in its normal relation with the articular surface of the trapezium. The essential deformity of this injury is one of angulation with the concave aspect on the volar side; the intact soft tissues which are to act as the ‘hinge’ for the reduction are thus to be found on the volar aspect of the base of the metacarpal.