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AN ANALYSIS OF A SERIES OF FRACTURES: Treated in the Surgical Unit of the Department of Clinical Surgery, University of Edinburgh.

MERCER, WALTER
The Journal of Bone & Joint Surgery: April 1929
Archive: PDF Only

From the table of results of the complete series, it is to be seen that statistics are based on sixty cases, as there were three cases that could not be traced and so were not included, although the last information about these was that they promised to be very satisfactory in their end results. The total number of beds at the disposal of this department is fifty with an additional four cots. During the year under review a total of 981 cases were treated. It is therefore interesting to know that sixteen per cent. of these were fractures. One case in every six seems a greater number of fractures than one would have expected. During the reviewed period it happened that the wards admitted emergencies every Saturday and it is an undoubted act that more accident cases are admitted that day than on any other in the week. This may account to some extent for the apparently large percentage. [SEE TABLE 7,8 AND FIG.34,35 IN SOURCE PDF]

Two patients died-a mortality of three and three-tenths per cent.-and in neither case was the death due entirely to the fracture under review. The one, a case of fracture of the femur, died as the result of a head injury and the other from a bronchopneumonia after discharge from the hospital. It is particularly gratifying to have only one death in eighteen cases of fracture of the femur. Ashhurst and Crossan report thirteen deaths in a series of 101 cases of fracture of the femur-a twelve per cent. mortality. [SEE FIG. 36 IN SOUCE PDF]

Sixty per cent. of the total number of traced cases were classed as good results; twenty-three and three-tenths per cent. as moderate; and thirteen and three-tenths per cent. as bad. This is not very different from Ashhurst's figures on femurs-sixty-three per cent. good; thirty per cent. moderate; and seven per cent. bad; nor yet from Estes' figures,-sixty-one per cent. good; twenty-seven per cent. moderate; and twelve per cent. bad. There are, however, no figures that are exactly comparable with those in this review.

It is interesting to note that no fewer than twenty-two cases were operated on in the series. Eleven of these were for the purpose of sterilizing a compound fracture, while eleven were operated on with a view to producing and maintaining an accurate reduction of the fragments. In no case was it necessary to operate with a view to securing bony union, all the cases uniting without undue delay.

In making this compilation of fracture figures, it was expected that two questions at least would be answered by it. Are the results of fracture treatment really tragic? Can these results be improved in any way?

It is a striking fact that four cases out of ten are left with some degree of permanent disablement and no doubt there is an element of tragedy about this, but in estimating the end results one must also take into consideration the primary condition. In thirty-two of the cases the fracture implicated a joint, in eleven of them the fracture was compound, and in two of the humerus cases there was a dislocation complicating the fracture. It will thus be seen that the cases were of a fairly severe degree,-what one might term major fractures. It is evident, therefore, that the end results are fairly good, but this only makes one keener to see them better. One feels that there are few fractures that should be placed in the 'bad' category if modern methods are used scientifically, always granted that the cases are admitted within a few hours of the accident. It is manifestly impossible to get a good result in a comminuted fractured elbow if the case is admitted days after the original injury, and particularly if ill advised attempts have already been made to reduce it. The first lesson to be taught, then, by such a compilation as this is that the earlier an attempt is made to reduce the deformity of a fracture, the greater the chance of getting accurate apposition of the fragments and, other circumstances being equal, the better the anatomica1 position, the better the functional result.

The patient with a fracture should, therefore, be considered just as imperatively in need of treatment as the one with an acute abdomen, and if comfortable even with the deformity, this should not be considered an indication to delay the initiation of treatment. In most cases it is of the utmost importance to have a two-view radiogram of the fracture prior to reduction. This is especially important in shaft fractures where damage may be done to soft tissues with an oblique fracture which would be reduced to a minimum were there a good x-ray available. Every surgical hospital should have a complete set of splints at hand. With modern ideas on the use of plaster-of-Paris this list has been reduced to very moderate dimensions, but nevertheless no hospital should be in the position of admitting a fracture case and, having admitted it, not be in the position to institute immediately the best treatment possible for that type of fracture. Included in such a list of splints one should have a Balkan frame or a Morison bed frame, and the means of applying extensions such as Finiochietto caliper, ice-tong caliper, etc. [SEE FIG. 37, 38 IN SOURCE PDF]

When the fracture has been reduced and immobilized, the most careful daily supervision should be instituted. It should be frequently x-rayed and measured, and attempts should be made to correct any deviation from the best possible position. [SEE FIG. 39 IN SOURCE PDF]

Carefully supervised physiotherapeutic treatment by a properly trained masseuse is of almost as much importance as the retention of the reduced fracture. At the earliest possible moment active movement and massage are instituted and attention is paid to every joint of the damaged limb.

Weight-bearing in the case of fractures of the lower limb should be advised only after careful consideration of the state of the callus and, when ordered, it should be started only by degrees and in the early stages always aided by some such splint as a walking caliper.

To know how your patients recover is to know if your methods are good; and so, lastly, the most carefully compiled reports should be made of all the various data in connection with the treatment of a fracture and, when the patient is discharged from the ward, he should be seen regularly and his progress reported on.

(C) 1929 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.

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