From the time ancestral man became bipedal, there has been a risk of falling and fracturing the wrist and hand. We can only assume that the treatment of these injuries in prehistoric times was symptomatic, and that the injured individual learned that elevation, rest, and perhaps immobilization aided comfort. These observations could have been spread orally. The advent of writing enabled the evolution of fracture treatments to be roughly traced (Table 1). Studying the history of wrist and hand fracture fixation allows insights into the history of medicine, and emphasizes the wealth of medical knowledge that has been collected regarding the treatment of these common fractures.
Articles and texts that emphasized the treatment of fractures of the hand and wrist were reviewed. All historical texts that documented the treatment of fractures and articles from the past two centuries that dealt specifically with hand and wrist fractures and contributed substantially to their treatment were included.
The treatment of fractures of the hand and wrist continues to evolve. Although we have made considerable advances in the treatment of these injuries, a consensus on optimal treatment remains elusive. We are not much different from ancient physicians in that many reasonable options are available for the stabilization of fractures but there is a lack of adequate clinical evidence that one treatment method is better than another.
The basic knowledge of fracture treatment has developed throughout centuries. Today, we have a deeper understanding of the biomechanics and cell biology required to heal a fractured bone. However, the clinical goals and treatment of fractures of the hand and wrist has not changed dramatically as time has passed. The earliest physicians realized that immobilization aided the maintenance of fracture reduction and improved pain. However, they also discovered that prolonged immobilization and swelling led to poor results. With the advent of lighter stronger materials for immobilization (plaster-of-Paris casts), patients were able to walk after fracture reduction.76,81,86 The materials used for immobilization continued to improve during the last 200 years, along with the realization that motion and edema control are critical to outcome.
Modern metallurgy, advances in operative techniques, improvements in anesthesia, hand therapy, and the advent of antibiotics have aided greatly in the treatment of these common hand and wrist fractures. The operative treatment of fractures has attempted to subvert well recognized problems with prolonged immobilization; however, patients continue to have stiffness, nerve injuries, malunion, hardware complications, and difficulties with chronic pain. Surgeons must continue to analyze outcomes and strive to improve the function of patients with injuries to the hand and wrist with improved implants, less traumatic surgical approaches, and a heavy emphasis on therapy and early motion.
Egyptians were well versed in the use of woven fabric roller bandages to prepare bodies for burial, so it is of little surprise that bandages were used for fracture treatment. Around 2800 BC, Imholep, an Egyptian architect, is believed to have written the earliest treatise on the treatment of fractures (now known as the Edwin Smith Papyrus after its discoverer).86 The terms fracture, open fracture, and comminuted fracture were first used in this text.86 Egyptians applied honey and other substances to the skin over fractures combined with cartonage, a cast-like material made from linen roller bandages glued together by incorporating plaster (gypsum).86 Wood bark splints were added for additional immobilization (Fig 1).86
The Greek physician, Hippocrates of Cos (460-377 BC), advocated frequent dressing changes with bandages stiffened with lard or oil mixed with wax, resin, or pitch.76,86 His contemporaries tended to apply roller bandages with flourishes of egotism, which Hippocrates disdained.86 He stated “It should be done . . . quickly by dispatching the work; without pain, by being readily done; with ease, by being prepared for everything; and with elegance, so that it may be agreeable to the sight . . . but don't turn it into a foolish parade of manual skill.”86 He said to “Leave aside theatrical bandages that serve no purpose; this is miserable and fit for charlatans, and often hurts the patient. Indeed the patient is seeking not ornaments, but help.”86
Susruta, one of India's most prominent ancient physicians and a contemporary of Hippocrates,86 applied bark, honey, and clarified butter to a fractured limb prior to reduction.38,86 After reduction, a mixture of bark, glue, and flour was placed on the limb with a splint of bark, wood, or bamboo bound to the limb.76,86
The practice of fracture care in the Middle Ages closely followed the recommendations of Hippocrates by frequent dressing changes with bandages stiffened with egg white and other solidifying pastes.81 The British surgeon, William Cheselden (1688-1752 AD) preferred egg white and wheat flour as stiffening agents.81
Hippocrates (ca 400 BC) first described a distal radius fracture. He did not identify this injury as a fracture through the metaphysis of the radius, but considered it a dislocation of the carpus or radiocarpal joint. He stated that
“The joint of the hand is dislocated either inward or outward, most frequently inward.”38
Hippocrates' inaccurate view that deformities after falls on outstretched hands were the result of dislocations pervaded the writings of medical scholars for 2000 years.38 Petit88and Pouteau of France38 along with Colles in Ireland,27 recognized the true nature of the distal radius fracture at the beginning of the 19th century.
At this same time, fracture care was becoming unduly time consuming and costly.86 The population in Europe was growing rapidly, and there were more injuries because of the Napoleonic wars. Surgeons were also in short supply. The French military surgeon, Dominique-Jean Larrey (1768-1842 AD), demonstrated that occlusive dressings with infrequent dressing changes could be used safely even in open fractures.86 He used camphorated alcohol and lead acetate with egg whites in water to stiffen dressings.76,78,81,86 The method was improved by Louis Seutin of Belgium in 1835,76,78,81,86 who used starch to make a more rigid bandage. However, these agents still required 2-3 days to harden. Seutin described splitting of the cast to allow inspection of the limb and cast tightening as swelling subsided, but the use of inspection had been documented by Arabian physicians centuries before,81 and subsequent tightening of bandages by Cheselden.81
After reduction of a fracture, surgeons performed frequent dressing changes with bandage, pads, and splints.76,81,86 For lower extremity fractures, patients were kept at bed rest for weeks until fracture consolidation occurred. Perhaps out of necessity, doctors realized that frequent dressing changes offered no particular advantage, and dressings hardened with starch and later plaster of Paris dried much more quickly. This led to the ambulatory care of fractures.76,81,86
The military surgeons Larrey (France), Seutin (Belgium), Antonius Mathijsen (The Netherlands), and Nikolai Ivanovich Pirogov (Russia) popularized the use of the hard cast in the middle of the 19th century,86 although knowledge of these techniques and materials had been improving for more than 1000 years in other parts of the world. For instance, in the 8th century, an Arabian physician, Rhazes, described a bandage that could be made as “hard as stone” with lime and egg white.81 In the 10th century, another Arabian physician, Abu Mansur Muwaffak, recommended that plaster be used to treat bony injuries.76 Arabian physicians recognized that adding water to soft powder of anhydrous calcium sulfate produced a hardened hydrated crystalline form long before Western physicians used this technique.86 Anhydrous calcium sulfate is produced by heating gypsum (a mineral composed of calcium sulfate with two molecules of water CaSO4·2H2O), to expel the water. The finely ground powder of the anhydrous mineral, known as plaster of Paris (named after the naturally occurring deposits of gypsum under Montmartre, Paris) hardens when water is added then allowed to dry.
Sixteenth century Turkish physicians were known for their use of gypsum to cover broken bones. They applied the gypsum paste directly to the injured limb and incorporated plugs of wood and greased cork to create openings in the cast. Once the cast hardened, the plugs were removed to allow ventilation and outlets for swelling.86
Plaster of Paris, was first used to immobilize fractures in Western civilization in the 1800s.38,77 Hendriks (Holland) used it in 1814,76,78 Hubenthal (Russia) used it in 1816,81 and Johann Friedrich Dieffenbach (Germany) used it in 1831.76,78 Hubenthal mixed in ground blotting paper that he applied to a greased limb to prevent adherence to the skin.81 Hendriks and Diffenbach placed the injured limb in a container or tray and covered it with liquid plaster of Paris, which when solidified resulted in a solid casing.78 The container was removed after the plaster had hardened.81 There were many obvious difficulties in treating patients this way including the lack of access to the fracture, constriction of the soft tissues, and the bulkiness and weight of the cast.
Mathijsen (1805-1878 AD) and Pirogov (1810-1881 AD) are credited with the first use of plaster of Paris roller bandages. Mathijesen (Fig 2) wrote his classic article on the use of a plaster of Paris bandage in 1852.78 He described adhering the plaster of Paris powder to moistened fabric strips that were then rolled and stored.78 When needed, the roll was immersed in water to activate the hydration of the calcium salt.78 It was rolled on in an identical manner performed today throughout the world.78 He described an ideal cast material that is comparable to the desires of the modern cast technician or surgeon: it should be easily applicable; it should acquire its solidity within minutes; one should have access to the injury or broken parts; the bandage should mold itself to the shape of the limb; the suppuration or the moisture of the damaged limb should not have any effect on the dressing; and it should not be too heavy or expensive.78
The use of plaster casts and splints for the treatment of fractures became popular in Europe, but was not frequently used in Great Britain or United States until after 1875.86
In the middle of the 19th century, French contemporaries, Baron Guillaume Dupuytren, Jean-Gaspar-Blaise, Jean Goyrand, and Auguste Nealton, as well as others from Great Britain and North America, preferred using metal or wood prefabricated splints for the maintenance of reductions in fractures of the distal radius.38 In 1859, Jean-Francois Malgaigne77 from France, described the treatment of distal radius fractures using straight splints placed on the forearm and extending distally only to the level of the fracture. The forearm was held in semipronation with a sling, which allowed the hand to fall into flexion and ulnar deviation to maintain reduction.9 Alfred Gordon from Belfast used a volar splint made of wood with a wedge placed at the level of the fracture to create a bending force to reduce a dorsally angulated fracture (Fig 3). Gordon's splint, although popular in Ireland and Great Britain, did not gain wide acceptance in the United States or Europe.38
During this time in America, Frank Hamilton described a curved splint placed volarly, and a straight dorsal splint to immobilize the wrist and hand to the level of the metacarpophalangeal joints.38 In Europe, the splints ended at the level of the radiocarpal joint or the fracture.77 Prefabricated splints produced by various manufacturers were popular in North America during the 1800s. Even with the broad acceptance of plaster of Paris in Europe and North America in the late 1800s, many surgeons in Great Britain continued to use prefabricated splints for distal radius fractures.38,76 Hugh Owen Thomas and Robert Jones, the fathers of British orthopedics, believed that using plaster of Paris was risky because it constricted and “embarrassed the local circulation, shutting out light and air and the surgeon's enquiring eye.”38 Jones continued to use tin splints for distal radius fractures until his death in the early 20th century.76
Prior to the advent of the Stryker cast saw (Stryker, Kalamazoo, MI) in 1947, plaster casts were removed with large handled cast shears (some known as the Stile cast cutter). The Stile cast cutter was nearly 2 feet long with small serrated blades the size of standard bandage scissors that gave the user a tremendous mechanical advantage (Fig 4). The cutter could only be advanced approximately ½ in with each closure. It was difficult and painful to remove casts around bony prominences, in which case the technician used a cast knife or hand saw.1 The oscillating Stryker cast saw revolutionized the removal of casts due to its oscillating motion that cut through plaster but not skin. However, complications can still occur, most notable, burns due to excessive friction with a dull blade or in cases when removing a cast over bony prominences or severely swollen skin. Finally, due to the loud noise produced by the Stryker saw, it remains perhaps as intimidating as the old fashioned shears.
The use of plaster of Paris casts remained largely unchanged for more than 100 years after Mathijsen's first report on plaster roller bandages until the introduction of fiberglass casting tape in the 1970s. The first tapes required the use of ultraviolet light for curing, and fiberglass only became practical when the formulation was changed so that water catalyzed the hardening. Fiberglass made it possible to construct a cast that was light yet durable enough to allow greater patient mobility. The introduction of waterproof cast lining material in 1990104 allowed patients with fiberglass casts the added advantage of bathing and swimming without jeopardizing cast or skin integrity.
Waterproof cast liners improve patient satisfaction and hygiene, and allow the patient to swim and receive hydrotherapy. However, the casts take longer to apply and are more expensive.103 Skin complications are more common in children, but are generally minor and resolve within 2 days.104
Although synthetic casting materials are used more frequently, plaster of Paris is still the mainstay for splinting, serial casting, and casting, particularly where careful molding after application is required. In 2002, Kowalski et al reported a prospective study comparing fiberglass cast material with plaster of Paris in short arm and short leg casts. The relative cost per upper extremity fracture treated with plaster of Paris was 17% less than for fiberglass. In 21 measures of activities of daily living and comfort, the fiberglass short arm cast was only better than plaster of Paris when weight was considered.72
Immobilization of the wrist with a plaster of Paris splint was reported as superior to fiberglass splints in a radio-graphic study of healthy volunteers. A volar plaster of Paris splint was equivalent to a short arm cast in immobilizing the wrist except in ulnar deviation.59 However, an ex vivo biomechanical study comparing the strength of fiberglass and plaster of Paris cast materials showed that fiberglass materials were stronger.15
Other important techniques for splinting the hand have maintained their usefulness over the centuries. The technique of “buddy taping” the injured finger to its adjacent intact digit was first advocated by Alexander Tertius from Edinburgh, Scotland (1773-1859 AD). In the 20th century, J. I. P. James, also from Edinburgh, first recommended immobilization of the hand in the “intrinsic-plus” position or “position of safety” with the metacarpophalangeal joints flexed and the interphalangeal joints straight.10 The Galveston metacarpal brace that was designed for the treatment of metacarpal fractures was introduced in the 1980s.109 The brace was designed to be used for apex volar or dorsal fractures of the second through fifth metacarpal. It has adjustable pads and an adjustable strap to provide a three-point bending force to maintain reduction. The brace provides unrestricted motion of the IP, MP, and wrist joints, while allowing the ability to adjust tension during the healing process. This was a substantial improvement compared with the ulnar gutter splint. Velcro hook and loop fastener, thermoplastic splinting materials, and the development of hand therapy as a specialty have further facilitated the use of splints for nonoperative treatment of fractures in the hand.
The use of radiographs and computed tomography (CT) has made fracture diagnosis progressively more accurate. Antisepsis, safe anesthetics, development of nonreactive metallic implants, antibiotics, and patient expectations in affluent societies have also contributed to the interest in treating fractures operatively. Although many fractures of the hand and wrist can be treated with minimal intervention, patients benefit from the application of more sophisticated splints, external fixators, pins, screws, and plates.
Albin Lambotte, (1866-1955), a Belgian surgeon, first documented an operative treatment for phalangeal fractures in 1904.108 He used an open approach to reduce a transverse fracture of the ring finger proximal phalanx, and constructed an external device to maintain the reduction (Fig 5). Lambotte coined the expression “fixateur externe” (external fixator).74 Three years later he reported on a thin carpenter's nail used to stabilize the lip of a Bennett fracture.53 He later reported on the use of wires, nails, screws, and plates to stabilize scaphoid, metacarpal, and phalangeal fractures.74 Lambotte was also the first to report percutaneous pinning of radial styloid fractures in 1908.91
The German surgeon, Martin Kirschner (1879-1942) used steel pins placed through the bones of lower extremity fractures to provide a traction reduction.68 Initially these pins were smooth with a 3.5-6 mm diameter that had a spatulate point; identical to those used today.67 Kirschner refined the skeletal traction treatment of fractures using smaller diameter pins to minimize soft tissue damage and pin track infections. By 1927, he was using chrome plated steel piano strings 0.7-1.5 mm in diameter that remain the smallest and largest diameter of Kirschner wires (K-wires) available in the United States.68 In 1937, David Bosworth used percutaneously placed K-wires to maintain reduction of a fifth metacarpal fracture.17 This technique was used widely during World War II.14,111
The first description of intramedullary (IM) fixation in the hand was in 1936.80 William Carrell used an IM rod carved from a cow's horn to stabilize an infected metacarpal fracture. The fracture healed, but the wound continued to drain until the rod was removed.110 In the late 1940s, Rush and Rush developed IM rods for fixation of long bones of all sizes, including metacarpals.99 In 1995, Gonzalez introduced the technique of closed IM pinning of metacarpals with flexible pins or pre-bent K-wires.49 Recently, Hand Innovations (Miami, FL) introduced the locking IM nail for the treatment of metacarpal and phalangeal fractures by allowing percutaneous fixation with improved rigidity and rotational control.
Among his other innovations, Lambotte first described the use of cerclage wires in the hand in 1913 (Fig 6).74 Interosseous wiring by drilling holes in hand fracture fragments and passing small wires to hold the pieces together was vaguely mentioned in the 1950s.16
Lambotte advocated screw fixation of metacarpal fractures but the technique took another 60 years to become widely used.80 He performed a primitive plate fixation of a metacarpal with an aluminum plate held to the bone with two cerclage wires in 1905.80 Four years later he used a similar plate with screws for fixation.74 In the late 1930s, Otto Herman developed the first plate and screw system specifically designed for the hand.55
The surgical treatment of scaphoid fractures was fraught with difficulty prior to the advent of the headless compression screw first reported by Tim Herbert in 1984.54 The Herbert screw had a threaded trailing head with a pitch that was less than the thread of the leading point of the screw. The trailing head could be completely buried within the scaphoid and the variable pitch design provided compression. Standard cancellous or cortical lag screws were larger with a prominent head that caused impingement and difficulty with insertion. Other screws such as the Acutrak (Acumed, Hilsboro, OR), Twinfix (Stryker, Kalamazoo, MI), and Kompressor (Kinetikos Medical Incorporated, Carlsbad, CA) have been designed to improve the Herbert screw.
The treatment of distal radius fractures was nonoperative until Lorenz Böhler introduced the pin and plaster technique in 1929, which anticipated the use of more elaborate external fixators to support the fracture reduction by ligamentotaxis.51 In 1944, Anderson and O'Neil reported on the use of external skeletal fixation to maintain fracture reduction by ligamentotaxis in a distal radius fracture.2
In the early 1950s, James Ellis from Southampton, England, began using a specially designed T plate to buttress the small marginal fragment in volar Barton's fractures.37 This technique has become widely accepted.7,37,61,85,105 The operative treatment of other unstable distal radius fractures has not reached consensus. Innovations include open reduction and internal fixation (ORIF) with plates and screws,60,62,95 percutaneous pinning,34,50,107 limited ORIF,8,93,102 external fixation (bridging58 and nonbridging41,73), combined internal and external fixation,12,30,90,96,98 arthroscopic assisted fixation,31,33,35,43,46,47 pins and plaster,26,52 and IM fixation.89
In the 1970s, the AO group designed plates specifically for the treatment of distal radius fractures, but the treatment of severely comminuted fractures with external distraction prevailed in the 1980s.13,101 Lack of versatility with the pins and plaster technique21 led surgeons to favor machined external fixation systems by the late 1980s.36 Articulated external fixators showed promise but never came into wide acceptance.25,32,39,44,45,66,87,106
The recognition that precise reduction of the distal radius is required for optimal outcome resulted in an increased interest in treating distal radius fractures with ORIF.6,18,19,69,71 However, there has been some doubt on the correlation between the degree of articular incongruity and posttraumatic arthrosis.23 In 1997, Ring and Jupiter's multicenter study94 on the use of the Synthes pi plate (Synthes Inc, West Chester, PA) popularized the use of low profile dorsal plates for the internal fixation of distal radius fractures. Similarly, Carter's results with the use of the Forte plate (Zimmer, Warsaw, IN) were favorable.22 This technique then lost favor because of complications with tendon irritation and rupture.24,40,56,94,97,100 Others reported restoration of articular alignment and overall patient satisfaction but a high rate of complications.9,42
In 1994, Agee's report on the successful treatment of distal radius fractures with multiplanar ligamentotaxis with the Wrist Jack (Hand Biomechanics Lab Inc, Sacramento, CA) renewed some interest in the use of external fixation.3,20,57,65 The use of nonbridging external fixation79 was reported to have outcomes equivalent to bridging external fixation while allowing early wrist motion. Complications related to overdistraction,63 pin track infections,4,5 and reflex sympathetic dystrophy28 continued to be vexatious. It became clear that ligamentotaxis alone could not restore perfect alignment in comminuted intraarticular distal radius fractures.11
Medhoff's TriMed wrist fixation system (TriMed, Valencia, CA) introduced in 1995 uses low profile plates and wire constructs to provide fragment specific fixation and aims to reduce tendon irritation and rupture seen with dorsal plating.70,92 Fragment specific fixation and the column theory (the distal radius consists of the radial, central, and ulnar columns) are concepts that have changed the way distal radius fractures are conceptualized.70
In 1995, Gesensway and Putnam's biomechanical study demonstrated the superior strength of a new distal radius plate design that incorporated the concept of the fixed angle blade plate with multiple tines replacing screws.48 It was the predecessor to the fixed angle plates that are widely used today. The plate was marketed by Avanta Orthopedics (San Diego, CA) with dorsal and volar options. Although acceptable results were obtained with this plate,112 the introduction of volar fixed angle plates in 2000 allowed more versatility in creating subchondral support and provided fixation of most distal radius fractures from a volar approach.82-84
In 2000, Orbay reported his initial experience with a plate designed specifically for the volar aspect of the radius and incorporated locking pegs for subchondral support.82 Subsequent reports have documented that dorsally displaced fractures of the distal radius can be adequately treated with a volar plate.64,83,84 Although standard AO volar distal radius plates have locking pegs and can be used to treat dorsally displaced distal radius fractures29,75 the majority of surgeons prefer the new, stronger, more versatile plates with locking screws. The fixed angle screws allow the plate to be placed volarly and maintain the stability of the distal fragment. The volar surface of the distal radius provides more room for the plate and may reduce the risk of tendon irritation. The improved strength of these plates has allowed immediate postoperative wrist motion, even in complex fractures. The Stryker distal radius locking plate system, introduced in 2004 provides improved flexibility in screw insertion allowing a 15° variable angulation. The titanium screw is harder than the plate and actually cuts into the hole, creating a locking effect. Although this allows more versatility, it has not been compared with the standard locking screw in biomechanical studies.
The ancient physicians treated fractures with stiffened dressings that were changed frequently to alleviate pain and maintain alignment. These methods pervaded popular medicine for centuries until physicians developed better methods for immobilization in the 19th century. With the advent of improved casting materials, the ambulatory era of fracture treatment was born. The surgical treatment of these injuries became a realization at the beginning of the twentieth century and continues to evolve. Surgical implants were developed to provide rigid immobilization of fractures to maintain reduction and allow early mobilization. However, rigid immobilization of fractures at the expense of the soft tissues can be just as damaging as the ancient physician's techniques. It is clear that the location of implants in relation to adjacent soft tissues, implant material properties and method of fixation can greatly influence outcomes.
Although the methods of fixation of fractures in the hand and wrist have changed dramatically as time has passed, what has not changed is the physician's desire to maintain fracture reduction, alleviate pain, and preserve patient function. Although linen rolls and bark sufficed for the ancient Egyptians, it is likely that even the most relaxed modern day patient would look at their doctor with dismay if these concoctions were applied. Modern implants, advances in operative techniques, improved anesthesia, hand therapy, and the advent of antibiotics have aided greatly in the treatment of these common hand and wrist fractures.
The future of hand and wrist fracture treatment lies in improving our ability to choose the appropriate treatment for the wide variety of patients that present. Each patient's perspective of an optimal outcome is different. Many times the surgeon's perspective of the result differs from that of the patients. A consensus on optimal treatment is difficult to reach between various surgeons. The ancient physicians were no different in that multiple different suboptimal treatments were used for centuries to treat fractures of the hand and wrist. Inadequate communication and lack of a systematic review of outcomes led to stagnation in the care of these injuries until the 19th century. Careful prospective studies of large numbers of patients with appropriate outcomes measures will help to improve our treatment of these difficult injuries. A fracture registry similar to the surgical registries used by our joint replacement colleagues may provide the vehicle to give us these answers. Coordinated multicenter prospective studies, although difficult to perform, will provide valuable data to support our quest to provide patients with the optimal outcome.
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