Arch Orthop Trauma Surg (2010) 130:13851396DOI 10.1007/s00402-010-1082-7TRAUMA SURGERY

Early history of operative treatment of fractures

Jan Bartonbek

Received: 29 December 2009 / Published online: 9 March 2010 Springer-Verlag 2010

Abstract Surgery in the Wrst half of the nineteenth centurywas primarily dominated by pain and fear of lethal infections.Therefore, the absolute majority of fractures and dislocationswere treated non-operatively. Development of operative treat-ment of fractures was inXuenced by three major inventions:anaesthesia (1846), antisepsis (1865) and X-rays (1895). TheWrst to use external Wxation is traditionally considered to beMalgaigne (1843). However, his devices cannot be consideredas external Wxation. Von der Hhe, in 1843, Wxed a non-unionof the femur by inserting into both fragments a couple ofscrews transversely connected outside the wound. VonLangenbeck in 1855 treated a non-union of the humerus withscrews connected by a devise designed for this purpose. Apredecessor of nailing of acute diaphyseal fractures may beconsidered to be Wxation of diaphyseal non-unions of thefemur, humerus and tibia with ivory intramedullary pegs, per-formed by DieVenbach in 1846. Nevertheless, until 1885,osteosynthesis was still a Cinderella having at its disposalmainly wires, ivory pegs and very primitive types of externalWxation. During the following 35 years (18861921), opera-tive treatment of fractures witnessed an unprecedented revolu-tion. Radiology became an integral part of bone and jointsurgery. All types of osteosynthesis, i.e. plates (Hansmann1886), external Wxation (Parkhill 1897) and intramedullarynails (Schne 1913) were introduced into clinical practice.Basic experiments were undertaken, surgical approachesdescribed and the Wrst textbooks on osteosynthesis published.

Keywords History of osteosynthesis Plates External Wxation Intramedullary nails Surgical approaches

Introduction

The history of the operative treatment of fractures is a fasci-nating story that has engaged many authors [37, 1418,22, 27, 29, 37, 40, 73, 8082, 87, 88, 103, 104]. The recent50th anniversary of the foundation of AO (Arbeitsgeme-inschaft fr Osteosynthesenfrage) was the occasion for itsrecapitulation. To understand the development of osteosyn-thesis, it is important not only to become acquainted withthe chronological sequence of individual facts, but also toanalyze the causes, implications and consequences of indi-vidual events, based on original sources.

Operative treatment of fractures in the Wrst half of the nineteenth century

In the Wrst half of the nineteenth century, the foundationswere laid for the modern treatment of injuries of bones andjoints, mainly thanks to the textbooks by Pierre-JosephDesault (17381795), Sir Astley Paton Cooper (17681841) and Joseph Franois Malgaigne (18061865), pub-lished and translated both in Europe and North America[19, 20, 23, 24, 6669]. However, but for a few exceptions,fractures and dislocations were treated non-operatively anddiscussions concentrated primarily on the position of thelimb during reduction, the manner of its performance andimmobilization of the injured limb. The main obstacles tothe development of operative treatment were the pain asso-ciated with surgery and, particularly, concern about infection

J. Bartonbek (&)Department of Surgery, 1st Faculty of Medicine of Charles University and Thomayer University Hospital, Videnska 800, 140 59 Prague 4, Czech Republice-mail: bartonicek.jan@seznam.cz123

1386 Arch Orthop Trauma Surg (2010) 130:13851396and its potentially fatal consequences. As a result, themost frequent operation at that time was limb amputation,mainly for war injuries and open fractures, with few casesof surgically treated non-unions or acute fractures [6, 10,24, 25, 29, 33, 36, 93]. The absence of anaesthesia andasepsis were compensated for by the speed and skill ofsurgeons.

The Wrst textbook to deal with osteosynthesis Trait delimmobilisation directe des fragments osseux dans lesfractures was published in 1870 [10]. Its author, LaurentJean Baptiste Brenger-Fraud (18321900), the Frenchchief naval physician and admiral of the French Navy, sum-marized from literature more than 400 cases of fracturesthat were operated on. At that time, the problem of anaes-thesia had already been solved and the Wrst steps were takenin the prevention of intraoperative infection. Brenger-Fraud described, in total, six types of direct Wxation ofbone fragments, the most progressive of which were wirecerclage and the Wrst prototypes of external Wxation knownat that time. However, in general, operative treatment offractures was at that time still in its infancy.

Discovery of anaesthesia, antisepsis and X-rays (18461895)

Surgery in the Wrst half of the nineteenth century wasprimarily dominated by pain and fear of lethal infections. Sur-geons were, to a great extent, inXuenced by their blindnessresulting from the absence of a method that would allow anaccurate diagnosis of fractures and dislocations, or monitoringthe course of healing, outcomes and complications of thetreatment. All this changed radically within 50 years.

On 16 October 1846, William Thomas Green Morton(18191868), an American dental surgeon, described forthe Wrst time the administration of inhaled ether vapour asan anaesthetic during operation. In the space of a fewmonths, this method had also spread to Europe.

The British surgeon Joseph Lister (18271912), wholived and worked in Edinburgh and later moved to London,was inXuenced by Pasteurs teaching and addressed the pre-vention of surgical infection [14]. In 1865, he treatedsuccessfully an open femoral fracture in an 11-year-old boyusing an antiseptic carbolic acid spray. In 1877, he per-formed osteosynthesis of a closed fracture of the patella,under carbolic acid spray, using a silver wire [65]. Thisoperation became an important part of the history of sur-gery. In Germany, the Listerian method was actively propa-gated by Richard von Volkmann (18301889) from Halleas early as in 1872 and its use quickly spread all overGermany [37, 102]. In 1886, Ernst Gustav Benjamin vonBergmann (18361907) from Berlin introduced asepsis(steam sterilization). Prevention of infection improved also

thanks to the introduction of rubber surgical gloves in the1890s by William Stewart Halsted (18521922) in the USAand subsequently by Emil Theodor Kocher (18411917) inEurope.

Wilhelm Conrad Rntgen (18451923) made his discov-ery of X-ray imaging on 8 November 1895 and published itin the Wrst week of January 1896. The Wrst clinical radio-graph, showing a projectile in the wrist of a 12-year-oldboy, was published in Lancet as early as 22 February1896!!! One of the Wrst radiographs appeared for instancein the Atlas of Fractures, published in 1897 by HeinrichHelferich (18511945) from Greifswald [42]. The Wrstbook on fractures, which had been diagnosed and treated onthe basis of radiographic examination, was published byCarl Beck (18561911), an American surgeon of Germanorigin, working in New York, in 1900 [8].

The decisive era of 35 years (18861921)

In 1885, osteosynthesis was still a Cinderella having atits disposal mainly wires, ivory pegs and very primitivetypes of external Wxation. After World War I, the situa-tion changed radically. During 35 years (18861921),operative treatment of fractures witnessed an unprece-dented revolution. Radiology had become an integral partof the bone and joint surgery. Introduced into the clinicalpractice were all types of osteosynthesis, i.e. plates,external Wxation and intramedullary nails. Basic experi-ments were undertaken, surgical approaches describedand the Wrst textbooks on osteosynthesis published. Thisextremely fruitful period was split by Roentgens inven-tion into two diVerent parts: the pre-radiological andradiological eras.

Pre-radiological period (18861895)

Due to the blindness of surgeons, operative treatment Wrstfocused on subcutaneous fractures, i.e. fractures moreeasily diagnosed by sight and palpation (patella, olecranon,tibia, clavicle and mandible), as well as fractures resistingnon-operative treatment (proximal femur, diaphyseal frac-tures of the forearm). In spite of this blindness, severalsigniWcant publications appeared in this period.

Carl Hansmann (18531917), a German surgeon fromHamburg, was the Wrst to publish in 1886 Wxation of frac-tures by a plate (Fig. 1) [38].

Heinrich Bircher (18501923), a Swiss surgeon fromBern, published in 1887 an extensive article on intramedul-lary osteosynthesis of diaphyseal fractures of the femur andtibia by means of pegs, and of the metaphyseal fractures ofthe tibia by ivory clamps (Fig. 2) [12].123

Arch Orthop Trauma Surg (2010) 130:13851396 1387Nicholas Senn (18441908), an American surgeon fromChicago, dealt in detail in 1893 with the then known meth-ods of osteosynthesis [92]. He studied absorption of asep-tic ivory and bone in the living tissues and developed ahollow perforated intra-osseous splint of which heassumed absorption in a comparatively short time. Foroblique diaphyseal fractures, he designed an extramedul-lary bone ferrule. He successfully used this absorbableosseous sleeve, made from ox bone, in three patients withnon-unions of the femoral, humeral and tibial shafts(Fig. 3). Thus, Senn can be called the father of biodegrad-able implants. His ferrule was predecessor of the Putti-Parham bands.

Pietro Loreta (18311889), an Italian surgeon and per-sonal physician of Garibaldi, was probably the Wrst in theworld to perform, in 1888, an open osteosynthesis of a non-union of the femoral neck, using multiple cerclage [1].

Julius Dolinger (18491937), a Hungarian surgeon fromBudapest, Wxed an acute extracapsular fracture of the femo-ral neck by open osteosuture using silver wire, in 1891 [26].

Fig. 1 Hansmanns plate (Verh Dtsch Ges Chir 15:134137, 1886)

Fig. 2 Birchers intramedul-lary ivory peg and clamp (Langebecks Archiv 34:410422, 1887)

Fig. 3 Senns hollow perfo-rated intra-osseous splint (a) and an extramedullary bone ferrule (b, c) (Ann Surg 18:125151, 1893)123

1388 Arch Orthop Trauma Surg (2010) 130:13851396Willy Meyer (18581932), an outstanding Americansurgeon of German origin and Trendelenburgs pupil, wasthe Wrst to treat in the USA a non-union of the femoral neckwith two nails in 1892 [71].

Elie Lambotte (18561912), a Belgian surgeon andbrother of Albin Lambotte, was probably the Wrst to treat anoblique fracture of the tibial shaft with screws, in 1890[55].

William Arbuthnot Lane (18561943), a British surgeonfrom London, advocated in articles published in 18931895operative treatment of fractures of such a bone as thepatella, tibia, Wbula, clavicle, jaw and olecranon. He Wxedfractures by wire sutures and later by screws [5759].

Radiological period (18961921)

The discovery of X-ray imaging provided bone surgeonswith a tool for diagnosing fractures and dislocations, aswell as for monitoring fracture healing, evaluation of theWnal outcome and of any complications.

Frederic Jay Cotton (18691938) from Boston, theauthor of an outstanding textbook, wrote in 1910 [21]: Weare fortunate today not only in having the X-ray as anaccessory method of diagnosis, but in having, as a result ofthis diagnostic method and of a vast array of observationsmade directly at operation, a material for deductions notaccessible to previous generations. Wisdom did not beginwith this generation, but we have had an unusual opportu-nity to learn. Similarly, in 1912 Emil H. Beckman stated:The use of the X-ray Wrst showed us how very inferior ourbone repair work has been [9].

The development of osteosynthesis was gaining momen-tum and the number of published articles on this subjectwas growing, both in Europe and in the USA [9, 13, 28, 31,32, 34, 35, 39, 4952, 64, 70, 72, 7679, 8385, 89, 94, 95,97, 98, 100]. Some authors, such as Nienhansen Preston,Schne and Sherman, became famous in this Weld, on thebasis of only one or two publications [76, 83, 84, 89, 95,96]. Others such as Lane, Lambotte and Hey Groves dealtsystematically with operative treatment of fractures andpublished their work in a book form [44, 46, 55, 56, 60, 63].This period was symbolically rounded oV with the secondedition of Hey Groves book in 1921 [46].

The development of implants in the late nineteenth and early twentieth centuries

One of the Wrst problems brought about by the introductionof operative treatment of fractures was a total lack of suit-able implants and instruments. Therefore, those whowanted to treat fractures operatively tended to develop their

own implants. It was a period of testing of suitable materi-als and the search for adequate surgical approaches.

Materials

EVorts were concentrated on Wnding a suitable implantmaterial. The oldest implants for internal Wxation of frac-tures were made from various materials, mainly ivory, boneand metal (bronze, lead, gold, copper, silver, brass, steel,aluminium). Ivory and bone pegs were used for intramedul-lary Wxation [2, 11, 25]. Silver was used for cerclage wires,plates and intramedullary pins. However, the Wrst plateswere made from nickel-coated sheet steel [38], and laterfrom silver [98], high carbon steel [60, 63], vanadium steel[95], aluminium [55, 56] or brass [13]. Nevertheless, all themetals were highly problematic from the viewpoint of theirmechanical properties and corrosion. This problem wassolved by the use of stainless steel. Although it wasinvented before WWI, it was not used for the production ofimplants until much later [101].

Experiments

Many authors tested their ideas experimentally. One of theWrst was Ferdinand Riedinger (18441918), a German sur-geon from Wrzburg. His article of 1881, dealing with non-unions of the forearm, included a number of experimentson rabbits and dogs [86]. While the implanted intramedul-lary ivory pegs and bone blocks integrated into the bonewithout problem, the wooden and rubber implants causedinfections. The article was supplemented also with micro-scopic drawings not only of integrated ivory pegs, but alsoof the adjacent physis (Fig. 4).

An outstanding researcher was Nicholas Senn, who in1889 published a book on experimental surgery [91]. Henot only studied the healing of intracapsular fractures of thefemoral neck [90], but veriWed in dogs the feasibility,safety and utility of direct fracture Wxation with bone fer-rules [92].

Harry M. Sherman (18541921), an American surgeonfrom San Francisco, studied experimentally in 1914 severalsigniWcant issues, including: Are screws and plates toler-ated inside a joint? and What are the early and late eVectsof well, and insuYciently, countersunk screws. Amongother things, he found out that The use of two diVerentmetals in these screws and plates does not change theresults in the articulation, except so far as the possible elec-trical reaction is concerned in the staining of the tissues[94].

The most extensive and comprehensive experimentswere made from 1914 by Hey Groves [44]. In most of his100 experiments, he studied on the cat tibias and femurs thehealing of fractures Wxed by plates, intramedullary pegs123

Arch Orthop Trauma Surg (2010) 130:13851396 1389(ivory, steel, metallic magnesium, wire spirals, bone, decal-ciWed bone) and external Wxators. He also studied Wlling ofbone defects with bone pieces or chips and regeneration ofbone after subperiosteal removal of a piece of its entirethickness. The results of his experiments were illustrated byskiagrams, and photographs of microscopic specimensand microscopic sections. His conclusions are valid to thisday. He thereby anticipated much of the experimental workof AO by more than 40 years.

Cerclage

Wire cerclage was one of the earliest methods of internalWxation [1, 10, 26, 29, 65, 71, 81, 82]. Improvement of thistechnique was published almost simultaneously by threeauthors. Robert Milne, an American surgeon, described in1912 cerclage using Xexible threaded pins [72]; VittorioPutti (18801940), an Italian orthopaedic surgeon, pre-sented in 1914 cerclage with a narrow metal band [85].Two years later (1916), a similar method was published byFrederick William Parham (18561927), an American sur-geon from New Orleans [77]. The implant spread world-wide under the name Putti-Parham bands and in variousmodiWcations it is occasionally used today.

Plates

The Wrst to publish his experience with plate osteosynthesiswas Carl Hansmann, in 1886, as mentioned above [39].Hansmann used plates from nickel-coated sheet steel in 20cases, 15 times in fractures (8 fractures of the tibia, 3fractures of the femur, 1 fracture of the radius, 1 olecranonfracture and 2 fractures of the mandible) and 5 times innon-unions (humerus, ulna, radius, femur, tibia). Part of theplate, and the shanks of the screws that Wxed it to the bone,protruded from the wound and could be therefore removedpercutaneously. Hansmann kept the surgical wound strictlyaseptic and used washable external rubber splints. He didnot mention any complications and removed the plates after48 weeks. Neither in Germany nor elsewhere in Europedid Hansmann have a successor for a long time. It was onlyafter a 14-year interval that other publications in this Weldappeared, mainly in the USA.

Lewis W. Steinbach (18511913) from Philadelphia in1900 treated four cases of fracture of the tibia with a silverplate of his own design, Wxed to each of the fragments bytwo steel screws [98]. He also described in detail the opera-tive technique, including the use of drainage tubes. It wasthe Wrst publication to use radiography to document theinjury, the plate Wxation and the Wnal outcome after implantremoval.

Edward Martin (18591938), also from Philadelphia,published in 1906 radiographs of fractures of the femoralshaft, and the tibial shaft and metaphysis, treated withplates and monocortical screws [70]. Among radiographspublished by Martin was also a healed fracture of the distalshaft of the radius treated with plate and bicortical screwsby John Ashhurst (18391900) 7 years before publicationof Martins article, i.e. in 1899!

William Lawrence Estes (18551940), from SouthBethlehem, in 1912 in an article on fractures of the femoralshaft, discussed in detail the operative technique, stating:In 1886 the writer devised a plate for direct Wxation offractured bones. It has been used in his clinic with goodresults ever since. It is a modiWcation of the early Schedeplate. It is made of soft steel, nickel plated. It has beenknown to bend a little but has never broken while in use[28]. This indicates that Estes developed the plate simulta-neously with Hansmann! Unfortunately, no details could betraced.

Joseph Augustus Blake (18641937) of New Yorkreported 106 surgically treated fractures in 1912 dealing indetail with plate osteosynthesis [13]. From 1905, he usedplates of his own design, made mostly of silver, and alsooccasionally of brass or steel. He later applied the Laneplates to the treatment of fractures of the shafts of thehumerus, ulna, radius and femur.

Emil H. Beckman (18721916) from the Mayo Clinic inRochester was probably the Wrst to publish, in 1912, aradiograph of a fracture of the medial malleolus Wxed witha plate [9].

William ONeil Sherman (18801979) from Pittsburghwas a strong proponent of internal Wxation in the USA andcontributed to signiWcant improvements in plate design. Ashe worked for Carnegie Steel Company, he had optimalconditions for experimenting with both the material and

Fig. 4 Riedingers experi-ments: a ivory peg (a) incorpo-rated in medullary channel, b physis of operated on bone, c physis of control contralateral bone, the diVerence in the height of both physes is clearly visible (Arch Klin Chir 26:985993, 1881)123

1390 Arch Orthop Trauma Surg (2010) 130:13851396design of plates. He published his results in 1912 [95]. Hissophisticated plates, designed on the basis of mechanicalprinciples, were made of vanadium steel, using self-tappingmonocortical screws. Later, in 1926, he dealt in detail withplate osteosynthesis of diaphyseal fractures of the femur,attaching the plates with bicortical screws [96].

In 1914, Miller Edwin Preston (18791928) from Denverdesigned the Wrst angled blade plate for osteosynthesis offemoral neck fractures, although he used it probably only ina few cases [83].

At the beginning of the twentieth century, plateosteosynthesis started spreading in Europe, mainly due toWilliam Arbuthnot Lane and Albin Lambotte, who werefollowed several years later by Ernest William Hey Groves.

Albin Lambotte stated in the 1907 Wrst edition of his bookthat from 1900 he had treated various diaphyseal fractureswith plates made of aluminium, which he Wxed by self-tap-ping monocortical screws [55]. In the second edition of hisbook, published in 1913, he described three diVerent types ofplates, one of which was contoured [56]. Albin Lambottealso used plates for the Wxation of fractures of the distalhumerus, distal femur, proximal tibia and the mandible.

William Arbuthnot Lane published, in 1907, a successfulWxation of diaphyseal fracture of the femur using a pair ofplates [61]. The second edition of his book in 1914 wasdevoted primarily to plate osteosynthesis [63]. Lane Wxedcarbon steel plates of his own design with monocorticalscrews. Their disadvantage was their Ximsiness and thenecessity to immobilize postoperatively the limbs with exter-nal splints. Lane used plates for the Wxation of all diaphysealfractures of the clavicle, humerus, radius, ulna, femur, tibiaand Wbula, and also of both malleoli, olecranon and scapula.

Henry S. Souttar (18751964), an outstanding surgeonfrom London, who later became famous for his operation formitral stenosis, published in 1913 his own design of a plateWxed with a Wnely threaded screw [97]. He considered thevascular impact of the plate on the bone and tried to reduceits footprint on the bone in order to not impair healing.

Ernest William Hey Groves dealt in detail with plateosteosynthesis, including experiments on animals [44]. Forinstance, he designed curved plates or plates with T-shapedends. He compared the mechanical properties of the Laneand Lambotte plates, as well as Wxation properties ofwood and metal screws. Hey Groves also used inter-fragmentary Wxation and bolted plates.

Due to the eVorts of the above-mentioned authors, platesbecame, at the beginning of twentieth century, the most fre-quently used implants for internal Wxation of fractures.

External Wxation

The Wrst to use external Wxation is traditionally consideredMalgaigne (Fig. 5) [16, 81, 82]. In 1840, Malgaigne used

and in 1843 published pointe mtallique, by which hepercutaneously Wxed fractures [66]. However, this devicecannot be considered as external Wxation [18]. The sameapplies to griVe mtallique, which Malgaigne designed in1843 and described in 1847 [66]. GriVe mtallique wassubsequently modiWed by Rigaud in 1850 and Chassin in1852 [10]. It was not a typical external Wxator and wasintended only for fractures of the patella [10, 18, 66].

Povacz [82] in Historie der Unfallchirurgie ascribedthe Wrst application of external Wxation to Carl WilhelmWutzer (17891863) from Bonn, Germany. In 1843, Wut-zer allegedly used the Wrst external Wxator to treat a non-union of femur persisting for 11 years [82]. But the realityis diVerent. Geller [33] in his dissertation thesis in 1847brieXy mentioned that C. Claus von der Hhe Wxed in 1843at Wutzers clinic a non-union of the femur by insertinginto both fragments a couple of screws transversely con-nected outside the wound. However, the patient died.Therefore, Wutzer in 1846 treated a non-union of the femurby resection of the ends of the fragments and use of a gold-wire cerclage, and the operation was successful [33].

Bernhard Rudolf Konrad von Langenbeck (18101887)from Berlin in 1855 treated a non-union of the humeruswith screws connected by a devise designed for this pur-pose [30]. Due to infection, the Wxator had to be removedafter 12 days and the non-union was left to heal conserva-tively.

Fig. 5 Malgaignes external Wxators: a pointe mtallique, b griVemtallique (Trait des fractures et des luxations. JB Baillire, Paris1847)123

Arch Orthop Trauma Surg (2010) 130:13851396 1391An original and today quite unknown concept of externalWxation was developed by Carl Wilhelm v. Heine (18391877), who worked in Innsbruck and later in Prague [41].In 1872, Heine Wxed a non-union of the femur by two ivorypins inserted transversely through both cortices of eachfragment, threaded at the end to accommodate the end cap.Each of the pins was transversely connected to the bar. Theother end of the bar was Wxed in an arch, the arms of whichwere integrated into the plaster bandage (Fig. 6). However,this Wxation proved to be inadequate. Therefore, in thepatients with non-union of the humerus, tibia and femur,the fragments were directly Wxed by bone clamp jawsresembling a pin-less external Wxator. The clamp protrudedfrom the surgical wound and was connected by a transversebar Wxed again in the plaster bandage (Fig. 6). In this way,Heine healed only the non-union of the humerus, while theother cases required amputation.

External Wxation, as we know it today, started to developas late as at the turn of the twentieth century. In the USA, in18971898 Clayton Parkhill (18601902) from Denver

designed external Wxation clamps and used them for diVer-ent types of fractures (Fig. 7) [78, 79]. His early death,caused by acute appendicitis when he refused operation,prevented him from developing this method, which wasthen further developed by his colleague Leonard Freeman(18601935). In 1911, Freeman described the detailedoperative technique, including various tips and tricks [31].In 1919, he introduced the turnbuckle to facilitate reduc-tion, which was a highly sophisticated precursor of the AOfemoral distractor [32]. Howard Lilienthal (18611946),from New York, who later became an outstanding thoracicsurgeon, used external Wxation of his own design in diaphy-seal fractures, including the infected ones in 1912 [64].

In Europe, Albin Lambotte became the father of externalWxation. He developed his own external Wxator clamps,independently of Parkhill. The design of the Lambotte Wxa-tor was highly sophisticated and was very similar to thecurrent AO tubular Wxator. The screws were self-threadingand self-tapping and the clamps provided the Wxator withdiVerent degrees of freedom. Lambotte used it successfullyfrom 1902 for all diaphyseal fractures [55, 56].

In 1916, Ernest Hey Groves described diVerent types ofexternal Wxator clamps for intraoperative reduction of frac-tures, allowing both distraction and compression of frag-ments. For stabilization of diaphyseal fractures of the femurand tibia, he used external Wxator frames [44].

Although external Wxation was not used as frequently asplates, it was relatively widespread both in Europe and theUSA during the study period.

Intramedullary nailing

A predecessor of nailing of acute diaphyseal fractures maybe considered to be Wxation of diaphyseal non-unions of thefemur, humerus and tibia with ivory intramedullary pegs,performed by the prominent Berlin surgeon Johann Fried-rich DieVenbach (17921847) and published in 1846 [25].

The same method for a non-union of tibia was used in1861 by the German surgeon Theodor Bilroth (18291894),

Fig. 6 Heines external Wxators: Fig. 1 and 2 ivory pins Wxator,Fig. 3 and 4 pin-less external Wxator. (Langebecks Archiv 22:472495, 1878)

Fig. 7 Parkhills external Wxator (Ann Surg 28:552570, 1898)123

1392 Arch Orthop Trauma Surg (2010) 130:13851396who worked at that time in Zurich [11]. He removed theivory grafts 2 weeks after operation, examined them micro-scopically and found their partial resorption. His methodconsisted in opening the medullary cavity of both diaphy-seal fragments with a drill.

The ivory grafts inserted subsequently served as biologi-cal stimulators, rather than as mechanical Wxation. Antisep-sis was not known at that time and thus the wound alwaysbecame infected and the pegs had to be removed after13 weeks. However, the subsequent inXammatory hypera-emia often resulted in healing of the non-union.

The superWcial resorption of ivory pegs by macrofagswas described also by Emanuel Aufrecht (18441933),from Magdeburg. In 1877, Aufrecht microscopically exam-ined ivory pegs, which an outstanding German surgeonWerner August Hagedorn (18311894), had used to Wx anon-union of the tibia under antiseptic conditions [2].

Carl Wilhem v. Heine described in 1878, in an articlepublished after his death [41], a successful Wxation ofdiaphyseal non-union of humerus and ulna with ivory pegs.Ferdinand Riedinger studied experimentally internal Wxa-tion with ivory pegs in 1881 [86]. Heinrich Bircher treatedsuccessfully in 1887 diaphyseal fractures of the femur andtibia with intramedullary pegs [12]. A similar type of intra-medullary Wxation was the intraosseous splint described byNicolas Senn in 1893 [92].

Metallic nails were initially used to Wx fractures of thearticular ends of bones, particularly in fractures of the fem-oral neck [71, 74, 93]. The Wrst operation in this respectwas performed by Langenbeck in 1858 [93]. Paul Niehans(18481912) from Bern, in 1904, described treatment of asupracondylar humeral fracture in a child [76]. The authorperformed open reduction and nailing in six cases, from theKocher radial approach after temporary osteotomy of theolecranon!

The Wrst successful closed nailing of a diaphysealfracture was described by Georg Schne (18751960)working in Greifswald in 1913 [89]. Under Xuoroscopiccontrol, he treated a total of seven diaphyseal fractures ofthe ulna or radius, using percutaneously inserted silverpins (Fig. 8).

A highly signiWcant, although until now not fully recog-nized, contribution to intramedullary nailing was made byErnest William Hey Groves. He conducted a series ofexperiments with intramedullary pegs and nails made ofbone, ivory and metal [44, 46]. Hey Groves also testeddiVerent designs of nails. In 1918, he treated two cases ofgunshot fracture of the femoral shaft by a steel nail [45].Unfortunately, Hey Groves remarkable contribution tointramedullary osteosynthesis has been rather overshad-owed by the eminence accorded to Gerhard Kntscher.

Despite all eVorts, nails did not win recognition in thetreatment of diaphyseal fractures at the beginning of the

twentieth century. One of the main obstacles was the lackof a suitable material.

Surgical approaches

It is surprising that the authors of this period paid such littleattention to operative approaches in their books and arti-cles. The Wrst book containing a more detailed descriptionand Wgures showing operative approaches was Operation-slehre (Textbook of Operative Surgery) published in 1907by Theodor Kocher, a Swiss surgeon from Bern [50].Kocher described therein a number of approaches thattoday bear his name (hip, elbow and calcaneus).

The very Wrst publication dealing in detail with operativeapproaches to long bones was the 1918 article by JamesEdwin Thompson (18631927) [99]. This English surgeonand anatomist, who moved to Galveston in Texas [17], deW-ned the requirements for operative approaches that are validtill today:

ease of access, preservation of all nerves, both sensory and motor, prevention of unnecessary injury to muscles, preservation of the vascular supply.

Subsequently, he described a number of approaches to allthe long bones, including their articular ends. Of the wholearticle, history remembers merely the posterolateralapproach to the radial shaft that is today named after him.

It was not until 1945 that the Wrst two comprehensivetextbooks of operative approaches were published. The Wrstof them was Extensile exposure applied to limb surgerywritten by Arnold Kirkpatrick Henry (18861982) [43].This Irish surgeon and anatomist, an outstanding represen-tative of the Dublin surgical school, formulated the conceptof extensile approaches in internervous planes. In additionto general principles, he described also a number ofapproaches, the best known of which is Henrys volarapproach to the radius. A comprehensive Atlas of surgical

Fig. 8 Schnes intramedullary nailing of forearm fractures (MnchMed Wschr 60:23272328, 1913)123

Arch Orthop Trauma Surg (2010) 130:13851396 1393approaches to bones and joints containing also approachesto the spine, pelvis, mandible and temporomandibular jointwas published by TouWck Nicola (18941987), an Ameri-can orthopaedic surgeon from New York [75].

Luminaries of bone surgery of the Wrst half of the twentieth century

Outstanding from the above-mentioned authors, who moreor less contributed to the development of osteosynthesis,are three extraordinary personalities especially worthy ofmention.

William Arbuthnot Lane (18561943), the British sur-geon working in London, was a pioneer of internal Wxa-tion who treated closed fractures operatively from 1892.His Wrst publications may be considered as the Wrst decla-ration rationally defending operative treatment of frac-tures [5759]. In 1905, he published the book Theoperative treatment of fractures [60]. In 1907, he addedalso plates of his own design [61]. These plates appearedas a preferred method only in the second edition of hisbook in 1914 [62]. Lane was an excellent surgeon with aprofound knowledge of anatomy. He was the originatorand a strong proponent of the no touch technique, forwhich he developed a number of dedicated instruments[15, 70, 78]. As a result, he had a very low incidence ofinfective complications. He was in close contact with theGerman Surgical Society, and regularly attended itscongresses at the beginning of the twentieth century. Hisconcepts became very popular, particularly in the USA[39, 62].

Albin Lambotte (18661955), a Belgian surgeon fromAntwerp, was a true genius of bone surgery, who at thebeginning of the twentieth century extraordinarily inXu-enced its development [27, 73, 81]. His contribution isremarkable mainly due to the comprehensiveness of themethods he used. Plates, external Wxation, cerclage, screwsand nails, all of which he used for various types of frac-tures. In addition, he invented or improved a number ofinstruments. In 1907, he published the book Linterven-tion opratoire dans les fractures rcentes et anciennesenvisage particulirement au point de vue de losto-syn-thse [55] the title of which presents for the Wrst time theterm osteosynthesis. The revised edition of 1913 is awork, which to date remains fascinating by virtue of itsscope of coverage [56]. Unfortunately, it has been trans-lated into neither English nor German.

Both editions contain a detailed documentation of a greatnumber of his surgical cases. Lambotte used radiographs asa standard for diagnosis, as well as for monitoring thecourse of healing. He carefully recorded the radiographdocumentation of each of his patients in the form of sche-

matic drawings made from X-rays using a pantograph,sometimes including functional results. The technique ofhis operations and their results were well ahead of his time.Although Lambotte was well known in the English-speak-ing surgical world, due to the language barrier his ideascould not spread as did those of Lane.

Ernest William Hey Groves (18721944) from Bristol isnowadays unjustly neglected in the history of osteosynthe-sis. During World War I, in 1916, he published a textbookthat is almost unknown today On modern methods oftreating fractures [44]. A second edition followed in 1921[46]. The textbook surprises by its comprehensive coverageof the given issue and many of its concepts are almost thesame as in current textbooks on bone trauma. The readerwill also Wnd here three extensive chapters dealing withoperative treatment, showing in detail how the author usedplates, nails and external Wxation. His extensive experi-ments on animals using all these implants are unique. Alarge space was devoted to mechanical properties of diVer-ent types of plates and screws suitable for the cortical bone.In fractures of the femur, he introduced nailing from the tipof the greater trochanter, as well as retrograde nailing fromthe fracture site [45]. In some cases, the author Wxed intra-medullary pegs by transversely inserted screws, whichanticipated the concept of locking nailing. Hey Groves wasa universal bone surgeon. He studied also the application ofsolid bone grafts and used them to treat fractures of thefemoral neck [48]. He signiWcantly inXuenced reconstruc-tive surgery of the hip and, in 1927, designed an ivory hipreplacement, similar in form to the later Judet prosthesis[47]. In spite of this, Hey Groves historical contribution tooperative treatment of fractures has not yet been fullyappreciated.

Contribution of individual surgical schools

British surgical school

Throughout the nineteenth century and in the early twen-tieth century, British surgeons were pioneers in the Weldof closed and operative treatment of fractures. Lister,Lane and Hey Groves could rely on the foundations laidby Sir Astley Cooper, and the Dublin and Edinburgh sur-gical schools [46, 19]. Lister succeeded in reducinginfection [14]. Lane became a respected proponent ofosteosynthesis and the no touch technique, not only inGreat Britain, but also in Germany and the USA [15].Hey Groves studied all types of osteosynthesis, includingexperimental ones; he published the Wrst modern text-book on closed and operative treatment of fractures andcontributed also to the development of reconstructive hipsurgery [4448].123

1394 Arch Orthop Trauma Surg (2010) 130:13851396German surgical school

In the second half of the nineteenth century, the German-speaking surgeons became strong advocates of the operativetreatment of fractures and promptly accepted the Listerianprinciples as early as in 1872 [14, 37]. In addition, manyof them gained experience from the PrussianAustrian(1866) and GermanFrench (1870) wars. As a result, in the70s and 90s of the nineteenth century, German surgery hadthe edge over the rest of the world. In 18471913, Germansurgeons published key original articles on external Wxa-tion, plate osteosynthesis and intramedullary nailing[25, 30, 33, 38, 41]. Unfortunately, none of these Germanauthors dealt systematically with operative treatment offractures. This was the main cause for the gradual declineof German bone surgery from its position of pre-eminenceat the beginning of the twentieth century. The only signiW-cant proponent of operative treatment in Germany in theWrst decades of the twentieth century was Fritz Knig(18661952), the son of the well-known German surgeon,Franz Knig (18321910) [5154, 104]. Fritz Knig wasalso the author of the Wrst German book on osteosynthesis,published as late as in 1931 [54].

French surgical school

In the Wrst half of the nineteenth century, the French schoolof bone surgery, represented by Dupuytren, Larrey andmainly Malgaigne, reached its climax. However, Branger-Frauds book of 1870, dealing with osteosynthesis, was anepilogue of this era [10]. Its author had no successor inFrance for many years. The situation radically changedwith Albin Lambotte, a Belgian surgeon with links toFrench surgery and writing in French, whose contributionwas cardinal [55, 56].

American surgical school

At the beginning of the nineteenth century, surgeons inthe USA had established close contacts with the English,German and French surgical communities. Clayton ParkhillsigniWcantly inXuenced the development of external Wxa-tion, both in the USA and around the world. Also, thedevelopment of plate osteosynthesis was extraordinary inthe USA, from the very beginning of the introduction ofthis method. It is amazing how many interesting articlesdealing with operative treatment of fractures, published bya signiWcant number of authors, appeared in the Wrst fewyears of the twentieth century [9, 13, 28, 34, 49, 64, 83, 94,95, 100]. Writers discussed in detail operative techniquesand many other related topics. Most of the articles wereamply documented by radiographs and drawings. Thisperiod culminated around 1912. Sherman plates subse-

quently spread all over the world. Many of the above-men-tioned authors excelled also in other surgical disciplines(thoracic surgery, neurosurgery, andrology), but in factnone of them was a full-time specialist in bone and jointsurgery. This was probably one of the reasons why a text-book on internal Wxation of fractures did not appear in theUSA until as late as 1947 [101].

Epilogue

It is fascinating how aptly Preston deWned the main prob-lems of internal Wxation of fractures as early as in 1916[84]: There is no branch of surgery in which nature ismore exacting then bone work. To be successful in thisWeld, the cases must be carefully selected, the most rigidasepsis should be observed, the surgeon must possess agood working knowledge of anatomy and fully appreciatethe laws of stress, strain and leverage. The internal Wxationof a fracture is decidedly an engineering problem, as wellas a surgical procedure, and it is probable that a larger per-centage of failures have resulted from violation ofmechanical laws than have been due to faulty surgicalasepsis.

After World War I, the way opened for operative treat-ment of fractures to spread successfully all over the world.Plate osteosynthesis, particularly, became highly popularboth in Europe and in the USA. However, the Wrst genera-tion of advocates of osteosynthesis was no longer as activein publishing works on bone surgery as hitherto. As aresult, internal Wxation of fractures, in many cases, passedinto the hands of unprepared surgeons, whose knowledgewas insuYcient to understand the principles deWned andrespected by their predecessors. Over a short period, a largenumber of catastrophes occurred to swing the pendulum ofspecialized public opinion in favour of conservative treat-ment, for many years. This, however, cannot change thefact that in a historically very short period of 50 years(18701921), solid foundations were laid for operativetreatment of fractures, many of which we continue torespect to this day.

Acknowledgments This article could not have appeared withoutthe extraordinary help in collecting original sources, oVered byMs. Ludmila Frajerov from the Klementinum (Czech NationalLibrary) and Ms. Mirka Plecit from the 3rd Faculty of Medicine,Charles University, Prague and Arsen Pankovich, MD. I also wish tothank Ms. Ludmila Bbarov and Chris Colton, MD for editing theEnglish version of the manuscript.

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Early history of operative treatment of fracturesAbstractIntroductionOperative treatment of fractures in the first half of the nineteenth centuryDiscovery of anaesthesia, antisepsis and X-rays (1846-1895)The decisive era of 35 years (1886-1921)Pre-radiological period (1886-1895)Radiological period (1896-1921)The development of implants in the late nineteenth and early twentieth centuriesMaterialsExperimentsCerclagePlatesExternal fixationIntramedullary nailingSurgical approaches

Luminaries of bone surgery of the first half of the twentieth centuryContribution of individual surgical schoolsBritish surgical schoolGerman surgical schoolFrench surgical schoolAmerican surgical school

EpilogueAcknowledgmentsReferences

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