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P

HISTORY AND GENERAL


PRINCIPLES OF
FRACTURE TREATMENT

M*-

C H A P T E R

Historical Review of the


Treatment of Fractures
and Dislocations
Ramon B. Gustilo, M.D.
Joan E. Bechtold, Ph.D.

EVOLUTION OF FRACTURE FIXATION DEVICES


DEVELOPMENT OF INTRAMEDULLARY NAILING
DEVELOPMENT OF BONE PLATES
DEVELOPMENT OF EXTERNAL FIXATION

EVOLUTION OF MEDICAL MANAGEMENT OF FRACTURES AND


DISLOCATIONS

Although the methods of fracture management have


changed throughout medical history, the goal of physicians has remained constant since the time of Hippocrates: to restore the patient to his optimal anatomic
and functional state.
Hippocrates (Fig 1-1), born in Greece in 460 B.C.,
advanced the five concepts of fracture management
antisepsis, bandaging, reduction, splinting, and trac tionthat would supplement or reinforce the "iiealing
powers of nature." The public's expectations of the
physician were minimal because of the strong faith in
mediacatrix natura ("natural medicine"). 9 Cases of
malunion were interpreted as inevitablenature's way
of handling the injuryand not the failure of the phy sician whose role was only peripheral to the healing
process.
Yet Hippocrates' most significant achievement, ac-

cording to historian Field H. Garrison, was to disassoci ate medicine from religion and philosophy. Hip pocrates' astute clinical observations, presented in 70
books, laid the foundation for the scientific method in
medicine.
Hippocrates appears to have been particularly interested in fractures and dislocations and wrote three
books on the skeletal system aione: On Fractures, On
Articulations, and Instruments of Reduction. Because
of their detail, it can be safely assumed that Hip pocrates had extensive practical experience in the
management of fractures and dislocations. Here's how
Hippocrates described fracture of the arms (Fig 1-2):
when the arm is broken, if one stretches the forearm
and adjusts it while in this position, the muscle of the
arm will be bound while extended; but when the
dressing is over, and the patient bends his arm at the
elbow, the muscle of the arm will assume a different
shape. The following, then, is the most natural plan of
setting the arm: having got a piece of wood a cubit or
somewhat less in length, like the handles of spades, suspend it by means of a chain fastened to its extremities
at both ends; and having seated the man on some high
object, the arm is to be brought over, so that the armpit may rest on the piece of wood, and the man can
scarcely touch the seat, being almost suspended; then

History and General Principles of Fracture Treatment

FIG 1-2.
Management of a broken arm as described by Hippocrates.

FIG 1-1.
Hippocrates, who laid the foundation for the scientific
method of medicine, appears to have been particularly interested in fractures and dislocations. (Redrawn from a drawing by Peter Paul Rubens, in Bettmann OL: A Pictorial History of Medicine. Springfield, IL, Charles C Thomas, 1962.)

having brought another seat, and placed one or more


leather pillows under the arm, so as to keep it a moderate height while it is bent at a right angle, the best
plan is to put round the arm a broad and soft skin, or
broad shawl, and to hang some great weight to it, so as
to produce moderate extension or otherwise, while
the arm is in the position I have described, a strong
man is to take hold of it at the elbow and pull it downward. But the physician standing erect, must perform
the proper manipulation, having the one foot on some
pretty high object, and adjusting the bone with the
palms of his hands; and it will readily be adjusted, for
the extension is good if properly applied. Then let him
bind the arm, commencing at the fracture, and do otherwise as directed above . . . and every third day let
him bind it anew and make it tighter; and on the seventh or ninth day let him bind it up with splints, and
leave it so until after the lapse of more than 30 days. 1

Between the 1st and 15th centuries A.D., superstition


prevented serious studies of gross anatomy and pathology. Galen's concept of "laudable pus"finding a miraculous substance to prevent sepsis and promote healingprevailed.
Devices (other than "laudable pus") to promote
healing have been invented, used, discarded, reinvented, modified, and evolved. The next sections detail
the evolution of appliances to treat fractures and dislocations. The following sections discuss the evolution of
fracture management techniques.

EVOLUTION OF FRACTURE FIXATION


DEVICES
Bones have broken since the beginning of humanity. As
described by Monro (1935),16 early methods to stabilize fractured bones include linen splints stiffened with
gum and plaster by the Egyptians and bandages suffused with resins, gums, and waxes as recorded by Hippocrates (350 B.C.) and with lime and egg white as recorded by the Arab physician Rhazes. In 1798, the first
European report of the use of gypsum by British surgeons in Arabia occurred, 16 but its properties were not
exploited until 1852 when the Dutch surgeon Matthysen devised a method to coat and infuse cotton ban-

Historical Review of the Treatment of Fractures and Dislocations


dages with gypsum. 3 Matthysen's method did have the
drawback that prior to use the cotton could not be come wet, which precluded efficient storage or transportation (such as to the battlefield). In the 1930s the
addition of binders such as starches, gums, and dextrins made commercial bandage preparation feasible,
although in the United States it was not until after the
mid-1940s that commercial bandages were in common
usage.6
Braces and splints remained of rudimentary design
from the time of Hippocrates until the mid-18th cen tury when Jean-Louis Petit (France, 1726) designed a
"fracture box," William Sharp (England, 1767) de signed a molded splint that is a predecessor of modern
modular cast brace systems, Benjamin Gooch (Norway,
1773) designed a wooden splint with articulation at
the knee for either a fractured femur or tibia, and Rob ert Chessher (England, 1828) designed a double inclined plane for either femur or tibia fractures. 1
The practical application of surgical internal fixation
began only in the last 30 to 50 years, although there
are sporadic reports of the surgical implantation of various materials throughout the last several centuries.
Writings of the 16th century indicate that the Incas
and Aztecs may have used "resinous wooden pegs in
the medullary canal of long bones for the treatment of
nonunions," but techniques and results were not recorded. 28 In a similar concept, ivory pegs were used by
the Germans Heine (1875), 2 5 Bircher (1886), and
Koenig (1913) with good results and gradual absorption of the ivory if infection did not develop. 28 Hoglund's bone pegs (1917) were another early prede cessor of intramedullary nailing. 28
The first recorded case of internal fixation of a fresh
fracture is thought to be that of brass cerclage wiring
of the humerus in 1775, although a recent review of
pertinent literature of the time casts aspersion on
whether the operation actually took place. 8 The surgeon purported to have performed the operation de nied any involvement, although he did say that he had
seen this operation at the hands of two Toulousse sur geons, Lapujade and Sicre. It is interesting that a peer
review criticized this operation for not following the
"skills of the time." 8
The earliest report of external fixation appeared in
1840 by Malgaigne with his description of a percutane ous spike with circumferential straps around the
tibia.29 In 1843 Malgaigne reported a device to achieve
reduction and stabilization of a fractured patella
through a four-pronged clamp. 29
Two devices were developed in the early 1900s that are
used today in virtually their original form. One is the
Steinmann pin. Fritz Steinmann was a Swiss surgeon * who
in 1908 published a report of his 3- to 5-mm stainless
steel pin with a sharp point at one end. Three

years following his report to the Swiss medical commu


nity, an Italian orthopedic surgeon, Alessandro Codivilla, wrote an article in the same journal stating that
he himself had designed this pin. Codivilla had in fact
in 1903 and 1904 reported on a traction device incor
porating a similar pin that anchored itself in bone. The
ensuing heated and public discussion ended in 1913
with Codivilla's death, and the contested pin retained
the name of Steinmann. 22
... -r
The second device that is still used in its. original
form is the Kirschner (or K) wire. Martin Kirschner
was born in Prussia in 1879 and studied in Freiburg,
Munich, and Zurich. After several years of training in
various German cities and an appointment in Konigsberg, he became chairman of the department of Sur gery in Tubingen. The steel wires that bear his name
were developed in 1909. He also developed new hernia operations and a new surgical approach to the knee
joint, was the first to successfully surgically treat pul monary embolus, and was an early advocate of routine
anesthesia.21
DEVELOPMENT OF INTRAMEDULLARY
NAILING
Dieffenbach (Prussia, 1841) performed early intramedullary nailing with ivory pegs, and his separate
techniques for fixing transverse fractures and those
with overlapping surfaces became known as "Dieffenbach's operation." 25 Heine (Germany, 1875) and Bardenheur, Socin, Bruns, and Bircher all reported the use
of ivory pegs in treatment of fractures, and Nicholas
Senn (Milwaukee, 1880s) used bone and iron nails in
addition to ivory, and performed animal experiments
on femoral neck fractures in cats. 25 Nicolaysen (Norway, 1897) identified intramedullary nailing concepts,
with particular attention to the importance of travers ing the isthmus of the medullary canal. 28 Lambotte
(Belgium, 1907, reported in 1913) is recognized as
also being a pioneer in intramedullary fixation by using
screws spanning from the greater trochanter to the
proximal third of the medullary canal to fix trochanteric fractures 28 as well as achieve clavicular fixation
(1907); he also used "carpenter's nails" for metacarpal
head fractures (1913). 25 Burghard (England, 1914)
chose knitting needles to fix femoral neck fractures. 25
Lilienthal (New York, 1910) performed intramedullary
splinting with an aluminum rod for a compound femur
fracture.
Others who were influential in the early decades of
intramedullary nailing were Hey Groves (England,
1914 to 1918), who used nails of similar design to
modern devices and experimented with resorbable materials but was hindered by sepsis; Lambotte (Belgium,
1924) and Joly (Belgium, 1935), who used Kirschner

History and General Principles of Fracture Treatment


wires in the forearm; Tennant (1924), who used polgemeinschaft fur Ostebsynthese Fragen/Association for
ished phonograph needles for metacarpal fracture fixathe Study of Internal Fixation (AO/ASIF), has extion; the Rush family (father and two sons, United
pounded on the fracture treatment principles proposed
States, 1939), who first used Steinmann pins in ulnar
by Kiintscher and his devices, developed a full range of
fractures and then developed the "Rush" pin (dedevices, and presented many educational courses. In
scribed in 1956); and Dickinson (United States,
more recent years, advances in intramedullary
, Wifdsaiso' aesigneb medullary'pins tor'the" tore- " nailing devices and techniques Jiave centeceri^rvru * bit
15,25, 28
arm.
use of interlocking bolts to provide rotational control
Note that Lambotte introduced the term
and prevent shortening. Early examples of interlocking
osteosynthesis and that he was a leader in the developintramedullary nails include the Livingston I-beam with
ment of the field of operative fixation of metacarpal
slots at both ends (1950) and the Modny X-shaped nail
and phalangeal fractures15 and has been called the fawith holes throughout its length."8
29
ther of systemic fracture surgery.
Intramedullary nailing changed from an interesting,
DEVELOPMENT OF BONE PLATES
fledgling treatment modality to an indispensable component of every trauma surgeon's armamentarium folThe first suspected use of bone plates was during
lowing Gerhard Kiintscher's pioneering work in Gerthe American Civil War (1861 to 1865), but their first
many prior to and during World War II. His basic
substantiated use was by Hansmann in 1886.4 Lambotte
principle was that the intramedullary nail should proin 1909 designed a diamond-shaped plate that was
vide "elastic impingement" and thereby stability in its
thickest at the fracture site and tapered toward either
contact with the medullary canal. His designs have inend; Lane in 1914 designed a plate with three round
cluded V-shaped, conical, and split cross sections, in
eyelet holes above and below the fracture and a scaladdition to the now-standard slotted cloverleaf cross
loped outer form to facilitate contouring the plate to
section. Instrumentation was not neglected, with sevuneven bone surfaces. The Sherman plate, designed in
eral extractors and reduction devices being designed
1912, was stronger than the Lane plate because of its
by Kiintscher and his associates Fischer, Maatz, and
more streamlined shape."1
28
Stoer.
Along with shape refinements, concurrent improveIn the early 1940s the scientific community's reacments in bone plates occurred with the advent of
tion to intramedullary treatment of fractures was restronger and more biocompatible metal alloys.
served and not unanimously positive. However, there
Slotted plates to allow coaptation of fragments were
were many accounts of intramedullary nailing in the
designed by Townsend and Gilfillan (1943), Eggers
German literature.2' Bohler (Vienna, 1943), a highly
(1948), and Collison (1950).4
respected traumatologist in Europe, was an early supAn early study of the effect of compression on fracporter who advocated careful case selection.25
ture healing was written by Eggers in 1949, and he
Kiintscher spent the later years of World War II as
concluded that muscle contraction provided an approcommander of an army hospital in Finland near the arcpriate level of compression.4 In the same year, Danis
tic circle. The Finns were early proponents of his
devised a plate that incorporated an in-line screw
method, and surgeons in the United States, France, and
mechanism for the surgeon to provide a controlled
other countries learned of Kiintscher's devices from reamount of compression.4 Perhaps due to the difficulty
turning prisoners of war. In Sweden, cases were perin manipulating the screw to provide compression,
formed in March of 1943 by Westerborn.25'28
other surgeons were not able to duplicate Danis' good
The first American intramedullary nailing may have
results, and the plate did not become popular.4 Miiller
been in September of 1945 by MacAusland in Boston,
in 1961 made an in-line compression screw separate
who used a tantalum nail of similar design to one he
from the plate and remotely accessible for turning.4
previously removed from an American air force pilot
Venable in 1951 raised the angle of the compressing
who received his intramedullary nail in Germany.25
screw, but this made the construct less stable.4 Boreau
Shortly thereafter, a stainless steel diamond-shaped nail
and Hermann (1952) described the theory of a plate
of their own design was implanted by Drs. Street,
shaped similarly to a Lane plate, but with a central
Hansen, and Brewer.25 Lottes developed a solid-core
turnbuckle to provide compression; the plate, howdiamond-shaped nail in 1951,25 and in the same year
ever, did not see extensive clinical use.4
Schneider developed a fluted solid nail that was selfGeorge Bagby, while working as a resident at the
broaching. Prebent nails followed soon thereafter.28
Mayo Clinic (1956 to 1958), performed studies on the
To aid in insertion, broaches were developed in
healing of canine osteotomies in the presence of com1950 by Stryker28 and flexible reamers by Kiintscher.25
pression. His plate, reported in 1956, incorporated the
Beginning in 1958 with its foundation, the Arbeits-

Historical Review of the Treatment of Fractures and Dislocations


basic features of compression plates currently in widespread use. In particular, his plate introduced the asymmetrically beveled slots that provide compression as
chamfered screws are tightened. Other plates incorporating these principles include the Dehnam plate (England, nonbeveled slot) and one by Kondo and
Marumo (Japan, beveled slots with two being fan
shaped). Plates with beveled oblong slots are the Dynamic Compression plate (AO/ASIF),20 Universal Compression plate (Howmedica), Self Compression Plate
(Zimmer), and Uslenghi plate (Orthopaedic Equipment
Corp).
In his review article of compression bone plating,
Dr. Bagby4 stated that he personally had used his plate
only 100 times and found that the complications and
risks attendant to open procedures were too great to
warrant its routine application.
DEVELOPMENT OF EXTERNAL FIXATION
Following Malgaigne's "claw," the first practical and
accessible external fixators were developed independently by Parkhill (Denver, 1894) and Lambotte (Belgium, 1902).29 Parkhill's device consisted of four
screws inserted into the cortex and attached to a
mechanism adjustable in both the transverse and longitudinal directions. Lambotte's external fixator also consisted of four screws clamped between two flat
bars.26'29
The increasing use of external fixators brought with
it an increase in complications such as pin tract infections and an inability to achieve or maintain reduction.29 This caused American surgeons to avoid their
use, and they have only begun to give external fixators
a second chance in the last few decades.
Pins were improved both by the better material
choice of stainless steel, which caused less reaction,
and also by better technique, i.e., insertion through
both cortices for improved stability.29 Fully and partially threaded pins that are self-tapping and
nonself-tapping have also been introduced.
In 1934, Roger Anderson incorporated transfixion
pins in an external plaster cast and subsequently added
an external frame to replace the plaster.29 From 1938 to
1954 the Swiss surgeon Raoul Hoffman devised and
revised a frame that ensured rigid fixation at the fracture site.27 Following Key's work in 1932 utilizing
transfixion pins and an external clamp for knee arthrodesis,4 in 1948 Charnley developed a more practical
frame for knee arthrodeses that was also used as a general external fixation device.27 During the same time
period, Wagner developed a unilateral device for leg
lengthening.5
In addition to the above unilateral, bilateral, or

quadrilateral frames, circular frames have been designed. Ilizarov in the Soviet Union has devoted years
of his life to the study of external fixation (particularly
with regard to bone lengthening) and built his own
hospital exclusively to study his circular fixator with
tensioned transfixion wires.

EVOLUTION OF MEDICAL
MANAGEMENT OF FRACTURES
AND DISLOCATIONS
Medical and military history are often related. The battlefield gave physicians ample opportunity to find alternative methods of fracture management and wound
healing. During the Napoleonic wars of the 18th century, major progress was made in treating open and
closed fractures. Faced with large number of battlefield
casualties, surgeons of the day quickly learned new
techniques. One of those battlefield surgeons to gain
prominence was Dominique Jean Larrey (1766- 1842),
who eventually became the Surgeon General of Napoleon's Grand Army. Thanks to Larrey, who performed
200 amputations in a period of 24 hours after the battle of Borodino in the Moscow campaign (Sept. 5 6,
1812),2'9 mortality rates were significantly reduced.
Larrey built on some of the ideas advanced by the
French surgeon Joseph DeFault, who was the first to
define the need for surgical debridement. Larrey also
advocated early amputations and immediate surgery
for open fractures and devised what may be regarded
as a primitive ambulance service for dealing with such
conditions. After participating in more than 60 major
battles and treating thousands of men, Larrey wrote in
his memoirs on the need for early amputations:
When it is well known that tetanus is caused by a
wound, we ought not to have any hesitation in amputating immediately on the appearance of the symptoms.
We may be assured that it is traumatic, by the nature of
the wound, the progress of the first symptoms, and by
considering the time of their appearance, which is
from the fifth to fifteenth day, or later.
Amputations of the limb being made on the first appearance of the symptoms, all communication with the
original of the evil is cut off. This operation unloads the
vessels, and convulsive motions of the muscles. These
first effects are followed by a general collapse, which
promotes the excretions and repose, and re-establishes
the equilibrium of the body.31

The next hallmark date in the evolution of fracture


treatment was 1867, the year Joseph Lister introduced
surgical antisepsis with carbolic acid.13

History and General Principles of Fracture Treatment

During World War I, the principles of open fracture


treatment first advanced by a rural Nebraska physician,
Dr. Winnette Orr, 19 became standard throughout the
armed services and, eventually, all of medicine: com plete primary debridement, primary reduction, com plete immobilization, provision of drainage, and infrequent dressing changes.
By World War II, application of local sulfanilamide
was added to the regimen. In 1944, parenteral penicil lin had replaced the sulfa drugs.
World War II witnessed other significant medical advancements. Colonel O.P. Hampton 10 of the U.S. Army
advocated delayed rigid internal fixation of fractures
and cited the following advantages: achievement of anatomic alignment; avoidance of repeated manipulation;
improved wound care of the open fractures; facilitation
of early joint motion; and improved management of
concurrent injuries, especially in patients with multiple
trauma. Despite some disadvantages, namely, increased
intrawound trauma during surgery and vascular stripping of the bone cortex, Hampton reported achieving
maximum results (complete fracture healing without
complication) in 77.2% of 332 cases of open fractures
treated by delayed internal fixation. In this group, only
7.5% failed. There was no mention of the functional
states of injured extremities, however.
Meanwhile, Gerald Kiintscher, 12 a surgeon in the
German army, introduced intramedullary nailing for
femoral shaft fractures, a practice that would have an
impact on orthopedic surgery for years to come. Even
today, some of Kiintscher's techniques of intramedul lary nailing of long bones are still utilized by surgeons
in Europe and the United States.
After revolutionary advances during the war years,
the profession adopted a more conservative approach
in the immediate postwar era, largely du< to the philosophies of two prominent English surgeons. In his monumental two-volume Fractures and Joint Injuries, 30 Sir
R. Watson-Jones advocated closed reduction and prolonged immobilization by casting; fractures eventually
heal if immobilized long enough, but he did not realize
the significant problems of "cast disease" due to prolonged immobilization. Meanwhile, J. Charnley wrote
The Closed Treatment of Common Fractures 7 in 1961
in which he outlined in detail an accurate and success ful fracture reduction method based on the mechanism
of1 injury, the resultant deformity, and the step-by-step
maneuvers to restore anatomic alignment and joint
congruency of a displaced fracture. Watson-Jones'
Fractures and Dislocation and Charnley's Closed Reduction of Fractures became the standard treatises for
healing fractures and dislocations for the next 20 years.
In the 1960s and 1970s at Hennepin County, Medical
Center in Minneapolis it was common for 60% to 75%

of the beds to be occupied in skeletal traction or spica


cast immobilization.
Americans began to try new nailing techniques in
the 1950s. Lottes and his.colleagues 14 published their
method of nailing for tibia fractures in 1952, followed
by Rush's 2 3 technique for nailing of long bones in
1954.
In the early 1960s, a new concept commonly called
the "AO technique" 18 came into vogue and revolutionized the management of fractures. Advanced by the Association for the Study of the Problems of Internal Fix ation (ASIF), its advocates urged full and rapid
recovery of the injured limb by open anatomic reduction and stable internal fixation. The approach sought
to preserve blood supply to the bone fragments and
soft tissue by atraumatic surgery. Early and active mo bilization of the muscles and joint adjacent to the frac ture would prevent so-called fracture disease, a
common condition following prolonged cast immobilization and characterized by chronic edema, muscle atrophy, osteoporosis, and joint stiffness.
The "Swiss system" spread quickly through the medical communities of Europe and the United States. But
two leading American surgeonsAugusto Sarmiento 24
and Vert Mooney 17and their colleagues sought to
neutralize the Swiss influence. Sarmiento proposed
early functional cast weight bearing or bracing for tibia
fractures, and Mooney advocated cast bracing for fem oral shaft fractures.
By the late 1970s, further refinements of Kiintscher's
technique were made by Hansen, 11 who achieved superior results with closed intramedullary nailing for
femoral shaft fractures. Recently, the introduction of
locking nails for the femur and tibia in unstable postures caused by bone loss or severe comminution has
showed superior results. It also relegates plating to displaced intra-articular and metaphyseal fractures of long
bones.
Advances in techniques and devices have been possible thanks to a better understanding of when, why,
and how to make the appropriate application.
Gradually through the years, with basic and clinical
studies, it has been mandated or concluded that articu lar fractures need to be restored anatomically and early
motion studies conducted in order to prevent the late
sequelae of post-traumatic arthritis and joint stifihess.
For displaced intra-articular fractures, restoration of
congruent articular surfaces by traction, closed reduc tion, or surgery have been advocated. However, in
many cases, the results have fallen short of anatomic
restoration of the joint surface, and post-traumatic arthritis eventually ensues.
Compelling reasons to use primary prosthesis replacement in some cases include a failure to achieve

Historical Review of the Treatment of Fractures and Dislocations


primary union and late complications of avascular necrosis or post-traumatic arthritis in fractures of bones
and joints (e.g., hip, humeral head, radial head, and
neck).
In an era of modern science and advanced technology, patients expect that their fractures will heal fully,
anatomically, and functionally. Indeed, during the past
decade advances in managing long-bone and intra-articular fractures have been tremendous. They include the
following:
1. Functionally casting and bracing with early weight
bearing
2. The AO method of internal fixation/
interfragmentary fixation and rigid plating and
early mobilization of the injured extremity
3. Closed intramedullary nailing (Kuntscher) and
interlocking nails
1. Rediscovery and improvement of external fixation
4. Surgical techniques for difficult intra-articular frac
tures (e.g., acetabulum, shoulder joint, knee joint,
ankle joint, and spine)
5. Internal fixation of traumatic spine injuries
anteriorly and posteriorly
6. Microvascular techniques for the treatment of
soft-tissue loss and large bone defects
7. Appropriate antibiotic prophylaxis and therapy to
reduce wound sepsis
2. Early cancellous bone grafting
10. Electric stimulation for delayed union and non
union
11. Ilizarov technique of bone transport to correct
bone loss, bone lengthening, and malunion
12. Aggressive management in patients with multiple
trauma by using early stabilization of long-bone
fractures
Above all, a new type of physician has evolved during the past decade. In addition to possessing technical
skills, the orthopedic and trauma surgeon of today is
also an anatomist, physiologist, and biomechanical engineer who transcends the fields of medicine and engineering in order to solve common problems.
REFERENCES
1. Adams F: Hippocrates: The Genuine Works of Hip
pocrates. New York, William Wood & Co, 1929.
2. Anderson JT: History of the treatment of open fractures,
in Gustilo RB (ed): Management of Open Fractures and
Complications. Philadelphia, WB Saunders Co, 1982.
3- Austin, RT: Treatment of broken legs before and after
the introduction of gypsum. Injury 1983; 14:389394. 4.
Bagby FW: Compression bone -plating, f Bone foint Surg ,
1977; 59:625-631.

5. Booker AF: History of external fixation, in Principles of


External Fixation. Baltimore, Williams & Wilkihs, 1983.
6. Callahan DJ, Harris BJ: Short history of plaster-of-Paris
cast immobilization. Minn Med 1986; 69:195-196.
7. Charnley J: The Closed Treatment of Common Frac
tures, ed 3. Edinburgh, E & S Livingstone, 1961.
8. Evans PEL: Cerclage fixation of a fractured humerus in
1775, fact or fiction? Clin Orthop 1983; 174:138-142.
9. Garrison FH: History of Medicine ed 4. Philadelphia, WB
Saunders Co, 1929.
10. Hampton OP: Management of compound fractures in
their early phases. Surg Obstet Gynecol 1946; 84:772.
11. Hansen S, Winquist R: Closed intramedullary .nailing of
the femur: Kuntscher technique with reaming. Clin Or
thop 1979; 138:56.
12. Kuntscher G: Practice of Intramedullary Nailing.
Springfield, 111, Charles C Thomas Publishers, 1967.
13- Lister J: On the antiseptic principle in the practice of
surgery. Lancet 1867; 2:95.
14. Lottes JO, Hill LJ, Key AJ: Closed reduction, plate fixa
tion and medullary nailing of fractures of both bones of
the leg. / Bone Joint Surg [Am] 1952; 34:861.
15. Meals RA, Meuli HC: Carpenter's nails, phonograph nee
dles, piano wires and safety pins: The history of opera
tive fixation of metacarpal and phalangeal fractures./
Hand Surg 1985; 10:144-150.
16. Monro JK: The history of plaster-of-Paris in the treat
ment of fractures. BrJ Surg 1935; 23:257.
17. Mooney V, Nickel VL, Harvey JP Jr, et al: Cast-brace
treatment for fractures of the distal part of the femur./
Bone Joint Surg [Am] 1970; 52:1563.
18. Miiller ME, Allgower M, Schneider R, et al: Manual of
Internal Fixation: Techniques Recommended by the
AO-Group, ed 2. New York, Springer-Verlag, NY Inc,
1979.
19. Orr HW: Compound fractures. Am J Surg 1939; 46:733.
20. Perren SM, Huggler A, Russenberger M, et al: The reac
tion of cortical bone to compression. Acta Orthop
Stand Suppl 1969; 125:19-29.
21. Rehder K: Martin Kirschner./AAM 1982; 247:1302.
22. Romm S: Fritz Steinmann and the pin that bears his
name. Plast Reconstr Surg 1984; 74:306-310.
23. Rush LP: Atlas of Rush pin techniques. Mississippi Doc
tor 1953; 31:94.
24. Sarmiento A, Latta L, Zilioli A, et al: The role of soft tis
sues in the stabilization of tibial fractures. Clin Orthop
1974; 105:116.
25. Seligson D: Historical introduction in Concepts in In
tramedullary Nailing. Orlando, Fla. Grune & Stratton,
1985.
26. Seligson D, Dudey D: Historical introduction. Concepts
in external fixation. Clin Orthop 1983;180:15-22.
27. Sisk DT: External fixationhistoric review, advantages,
disadvantages, complications and indication. Clin Or
thop 1983; 180:15-22.
28. Street D: The evolution of intramedullary nailing, in The
Science and Practice of Intramedullary Nailing. Phila
delphia, Lea & Febiger, 1987.
29. Vidal J: External fixationyesterday, today, and tomor
row. Clin Orthop 1983; 180:7-14.
30. Sir Watson-Jones R: Fractures and Joint Injuries, vols 1
and 2, ed 4. London, E & S Livingstone, 1955.
31. Zimmerman LM, Veith I: Great Ideas in the History of
Surgery. Baltimore, Williams & Wilkins, 1961.