EXPLORATORY INCISION IN THE TREATMENT OF CLOSED FRAC- TURES AND DISLOCATIONS. BY JOHN B. ROBERTS, M.D., OF PHILADELPHIA. PA.J PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC, AND THE WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA. FROM THE MEDICAL NEWS, January 16, 1897. [Reprinted from The Medical News, Jan. 16, 1897.] EXPLORATORY INCISION IN THE TREAT- MENT OF CLOSED FRACTURES AND DISLOCA TIONS. 1 By JOHN B. ROBERTS, M.D., OF PHILADELPHIA, PA.; PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC, AND THE WOMAN’S MEDICAL COLLEGE OF PENNSYLVANIA. Complete reduction, exact restitution of contour, and perfect retention, are the conditions of full suc- cess in the treatment of fractures. Deformity, im- pairment of articular movement, non-union, and neuralgic pain are remote results of failure to obtain these desirable conditions. Since aseptic surgery has made possible the prevention of infective inflam- mations in most open fractures, it is quite probable that better reduction, coaptation, and retention re- sult in open than in closed fractures of the same grade and character of bony lesion. The recent application of skiagraphy to surgical diagnosis has proved that fractures seemingly well re- duced and properly dressed with splints may be the seat of considerable deviation from the normal skele- tal relations. At the Polyclinic Hospital recently, for example, a fracture of the middle of the radius, supposed to be well reduced and dressed, was shown, by the use of the Rontgen ray, while the splints were in position, to have its fragments overlapping to the extent of about half an inch. In another case a painful swelling at the seat of a former injury to the fibula 1 Prepared for the Second Pan-American Medical Congress, November, 1896. was discovered to be due to unrecognized non-union at that point. The rigidity of the tibia prevented the lack of union of the smaller bone being detected, but skiagraphy showed it plainly. Nearly twelve years ago I advocated conversion of closed fractures of the cranium into open fractures by incision of the scalp, whenever uncertainty as to the character of the cranial lesion was prejudicial to in- telligent treatment.1 As part of my argument I said that no surgeon would hesitate to convert a closed recent fracture of the thigh or leg into an open one if it were impossible to replace fragments which were threatening life. I admitted that closed wounds are less serious than open ones, but asserted that with modern surgical methods, open wounds are prefera- ble to closed wounds having inherent dangers that cannot be recognized without opening them. Fur- ther consideration and experience convinced me that this method should be extended to fractures in the limbs, even when life was not threatened, if obscur- ity of lesion or difficulty in reduction jeopardized function. Accordingly, a few years later,2 I gave it as my opinion that recent fractures of the lower end of the humerus might with propriety be subjected to exploratory aseptic incision, if satisfactory coapta- tion was not obtainable under anesthesia; and that such action, though it involved opening the elbow joint, was as legitimate in properly selected cases as the recognized exploratory incision made in obscure abdominal conditions. My belief in the propriety and value of exposure of the fragments in a certain limited number of closed fractures has been strengthened as years have passed. 3 The method, which I do not claim as novel, has, however, not been sufficiently impressed upon the profession to cause its adoption by surgeons in gen- eral. Allis of Philadelphia has advocated it3 in rebel- lious fractures of the upper third of the shaft of the femur, in order to apply steel screws for retentive purposes. In England, Lane has employed it4 in oblique fractures of the tibia and fibula near the ankle, for the same reason. McBurney6 and others have resorted to it in fracture of the upper end of the humerus complicated with dislocation. Dennis6 and Ricard 7 also approve of it in cases where there is difficulty in obtaining correct apposition of fractures. Other writers may have mentioned the subject, and cases may have been occasionally reported; but, ex- cept in fractures of the cranium and patella, I think that most surgeons are more apt to be satisfied with imperfect results than to advise immediate exposure of the fragments before the patient comes out of the anesthesia induced for the purpose of examining and reducing the fracture. This attitude of the profession in general has been evident in societies at which I have incidentally men- tioned my views ;* and is due to conservatism bred by the fear of open fractures felt by all in the pre-anti- septic period of surgery. The method has suggested itself to many practical surgeons, but it needs to be ever before our minds as a legitimate procedure. My advocacy of cutting down upon closed frac- tures is limited to cases in which ignorance of the exact lesion, impossibility of reduction, imperfect immobilization, or failure to deal efficiently with complicating lesions makes the incision the less of 4 two evils. An aseptic incision is almost devoid of risk, even if it opens a joint; but that slight risk should not be added to the patient’s burdens unless the probability of deformity, of interference with joint movements or other functions, of pain, of para- lysis, or of non-union justify it. Here, as in all de- partments of surgery, it is the surgeon’s duty to ex- ercise care and good judgment in selecting the method of treatment. To illustrate my meaning I cite frac- ture of the patella, which I have never treated by incision and suture of the bone, because I have thus far always been able to satisfactorily bring the frag- ments together by hooks, subcutaneous suture, or splint. In one or two instances I have almost de- cided to lay open the overlying tissues in order to obtain approximation by direct appliances, but I have finally not been obliged to do so. The open opera- tion I believe to be legitimate, and probably need- ful in a very few selected cases, but I am opposed to it as a routine treatment. It is self-evident that the wound exposing a frac- ture must be aseptic, and that the operator who adopts incision must be familiar with the steps to be pursued at the inception of infective inflam- mation. A man who will hesitate to reopen the wound or drain the joint, at the moment septic premonitions show themselves, should associate a more energetic surgeon with himself in such operative treatment of fractures. The risk of incising mus- cles and opening joints, if done in an aseptic manner by an operator familiar with truly aseptic and anti- septic surgery, is unquestionably very slight. Primary union without disturbance of joint-function will be almost universal. If it once be admitted that the seat of a fracture can be exposed by incision, with little or no risk to life, there are many advantages that will at once suggest themselves: 1. The exact lines of separation can be seen, and the significance of lines of comminution in relation to subsequent reconstruction can be fully appreciated. 2. Coaptation need no longer be guessed at by the sensations imparted to the examiner’s fingers, separ- ated as they are from the bone by varying thick- nesses of muscle, fat, and skin; nor need it be de- pendent upon the possibility of having conveniences for taking a skiagraph. 3. The fragments can be accurately fitted together, torn periosteum replaced, and muscular and fascial bands, nerves and muscles disentangled from unde- sirable positions between the pieces of broken bone. This prevents deformity by permitting restoration of normal contour of the limb, and lessens the occur- rence of non-union, neuralgia, atrophy, and ankylosis. 4. When the osseous, muscular, and vascular re- lations have been restored, they can be perfectly maintained by the application of sutures, pegs, nails, screws or ferrules to the bone, and sutures or liga- tures to the muscles, nerves, and vessels. 5. The pain, due to extravasation of blood, rapid inflammatory exudation or traumatic synovitis, is re- lieved by the removal of the clots and leaking out of exudation and synovial fluid. The interstitial pressure caused by extravasated blood and exudate has often heretofore caused surgeons to split the skin and 5 6 deep fascia by long incisions, in very bad fractures, in order to avert threatened gangrene. A similar relief of tension in less urgent cases will undoubtedly lessen pain and suffering, though such operative treatment would ordinarily not be adopted. The incisions em- ployed to uncover the fractures are therefore indirectly of value as relievers of pain. 6. Pain is also lessened, in the few cases requiring direct retentive apparatus, because the sutures, nails, or screws prevent motion between the fragments better than external splints. Muscular spasm or incautious movement has therefore little opportunity to cause suffering. 7. Fat embolism is probably less likely to occur in fractures liable to its occurrence, if early escape for the fatty debris is permitted by incision. 8. Ankylosis from faulty position of fragments, irregular formation of callus due to stripped up peri- osteum, and gluing down of tendons, will seldom occur after the fracture has been disclosed to the scrutiny of a competent surgeon. 9. Repair of the broken bone and functional resti- tution of the surrounding tissues occur more rapidly than when coaptation is imperfect, or when dam- aged, muscular and other structures are left to the unaided efforts of nature. Impairment of digital movements after fractures is probably often due to coincident rupture or laceration of muscles, which might have been repaired by suturing with catgut, if the surgeon had known of the existence of the com- plication. The aseptic wound affords him this op- portunity; and afterward usually heals so rapidly that it is of no disadvantage to the patient’s period of convalescence. This early restoration of wage-earn- ing capacity is of great value to many patients. io. It not infrequently happens that a closed frac- ture seems to have been well set, and to have left little deviation from the normal; and yet the patient has lost some of his availability as a machine. This is most likely to occur in the lower limb which, dur- ing locomotion, carries the entire weight of the man. A slight change in the axis of a bone or in the plane of an articulating surface may perhaps throw the weight upon the hip, knee, or ankle in an abnormal way and induce a considerable and ever increasing disability. This contingency is usually avoidable after the accurate inspection of the injured bone permitted by uncovering the fracture by incisions. In vicious union of fractures due to absence of treatment, or to injudicious treatment, I believe that it is sometimes much better to expose the seat of de- formity and divide the deformed bone with an os- teotome than to refracture subcutaneously by an osteoclast or the surgeon’s hands. Many cases can indubitably be well treated by refracture without in- cision or by subcutaneous osteotomy; but if there be a reasonable doubt as to one of these methods en- abling the surgeon to accomplish relief of the de- formity, free exposure, such as I have just been ad- vocating in recent fractures, is the proper treatment. A similar method of dealing with luxations which are not readily reduced by manipulation under anes- thesia is, in my opinion, preferable to a long con- tinuance of unsuccessful manipulations, the application of great power by apparatus, or a relinquishing of the attempt to restore the integrity of the joint. It is true 8 that in all dislocations, except those of the spinal col- umn and the backward luxation of the second phalanx of the thumb, reduction is usually readily accomp- lished by skilful manipulation under anesthesia, pro- vided the attempt is made while the injury is recent. My contention is that in recent dislocations, when this is not the case, and in old dislocations, arthrot- omy should be promptly done. No surgeon would recommend allowing the displacement to remain without attempting reduction ; and I believe that compound pulleys or other methods of applying great force are usually more risky than prompt and thor- ough exposure by incision. Immediately before making the incision it would be well in .most cases to make a final effort to reduce by manipulation; but this should not be carried to a sufficient extent to cause much bruising or muscular laceration. The presence of such traumatism would increase the lia- bility to septic processes, if imperfect asepsis allowed germs to gain access to the wound during the operation. Arthrotomy for irreducible dislocation is not a novel suggestion, for it has been repeatedly done by many surgeons in old injuries. It has not, however, I think, been often adopted until after vigorous ef- forts have been made to subcutaneously replace the separated articular surfaces. Its use in luxations a few hours or a few days old, except perhaps in the fingers and toes, is probably almost unknown as an accepted surgical procedure. I believe it ought to be the approved treatment in a small number of cases. The advantages of the open method will at once be patent when the accidents that occasionally 9 follow the employment of the older methods are re- called. Fracture of the bone or laceration of artery, vein, or nerve, is only likely to occur when the re- gion is not exposed to the operator’s eye, In case of impossibility to properly reduce the dislocation, moreover, the end of the luxated bone can be ex- cised. This will probably nearly always give a better functional result than to allow the previous con- dition to persist. Excision is not infrequently re- quired after attempts to reduce old luxations without incision have proved unavailing. In an attempt to reduce an old luxation of the humerus I have dis- placed the head of the bone in such a way that it rested on the brachial plexus and caused more trouble than the original deformity. This would not have been the result, I think, if I had exposed the luxated bone by arthrotomy. If the open treat- ment is to be adopted it is evident that the patient will receive the greatest advantage if it be instituted before the head of the bone is altered in shape, the socket changed, and muscles and fasciae con- tracted or adherent to surrounding tissues. The open method in addition gives opportunity to divide any ligaments, tendons, fasciae and muscles which re- strain reduction, to scrape out any material filling the socket, and to make provision for preventing re- currence of dislocation by retrenching the capsule or other plastic measures. Skiagraphy may have a field in this department of surgery, as in fractures, by indicating the character of the luxation before the incision is made. It may perhaps be urged to this plea for a more general em- ployment of exploratory incision in closed fractures and dislocations that there are great objections to making a closed lesion of the osseous system an open one. I know of no objection except the risks inher- ent in anesthesia, the possibility of infection, the oc- currence of serious bleeding, and the production of ankylosis. The objections are of no force when the injury is one requiring exploratory incision. Anes- thesia will have been used in such instances for diag- nosis or attempted reduction. Its moderate pro- longation for the necessary time will add practically nothing to the risk. Bleeding is no contraindication except in that rare condition, hemorrhagic diathesis. Ankylosis is more liable to occur from displaced fragments or articular surfaces, irregular callus due to stripped up periosteum, and interference with articular contact, than from aseptic incision into the joint and readjustment of the joint structures. The possibility of infection is, then, the only factor that requires consideration. Fifteen or twenty years ago, even subcutaneous tenotomy at the heel, recommended by the surgeons of the Pennsylvania Hospital in cases of marked displacement after frac- tures of the tibia, was undertaken with some hesita- tion. Now operative infection in muscular and osseous lesions is so preventible and so readily man- aged by prompt action that it is no longer a valid ob- jection to incision in a closed fracture or dislocation, if functional disability is liable to occur unless this operation is performed. For some years it has been the practice of surgeons to incise open fractures freely in order to thoroughly cleanse the deep re- cesses, obtain an antiseptic condition of the lesion, 11 and get rid of effused blood. An extension of oper- ative surgery is, in my opinion, now warranted in closed fractures and dislocations in which ordinary methods of reduction prove unavailing or unsatisfac- tory. Bibliography. 1 “ Trans. Am. Surgical Asso.,” vol. iii (1885), pp. 6 and 105. 2 “ Trans. Am. Surgical Asso.,” vol. x (1892), p. 58. 3 Medical News, November 21, 1891, p. 590. 4 “Trans. Clinical Society of London ” (1894), p. 167. 5 “ Annals of Surgery,” May, 1896. 6 “ System of Surgery,” vol. i. 7 “ Traite de Chirurgie,” Duplay & Reclus, ii, 376. 8 “ Annals of Surgery,” April, 1895, p. 457, and “ Philadelphia Polyclinic,” August 21, 1S96. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The A merican Journal OF THE Medical Sciences. Established in 1820. A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTATION RATE, £7.50 /3.£V? ANNUM. LEA BROS &> CO NEW YORK AND PHILADELPHIA.