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The Classic: The Treatment of Fracture of the Neck of the Femur at Bellevue, St. Vincent’s, and New York Hospitals*

2005; Lippincott Williams & Wilkins; Volume: 431; Linguagem: Inglês

10.1097/01.blo.0000153078.80038.45

1528-1132

Joseph B Bissell, Henry H Sherk,

Diversity and Career in Medicine

In this classic article, Dr. Joseph H. Bissell (Fig. 1) reports on his review of 316 patients treated at three large hospitals in New York from 1900 to 1903. Generally these patients received no real treatment. Side splints, skin traction, sand bags, and rarely plaster casts resulted in severe lower limb shortening, continuous pain, pneumonia, bed sores and premature death in a very high percentage of these patients. Dr. Bissell recognized that “clinical experience convinces us that some direct and more certain method of exact fixation must be sought for and applied. Operative interference for this condition is feasible, practical and obligatory in many instances.... Cutting down upon the break and making firm fixation of the fractured ends can be done almost with impunity... “Fig 1.: Dr. Joseph H. Bissell is shown. Photo courtesy of the New York Academy of Medicine Library.Dr. Bissell’s paper, written more than 100 years ago, reveals with considerable clarity that neglected trauma can have serious adverse consequences and in it he points the way toward correcting this approach to such injuries by using active surgical intervention. His paper was abstracted in the first edition of the American Journal of Orthopedics, which after World War I, became the Journal of Bone and Joint Surgery. The Philadelphia Medical Journal ceased publication with this issue and became thereafter consolidated with the New York Medical Journal. Dr. Bissell was born in Lakeside, Connecticut in 1859. He graduated from Yale University in 1879 and from Columbia University College of Physicians and Surgeries in 1883. His years of education predated the founding of the American Orthopaedic Association in 1887 but Dr. Bissell’s bibliography suggests a strong interest in the treatment of abnormalities of the musculoskeletal system. Indeed, his thesis at Columbia, published in the 1888 Archives of Pediatrics, was entitled “The Morbid Anatomy of Talipes Equinovarus.” After he received his Doctor of Medicine degree he remained in New York and served as a surgeon on the staffs of the hospitals noted in the title of this Classic Article. He published extensively during his 31-year career and the range of his interests in those years, which preceded the rise of the surgical specialties, included articles on abdominal surgery, urology, treatment of cancer with radium, and what today would be considered orthopaedics. The Classic Article, which documents the dire results of treating hip fractures with “benign neglect,” is an example. The following brief abstract of his obituary reveals how well Dr. Bissell’s colleagues regarded him: The Executive Committee of the Medical Board of Bellevue Hospital records with profound sorrow the death of their esteemed colleague, Dr. Joseph B. Bissell; Major Medical Corps, U.S. Army and Chief of the Surgical Service of Fort McHenry, Maryland and Visiting Surgeon and Chief of the Fourth Division of Bellevue Hospital.... At a time of life when most men his age might reasonably expect that our nation’s right might safely be left to younger men, he volunteered for active duty in the service of his country. He died in that service as a result of the strenuous life incident to active duty. Dr. Bissell’s obituary was published in the Boston Medical and Surgical Journal in 1919. That publication became the New England Journal of Medicine in 1928. The treatment of fracture of the neck of the femur is a subject of considerable practical interest. The results of the treatment of this injury, no matter what methods may be used, are, as a rule, far from satisfactory. All of us are more or less disappointed with the condition remaining after weeks of confinement of the limb, and alarmed at the dangers at times produced by it. The disappointment is greater still to the most interested individual in the case—the patient. If he escapes with his life, he has to be contented with loss of function, loss of symmetry and equipose, and is often obliged to go about permanently crippled. The active surgeon is occupied more or less constantly with operative and diagnostic as well as pathological work. He has little time to consider the treatment of such a traditionally hopeless sort of condition as a fracture of the neck of the femor. He knows that there will be shortening, that there may be or may not be union of the bone, depending upon the age of the patient and whether or not it is impacted. Further than that, excepting to anticipate the well-known dangers of keeping these old people in bed, he cares little. The busy New York surgeon does not, as a rule, give much time or thought to this injury. If he sees a patient in consultation, he gives a few general directions, and his responsibility and further care of the case ceases. Not so with the general practitioner and our colleagues in country work. To them the subject is a most practical one. These cases are not infrequent. They are not uncommon in country practice, perhaps, in some well-known person in whom the community is deeply interested. The care and skill with which the case is treated is commented upon continually, and the patient is constantly in the minds of the community, and the fame, reputation and future of the physician in charge may rest greatly upon the comfort of such a patient and the result produced. Moreover, of much greater importance is the result to the patient. If after weeks of weary confinement and pain life is sacrificed, or even the future well-being and comfort of the patient is hampered by a deformed or a painful and useless leg, the excuse must be a substantial and valid one that will satisfy a critical and exacting public opinion that even with the best possible methods and modern surgical devices we were able to obtain no more satisfactory result. With these thoughts in mind it occurred to the writer that the manner and the results of treatment of a large number of such cases would be of interest. In no way can this be studied so well as in the wards of a large general hospital. I have, therefore, taken a series of cases as they entered three of the largest hospitals in this city. The three hospitals selected are those having the largest ambulance services in the most active and thickly populated parts of the city, and also having the largest daily hospital census—Bellevue, New York and St. Vincent’s. In St. Vincent’s, during the whole year of 1900, there were but two cases of fracture of the cervix femoris in twenty-one cases of fracture of the femur. The reason for so few in an active ambulance hospital is that the house surgeon was unwilling to fill his beds with patients who required weeks of treatment to the exclusion of active and acute operative cases. In the two years following, 1901 and 1902, the histories were rather defective, but the number of cases are nine in 1901 and thirty in 1902, making for the three years forty-one cases. The youngest patient was 34 years of age, the oldest 71 years. The treatment in this hospital is entirely routine and left pretty much to the house surgeon. It consists of a fracture board under the mattress, a Hamilton long side splint, Buck’s extension with a weight, usually rather heavy, fifteen to twenty pounds, but enough, if possible, to reduce the shortening, if not completely, down to about one-half inch or under. Thirty pounds were used in one case, that of a sailor who was first treated on board his ship for supposed subluxation which was reduced under chloroform. He came to the hospital several days afterward with 2½ inches of shortening, a false point of motion below the joint and great pain and tenderness over the greater trochanter. The thirty-pound weight was left on six weeks, and the shortening was one-quarter of an inch. Forty pounds was the heaviest weight used, and that in a woman. Frequently a certain number of pounds were found by experiment to overcome, or nearly to overcome, the deformity. This then regulated the amount. The Hamilton splint was removed frequently comparatively early, often at the end of the fourth or fifth week. In a few instances sand-bags were employed. In these patients the Hamilton long side splint was omitted and long sand-bags were adjusted to keep the leg from rotating, and also to keep the patient from moving it. No cutting operations are recorded as having been done for this trouble at St. Vincent’s Hospital. No plaster-of-Paris dressings have been used during these three years. Of these forty-one cases there were no deaths recorded. In Bellevue, from January 1, 1900, to January 1, 1903—three years—241 cases are recorded in the various wards. The large number of cases in this hospital is accounted for from the fact that the other emergency hospitals of the city remove such patients as quickly as possible to Bellevue, where, for the most part, they have to be kept and treated. The ages of these persons were from the youngest, at 38 years of age up to 81 years of age. Of the 241 patients treated, only three died from intercurrent diseases—one from pneumonia and two from nephritis with alcoholism. In no case was there a shortening recorded of over three inches, and in most the shortening was from ¼ to 1 inch. This record was made at the time of the admission of the patient. When recorded at the time of the discharge of the patient in cases called “cured” or “improved,” the shortening was usually ¼ to ½ inch, but in many cases, both in these and in the cases in the other hospitals, the record showed simply that the patient was discharged “cured,” and for that reason is a questionable record, in that respect at least. The average time of keeping the patients in bed with dressings applied was eight weeks. Some were retained in bed as long as fourteen weeks, and the shortest time of keeping them on their backs was six weeks. The large majority was from eight to nine weeks. Fracture boards, Buck’s extension and long Hamilton splints were the usual means of dressing the fracture in this hospital. This was done immediately upon the admission of the patient, and was, as a rule, kept up during the entire time of the patient’s remaining in bed. The weight adjusted was from twelve to twenty pounds—depending upon the amount it took to reduce the shortening. If the shortening could be entirely removed by a small weight, of say from eight to ten pounds, that was attached. In a few cases the sand-bags were used in the place of a Hamilton splint, and in a large number of cases the Hamilton splint was removed at the end of four to six weeks and the sand bags adjusted in its place. In one case only was plaster-of-Paris spica used in place of the usual dressing, from the beginning of the treatment to the end. That one was a failure, for it did not in any way reduce the shortening. However, in a number of cases, in several of the wards of the hospital, plaster-of-Paris was applied after the Hamilton splint had been removed, and after the shortening had been reduced as much as possible, and when no amount of weight seemed to reduce it further. This was in most of the cases after the fourth or fifth week. It was usually left on about two weeks. It was then removed because of failure to accomplish its purpose, and the Hamilton splint re-applied. In the New York Hospital, for the three years from January 1, 1900, to January 1, 1903, were found thirty-four cases of fracture of the neck of the femur. The age of the patients ranged from 34 to 83 years. The usual treatment in almost every case was to apply the Hodgen splint. Fracture boards for the bed and occasionally Buck’s extension were used with sand-bags and a moderately heavy weight, the weight being usually applied until the shortening was reduced as much as was possible to be done by traction. The longest period in which the patients were kept in bed was sixteen weeks, and the shortest was six weeks. The histories were very defective in not giving the amount of shortening at the time the patients were discharged. Of the thirty-four patients treated, fifteen were discharged as “cured,”’ four as “unimproved,” fourteen as “improved,” and one died. The fatal case was due to pneumonia and occurred within twenty-four hours after admission. In none of these three hundred and sixteen cases was an operation performed either to unite the fractured surfaces, to remove a detached head or to carry on or assist in any manner the treatment. The above cases are not selected ones and have been under the care of no less than sixteen well-known surgeons, some of them eminent teachers of surgery connected with the medical schools of New York, others no less skilled but not teachers. The interest, or lack of it, shown in these cases is quite typical. In some of the beds the visiting surgeon, regarding the treatment as more or less routine, barely gives them a passing glance, treatment being left entirely to the house surgeon, who, as a rule, turns them over to an assistant. The case may excite a mild interest from a diagnostic standpoint as to whether it is really a fracture or a dislocation, and, if a fracture, whether it is within or without the capsule (a point, by the way, apparently of no importance whatever in its relation to treatment). Otherwise this wealth of clinical material lies fallow. On the other hand, in some of the services a certain amount of interest is shown by attempts to make the general condition of the patient comfortable as well as by endeavoring in every possible way to promote the healing of the disability with a serviceable limb. No other treatment except that mentioned above is recorded in any of the three hospitals under consideration. The same treatment seems to have been applied without regard to whether the fracture was intracapsular or extracapsular, or whether or not it was impacted. In none of these histories is it recorded that any effort was made to relieve the patient from the possibility of a congestive pneumonia or nephritis. This was probably due, however, not to the fact that such cases did not occur but that the histories were kept—if one may say so—somewhat inefficiently. It is to be seen, too, from a consideration of these statistics that no special effort was made to obtain union of the fragments or restoration of function, or to prevent any intercurrent disease, or, aside from the perfunctory application of the apparatus, to obtain comfort for the patient. I do not believe, however, that these statements are true as facts. As to those cases that are recorded as “cured”—they are open to question as to whether the visiting surgeon entered such a statement on the discharge cards and also what “cured” meant. If it meant restoration of the fragments, with normal length of the leg, it would seem that this is again open to question, excepting, of course, in the impacted fractures. In all the younger patients—cases of young adults—when the X-ray picture was taken, the fracture was found to be impacted in every case in which a good history was given; it was found also in these young adults that the fracture was due to direct injury. These were the patients who were kept in bed the shortest time, who had on the lightest weights and in whom recovery may be presumed to be fairly complete. Yet one case is recorded in the New York Hospital list of a man, 71 years old, who had 1¼ inches shortening and who was treated by means of a Hodgen’s splint and kept only six weeks in bed and discharged from the hospital “cured.” He came to the hospital in June, 1901. In the New York Hospital alone is a satisfactory conclusion as to the treatment to be drawn from the history records. By far the largest percentage of cures was at this hospital; 44% of all the cases treated there were discharged “cured,” and 41% “improved.” The routine treatment was by means of the Hodgen splint almost exclusively. A direct inference would be that this apparatus is much more valuable than the commoner methods in use—the Hamilton splint and Buck’s extension. In all three of the hospitals it seems to me that the patients were kept in bed either much longer than was necessary or not long enough. If the broken neck would not unite at the end of six weeks under treatment while confined to bed, it is hard to be convinced of the possibility of its uniting at the end of eight or nine weeks, especially as these splints do not in most cases prevent motion between the fragments and do not secure perfect co-aptation, neglecting in this way the two essentials—immobilization and firm co-aptation—without which a splint is not only useless but of positive harm. When the fracture is impacted, extension is contra-indicated, but fixation is imperative; yet, as a rule, exactly the same treatment is used for these cases as for those of nonimpaction. Another disappointing conclusion to be drawn from these 316 cases is that plaster-of-Paris is useless and almost never of value. It is not recorded in any of the history blanks—probably because it was considered a matter of small interest—but it is the personal experience of the writer as well as of many others that, in elderly people especially, great pain and discomfort are present most of the time through their period of confinement, and that the pain is excruciatingly worse when motion is beginning to be made at the end of the splint period or when the patient first begins to use the leg. The experience of the writer, again not confirmed by the histories of these three hundred and sixteen cases, has been that bed-sores are a common intercurrent trouble. These ulcers have been most extensive and very painful, and the older the patient the larger and more difficult they are to heal. The longer the patient is kept in bed, the greater the tendency to the sores. It is a rather curious fact, according to the records, that so few of these patients taken as they are from the lower portions of society, have developed any congestive disease like hypostatic pneumonia or Bright’s disease, conditions such as the text-books are continually warning us of. Of course, the age of the patient and the constitutional feebleness predisposing to this injury, with the coincidental diseases or troubles of old age, are constant factors increasing the difficulties of treatment and decreasing the chances of recovery. It would seem from these facts that there is much to be gained by earlier removal of the splints and in getting the patient out of bed even before the classical period of osseous union is over. It is well known that this period in fractures of the neck of the femur is an extraordinarily long one. Dupuytren estimates the time at from one hundred to one hundred and twenty-five days. Gurlt gives a wide choice of from fifty-six to two hundred and seven days, and the patients in the H|f.tel Dieu are kept in bed from eighty to one hundred days. Dr. Senn keeps his patients in his retentive apparatus for exactly that length of time, stating that, if it is removed earlier, secondary displacement may occur. The reason why the results in fracture of the cervix femoris are so unsatisfactory is because of the difficulty of meeting the indications for treatment; perfect co-aptation and uninterrupted immobilization of the fractured bone together with attention to the comfort, health and nourishment of the patient. That these indications are not fulfilled by the treatment as carried out in the three hospitals under consideration is plain. As to the first two indications, an approximation is obtained possibly by means of the Hodgen splint. But in order properly to treat these patients it is necessary to give as much attention to the relief of pain, to the prevention of bedsores and of the tendency to the diseases arising from the long-continued recumbent position, as it is to immobilize and co-apt the fragments and restore the leg to its normal position. The use of a hip splint which will allow the patient to be up and about, such as is used in tubercular disease of the hip-joint, and the fixation by means of a plaster-of-Paris are the only alternatives, to the last, or better to the first, resort of the surgical mind—an open operation down to the seat of the fracture and an accurate securing of the fragments by mechanical means, such as is often done in other joint fractures or when bony union has failed. The inaccessibility of the injured part is a great objection to operative procedures. The class of patients in whom this injury is common are, from the very cause of the accident, just the patients on whom it is most inadvisable to operate. Obesity, general debility, arteriosclerosis, atheroma and very old age are the predisposing causes to the injury and are contra-indications to operation which cannot be ignored. The plaster-of-Paris splint, to be efficient, must be extensive. To secure perfect immobility, according to Senn, “it must include the fractured limb and the entire pelvis, and also the opposite leg to the knee and extend above to the eighth costal cartilage, and it must also include an adjustable compress for making lateral pressure over the greater trochanter. This apparatus must remain on for months, but it has a vast advantage in that it allows the patient to be up and about and out of doors, an important influence in the prevention of a number of the fatal complications.” The Thomas hip splint, or some similar apparatus, which has been suggested for use in the treatment of fracture of the neck of the hip, is familiar to most of us, and we can all appreciate that it would be extremely difficult to fulfil the indications for treatment by this means in these aged patients. Clinical experience convinces us that some direct and more certain method of exact fixation must be sought for and applied. Operative interference for this condition is feasible, practicable and obligatory in many instances. The risk from old age and feebleness is present, but is not as great as is the risk incurred by the time-honored methods of the troublesome and dangerous side splints and plaster-of-Paris apparatus combined with the tedious and depressing weeks of confinement in bed. The operation is simple. It can be quickly and satisfactorily performed, whether it be to remove a displaced and broken-off head of the femur or in order to unite the fractured bone. A number of such cases with good results are on record. At the worst it is a choice of evils with the advantage vastly in favor of operative treatment. At the best, and it is at the best we ought to look, cutting down upon the break and making firm fixation of the fractured ends can be done almost with impunity in spite of the age and poor constitutional condition of the sufferer. Thus we can hold out hope to a class of patients the vast majority of whom medical literature, and medical opinion and practice as well, have heretofore given over as hopeless. The experience of the writer has led him to a much more optimistic view than is usually held, and he would suggest that the best treatment for this injury would be an open operation with the pegging or wiring of the fragments, or the application of whatever other method or means may be necessary to retain them in a correct position until bony repair takes place.