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Castless Ambulatory Method of Treating Fractures*

2000; Lippincott Williams & Wilkins; Volume: 375; Linguagem: Inglês

10.1097/00003086-200006000-00002

1528-1132

Roger W. Anderson,

Dental Education, Practice, Research

Roger Anderson (1891-1971) Roger Anderson (Fig 1.) was born in St Paul, MN, where his father was a contractor. After attending public school in St Paul, he attended Hamlin University where he received his bachelor's degree in 1914. He then went to Northwestern University and received his medical degree in 1918. He spent 3 years as an intern and surgical house officer at the Cook County Hospital in Chicago, then concluded his postgraduate training with a tour of surgical clinics in London and Vienna. Dr. Anderson began his practice in Tacoma, WA, but soon moved to Seattle, where he remained for the rest of his life. He had a large practice in various Seattle hospitals and became a Clinical Professor of Orthopaedic Surgery at the University of Washington.Fig 1: Dr. Roger Anderson (Reprinted from the Encyclopedia of American Biography. New York, J.P. White 1972).Roger Anderson became well known throughout the world as an innovator and inventor of orthopaedic equipment. To manufacture and market his inventions, he founded the Tower Company of Seattle. One of his early and most successful inventions was the Well Leg Splint, designed to treat extracapsular hip and some femoral shaft fractures. This device allowed the patient to get out of bed while traction still was maintained on the injured leg. It was used widely at a time when prolonged bed rest carried a high morbidity and mortality in elderly patients. He designed a plastic casting material, called "Aircast," which was one of the first waterproof casting materials to be used widely. His fracture table also was very popular. A portable version was used in military hospitals during World War II. Anderson's greatest invention was his method for the external fixation of fractures, for which he developed all of the technical devices, including a fracture machine that he used to reduce fractures of the tibia while applying his devices. Although external fixation using Anderson's method was very successful in his hands, the technique could lead to disaster in the hands of those surgeons who were less skilled or those who had less training. Pin tract infection was a major problem, especially before the introduction of antibiotics. Detractors spoke of the purulent drainage that often occurred around the pins as "Seattle Serum". Although initially adopted by the United States Army early in World War II as a method for treating tibial fractures, the system failed in the hands of inexperienced and poorly trained surgeons. As a result, the method was abandoned and received little support in the orthopaedic community during and after the war. Techniques developed by Roger Anderson for the external fixation of fractures still remain an important contribution to orthopaedics. Leonard F. Peltier, MD, PhD PROGRESS in fracture therapy, as in any field of science, is based on change in the current concepts of treatment. Castless ambulation for all types of shaft fractures would, at first thought, seem to be wishful thinking, but when certain principles are employed it becomes a reality of practical importance not only for war surgery but equally so for civilian practice. The operating principles of this castless procedure are (1) to control the fracture by angularly inserting two transfixions into each fragment, and (2) to supply immobilization by connecting the two sets of transfixions with a slender rod. Anatomic studies have demonstrated that there is a safe door for transfixing both fragments of any one of the long bones. Furthermore, transfixation can be carried out without incision of the skin or preliminary drilling of the bone. This method is applicable to any fracture of the long bones in any extremity, whether transverse, comminuted, or compound, and is effective even when the fracture extends into one of the distal joints. It is an ideal supplement to many orthopedic procedures, such as arthrodesis of the knee, non-union or mal-union operations, and length equalization and reconstruction operations. So comprehensive is its scope that the treatment of fractures of the long bones can at last be said to be standardized. Furthermore, standardization and simplification have been extended to the transfixation units themselves. For instance, the same unit can be used for the femur or humerus in the largest man or the smallest woman. The units have been so devised that they hold half-pins, through-and-through pins, or wires. An external safety stop makes possible the use of thinner pins than previously employed. As these fracture units can be used for all fractures of either extremity, and will hold any type of transfixion, they are referred to as universal fracture units. The units and fixation rods, as illustrated below, (Figure not shown) are constructed of a rustless alloy, so light that the whole apparatus for immobilization of a fractured shaft of the femur weighs only twelve ounces. TECHNIC The skin area for transfixation is cleansed with soap and water, ether and, if desired, a weak solution of iodine. No preliminary cutting or pulling of the skin is necessary before inserting the pins. Two half-pins are angularly placed into each fragment. Small, dry dressings are spiked over the pins, a pin clamp is slipped over each half-pin, and then a universal rod is securely fastened into the pin clamps. Reduction by direct control of the fragments is accomplished by manipulating the fracture units by one of three means: (1) manual; (2) fracture table, or (3) anatomic splint. We prefer the latter because each fragment can be directly and individually controlled by mechanical movements, operating upon the exact anatomic center; furthermore, both fragments are held rigid during the radiographic checkup. Through-and-through transfixation, where practicable, as in the distal femur, employs the same fracture units and operates upon the same principles. Kirschner wire can also be used without any change in technic, and the operator may insert one, two, three or four wires, according to his judgment. Immobilization is quickly obtained by fastening the fixation rod to the two fracture units by the fixation rod clamps. Compound fractures can be effectively treated, as reduction is positively immobilized by the rod so that thereafter all attention may be directed toward treatment of the soft tissue wounds by any method of choice. If Orr's method is selected, the obnoxious odor may be minimized as the plaster may be changed as often as is indicated without danger of losing apposition. A complicating gas infection can be readily approached for radiotherapy. Rod fixation also provides access for later sequestrotomy, skin grafting, and removal of foreign bodies. As we all recognize, callus can be derived only from the blood stream. Thus it is evident that any improvement in circulation will naturally hasten the formation of callus. Ambulation with muscle contraction and contiguous joint movements cause an increased circulation of blood and lymph. This sovereign advantage has not been emphasized in the past, possibly because it was unobtainable. The words "castless" and "ambulatory" vividly portray the advantages of this method, and the physiologic and economic benefits are so numerous and evident that they need no further elucidation. SUMMARY A technic for a castless, ambulatory method of treating fractures of the long bones has been outlined. SUMARIO El tratamiento ambulatorio de todas las fracturas de las diafisis oseas se puede llevar a cabo, sin tener que practicar el enyesamiento, utilizando ciertos aparatos que consisten de tallos delgados conectados a ciertas unidades de transfixacion. Estas unidades han sido ideadas de tal manera que puedan asegurarse al tipo de alfiler o alambre de traccion que se quiera usar en un dado caso. Los tallos de fijacion son faciles de aplicar, aseguran la inmovilizacion rigurosa de los fragmentos, y pueden re-adjustarse con facilidad en los casos que se quiera cambiar la posicion de los fragmentos. La reduccion de la fractura se hace de acuerdo con una tecnica semejante a la que el autor advoco anteriormente, como sigue: Dos alfileres de transfixion son introducidos directamento y en direccion angular en la substancia de cada fragmento: lo que se ejecuta sin tener que hacer antes una perforacion del hueso o una insicion previa de la piel. El tipo de la fractura y su localizacion determinan la clase de alfiler que se debe de usar. Los dos alfileres de transfixion introducidos en cada fragmento, cuando son conectados con su correspondiente tallo, constituyen lo que se llama una unidad de transfixion. Con la manipulacion correcta de estas dos unidades de transfixion se puede obtener la reduccion satisfactoria de la fractura. La inmovilizacion se asegura conectando las dos unidades de transfixion con uno o dos tallos de fijacion.