Fractures

Immobilization and rest have been the paramount points with most

physicians in the treatment of fractures and sprains. They have claimed

that a sprain should be manipulated but rarely, much less a fractured

bone. Rest, quiet, and fixation of an injured joint or bone have been

rules that should not be violated under any consideration. In cases

of sprain the great cry has been to let the joint alone for fear of

spreading a possible =tubercular infection=. It is well to recall

Mumford’s statement that if immobilization is too long continued,

should there be a tubercular taint, proper conditions for a localized

tuberculosis is established. And still a word of caution here, that an

osteopath should not be over zealous and should carefully weigh all

possible factors, both local and constitutional, may not be amiss. In

previous tubercular, syphilitic, and other diseased states discretion

should be employed.

Reducing rest and immobilization to a minimum means much to the

patient, not only in the loss of valuable time but in annoying and

serious after effects. Many cases of sprains and fractures come to

the osteopath. In sprains that have become chronic through too much

rest of the part and improper treatment, almost invariably there is

found displacements of bone and adhesions that should never have

existed; then has followed organized exudates and chronic synovitis. In

fractures and even in complete dislocations the osteopath continually

observes that too much rest has been given the part, resulting in

unnecessary adhesions, contractions, atrophy of muscles, and impairment

of function. Treatment almost always cures the condition, or at least

materially relieves. How much better if the proper treatment had been

first instituted and thus a large percentage of cases prevented from

becoming chronic.

Of particular interest to the osteopath is the paper prepared by

Eisendrath on “Early Massage and Movements in the Treatment of

Fractures and Sprains,” and the discussion that followed before the

Chicago Medical Society. The Illinois Medical Journal, December, 1903,

contains a report.

Eisendrath said in part: “The former routine of immobilizing all

fractures and the adjacent joints for a period of four to six weeks

must, I feel, be subject to slight modification in the light of recent

experience, and it shall be the aim of this paper to show what these

changes are. When we are called to a case of fracture, it should be

one’s first duty after its reduction to consider how can I best aid

the patient in recovering the usefulness of his or her limbs? Can we

shorten the long convalescence with its resultant loss of valuable

time and earning capacity? How can we most rapidly restore to the limb

its normal joint functions and prevent an atrophy of muscles and an

ankylosis which will require many months to overcome?...

“The use of massage and of active and passive movements in the

treatment of fractures and of severe sprains has been gradually

gaining in the number of its advocates through the writings of

Lucas-Championniere of Paris. We owe him a great debt for calling the

attention of the profession to the employment of these methods in order

to prevent atrophy and ankylosis as well as to promote healing....

“Before taking up my subject in detail permit me to recall a few

salient points in the surgical pathology of fracture. Soon after the

injury the blood clot around and between the ends of the fragments is

absorbed and replaced by a jelly-like mass of young connective tissue

cells called the callus. It corresponds to the solder which the plumber

places over the ends of two pipes he desires to join. Bone begins to

form at the periphery of the callus about the tenth day and advances

toward the center rapidly, forming a ring of bone around the ends

of the fragments so that by the end of the third week there is but

slight abnormal motion at the point of fracture (exception to this is

the femur). This entirely disappears by the end of the fourth week,

especially in young people, and the union is firm. In the case of the

femur it requires six or eight weeks. The greater the displacement

of the ends of the fragment, the larger the callus and the slower the

healing of the fracture.

“During these changes (callus formation) the muscles which supply

the immobilized joints atrophy and the circulation in the skin and

neighboring tissues is sluggish, resulting in swelling, etc., of the

limb. The enforced rest causes more or less fluid to accumulate in

the tendon sheaths and joints. This becomes organized and results

in fibrous ankylosis of the joints and great impediment to the free

action of the tendons within their sheaths. It is this atrophy, fibrous

ankylosis and tenovaginitis which interfere with the restoration of the

normal functions of the limb....

“Can we decrease the amount of wasting of muscles and control the

stiffness of joints and tendons after fractures?

“It is the belief of the writer, based on a large experience, that the

earlier use of massage, active and passive motions, will to a great

extent eliminate the above conditions, which retard convalescence and

in some cases cause permanent disability.

“Massage of an injured limb increases the amount of blood supplied to

it, promotes the absorption of the swelling and prevents atrophy of

muscles. In the case of a joint injury the exudate rapidly disappears

and the articular surfaces can be again approximated so that movement

is facilitated. By the cautious use of active and passive movements,

either with or without the aid of apparatus, the normal functions of a

joint can be rapidly restored....

“The active and passive movements of the limbs can be carried out

immediately after the massage, but should only be permitted for

a period of =five minutes= at first and the time then gradually

increased. When a severe sprain, say the elbow or ankle, is first

massaged, the pain seems to be almost unbearable, but this discomfort

as well as the swelling rapidly disappears, and it is surprising to

those who have never applied this treatment how quickly the normal

function of the joint reappears. The same applies to the synovitis

which accompanies fractures in close proximity or even into joints.”

The relief given these cases by massage, movements and manipulations

by the osteopath is a daily experience, and results to him are not

surprising. Then in addition to what the surgeon would do, the

osteopath applies his principles of careful detail readjustment.

Eisendrath continues his paper by referring to the principal varieties

of fractures and giving the treatment for each. He says that if correct

treatment is carried out with proper massage and movements in fractures

of one or both bones of the leg, the patient will be at work in six or

seven weeks instead of three or four months, that in Colle’s fracture

some surgeons do not employ a splint, and that in fractures of the

olecranon, massage from the first week on is of the greatest use. This

part is very interesting but space forbids giving it.

He then concludes his article with citation of several very interesting

cases of fractures and severe sprains. These cases are exceptionally

interesting to the osteopath, but still the same good treatment and

results are duplicated every day in the osteopathic school.

The doctor’s contraindications to the use of early massage in fractures

or sprains are the following:

“1. Tendency to displacement of fragments in oblique fractures. Under

such conditions it is best not to begin either massage or movements

until the union is firm (fourth to fifth week).

“2. In compound fractures until the wound is healed.

“3. Whenever the condition of the skin is such as to permit of

infection; for example, the presence of blebs, or extensive abrasions.

“4. The presence of fragments which project but do not penetrate the

skin.”

His conclusions are:

“1. Massage, active and passive motions prevent atrophy of muscles,

tenovaginitis and ankylosis so frequently accompanying and following

fractures, especially those close to the shoulder, elbow, wrist, knee

and ankle joints.

“2. They give far better results than complete immobilization in the

majority of fractures.”

In the discussion that followed Henrotin said that for some time, “I

have never put a restraining apparatus of any kind, nor have I used any

lotions on any sprain, no matter how severe....

“It has taken many years to bring this subject before the profession.

It is a method that is absolutely effective as regards sprains and some

forms of fractures. I have treated several hundred such cases with the

greatest success.” He also said that, “In treating an inflamed joint

it is improper to use a restraining apparatus of any kind. I consider

that the plaster cast is the bane of all inflamed joints unless there

is a =specific form of infection=, a traumatic condition.” Neither does

he believe that an inflamed joint should be put at rest. He says the

patient is a good judge as to the amount of quiet the joint needs. He

has treated Colle’s fractures and fractured clavicles without bandages

or apparatus.

To sum up, the osteopathic procedure in the treatment of fractures

would be as follows:

1. Immobilization in those cases especially demanding it, from the

character of the fracture, until formation assures solid and firm union.

2. Manipulation and massage and movements of parts at an early period,

compatible with the above, to render soft tissues pliable, to remove

stiffness and adhesions, to restore a normal circulation, and to

exercise and function the parts.

3. In cases of laceration of soft tissues, abrasions, etc., great care

should be taken so as not to infect the parts.

4. Great care should be taken where fracture is compound, and where

fragments exist.

5. In all cases, both acute and chronic, critically examine for slight

anatomical deviations locally and remotely.

In dislocations the fundamentals of the above are applicable. Do not

let chronic stiffness, or rigidity, adhesions, or synovitis supervene

if possible to prevent.

An important consideration in all cases of sprains, fractures, and

dislocations that become chronic is the probable effect upon dependent

tissues by way of nerve impairment and vascular obstruction; for

examples, the sprained back may readily impair organic life, the

fractured elbow prevent use of the arm, the injured leg predispose

to flat foot. (See J. B. Littlejohn—Osteopathic Surgery, including

Treatment of Fractures, Journal of the American Osteopathic

Association, Nov., 1905.)