Table Of ContentA. Sarmiento L.L. Latta
Closed
Funet· anal Treatment
of Fraetures
With 545 Figures and 85 Tables
Springer-Verlag
Berlin Heidelberg New York 1981
AUGUSTO SARMIENTO, M.D.
Lowman Professor and Chairman
Department of Orthopaedics, University of Southern California School of Medicine,
Los Angeles, California, USA
LOREN L. LATTA, Ph. D., P. Eng.
Director of Orthopaedic Research, Assistant Professor Orthopaedics and
Rehabilitation
University of Miami School of Medicine, Miami, Florida, USA
ISBN-13: 978-3-642-67834-9 e-ISBN-13: 978-3-642-67832-5
DOl: 10.1007/978-3-642-67832-5
Library of Congress Cataloging in Publication Data. Sarmiento, Augusto, 1927- . Closed functional treatment
of fractures. Includes bibliographies and index. 1. Fractures. 1. Latta, Lorn L., 1944- . joint author. II. Title.
[DNLM: 1. Fractures-Therapy. WE180 S246cj RDlO1.26 617'.15059 80-29031
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Softcover reprint of the hardcover 1st edition 1981
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Preface
The purpose of this book is to report on my 17 years of experience in the development
and implementation of a closed functional method of treatment of certain fractures
of long bones of the appendicular skeleton.
My personal experiences, clinical results, and the basic concepts underlying the
treatment philosophy are reported. Illustrations demonstrating the techniques of
application of functional casts and braces are presented in detail as well as a
step-by-step description of the management regime and a discussion of the behavior
of fractures under this system. Indications and contraindications for the use of
this method of treatment are clearly outlined.
I consider it important to compile this information for I believe that the system
has withstood the test of time and is sufficiently sound to be incorporated in
the armamentarium of the orthopaedic surgeon. Also, it may have a favorable
socioeconomic impact since it offers a viable alternative in the treatment of frac
tures.
The basic concept of closed functional treatment of fractures is predicated on the
belief that function is good for tissue healing, rehabilitation, and the prevention
of disability of joints and limbs; and the sacrifice of absolute anatomic reduction
of fractures is a small price to pay for the restoration of function and rapid healing
without compromising the cosmesis of the limb. Fracture bracing does not replace
other methods of treatment which have, and will continue to have, a place in
orthopaedic surgery. Even though internal fixation is nonbiologic and interferes
with the normal physiologic process of healing, there are times when its practical
advantages outweigh its biologic disadvantages: at times it should be given pref
erence over functional fracture bracing. Fracture bracing provides a viable
alternative to internal fixation in many cases where early restoration of function
is imperative for an optimum functional result without the risk of surgical inter
vention.
Closed functional treatment of fractures is aimed primarily at taking the best advan
tage of the biologic parameters involved in fracture healing and restoration of
function. It approximates the natural reparative processes and the rehabilitation
schemes which the body provides through the most normal feedback mechanism
(pain) which the biologic system has evolved. Through the development of these
methods, the incapacitation during and after treatment has been significantly re
duced.
VI Preface
I developed functional fracture bracing 17 years ago while attempting to utilize
amputee prosthetic principles in the treatment of fractures. The developments in
cluded, originally, the patellar tendon-bearing prosthesis for below-the-knee and
the ischial weight-bearing prosthesis for above-the-knee amputations which eliminat
ed bulky corsets and joints that had been previously required above the joint proxi
mal to the amputation site. These tools, when applied to fracture bracing, appeared
to work well since the original goal of avoiding immobilization of joints was
achieved. However, the success of this method was found to be related to a great
extent to the role placed by the soft tissues rather than by the bony structures
of the extremity. Laboratory studies were performed to clarify the role of the
soft tissues.
Extensive experience with this functional method of treatment has indicated that
in closed fractures the initial shortening remains essentially unchanged in spite
of the early institution of function and graduated weight-bearing ambulation. Consis
tent healing with the formation of a periosteal callus has been observed and the
significance of these observations has been investigated in the laboratory. The com
bination of clinical experiences and laboratory data has gradually led to refinements
of the original technique and application to additional fractures of the appendicular
skeleton.
Results to date have indicated that closed functional bracing of fractures is not
applicable to all types of fractures in all bones, but that the method cer
tainly is successful in a large number of instances. Success utilizing these methods
has been predicated on paying close attention to basic concepts and careful fol
low-up.
Trauma will always be with us. Considering escalating costs and resultant disability,
any method of treatment which aids in lowering these costs and the time and
degree of final disability should have a significant socioeconomic impact.
This method of treatment has lowered the cost of care of many common fractures.
It has successfully eliminated or reduced the need and time of hospitalization,
the number of surgical procedures, the length of rehabilitation and disability, and
the loss of productivity of the injured patient. I feel that because of the escalation
of medical costs, it behooves the orthopaedic surgeon to seek solutions which
address the socioeconomic aspect of medical care attempt to reduce the morbidity
that inevitably accompanies the surgical treatment of fractures.
The cost of trauma should not be underestimated in today's society. Each year
in the United States alone one out of every ten persons is affected by fractures,
dislocations, sprains, or strains. This incidence of trauma seems to be irrespective
of age. The National Safety Council data (1971) indicate that the average number
of days of restricted activity for patients between the ages of 17 and 44 was 19.5
days for fractures and dislocations and 6.5 days of bed disability per episode.
For patients over the age of 45 the average number of days of restricted activity
was 27.9 and the average number of days of bed disability was 9.2 per episode.
In 1971, musculoskeletal injuries accounted for 53.9% of days of restricted activity
and 50% of the bed disability days as well as 53.1 % of the loss of work days
compared to all other injuries combined.
It is estimated that a reduction of one day per year in the average annual absenteeism
rate among the labor force in the United States would increase the gross national
Preface VII
product by 10 billion dollars. Musculoskeletal conditions account for 1.9 days
per year according to 1973 figures [2].
In 1971 it was estimated that 6 million fractures occurred in the United States.
Of these, 570,000 were long bone fractures which were treated in hospitals of
which 258,000 were treated by closed means. An additional 302,000 surgical opera
tions were carried out for the removal of plates [1].
My years of experience and careful development of this method of treatment involved
the time, efforts, and ingenuity of many people. LOREN LATTA, PH. D., P. Eng.,
is coauthor of this book because of his invaluable contributions to all the laboratory
research aspects of this project. His ideas and suggestions have helped to shape the
entire system of fracture bracing. He has also been instrumental in the organization
and preparation of the manuscript. Contributions have been made by many others
and they are acknowledged in the references. Working hand-in-hand with the authors
for varying periods of time were many physicians, investigators, prosthetists-ortho
tists, technicians, and so forth, without whom the experiences we share would
not have been possible. In alphabetical order we gratefully acknowledge the following
individuals: RALPH ALVAREZ, B.Sc.; LINDA BECKERMAN, M.S.; ROBERT CATANZARO,
M.D.; ROBERT CHANDLER, M.D.; JACK COOPER, M.D.; GRACE CRuz-ALONZO, M.D.;
EUGENE GALVIN, M.D.; RALPH GAMBARDELLA, M.D.; ARTHUR GARFINKEL, M.D.;
PHILLIP KINMAN, M.D.; KEVIN LESTER, M.D.; NEWTON MCCOLLOUGH III, M.D.;
DONALD MULLIS, M.D.; ROBERT MURPHY, M.D.; GREGORY NORLING, M.D.; JAMES
PHILLIPS, C.P.O.; JULIO PITA, Ph.D.; ROBERT POSIVAL; GILBERT PRATT, M.D.; WAL
TER RACETTE, c.P.O.; JAMES Roupp, M.S.; JOHN SCHAEFFER, M.D.; ROGER SCHMIDT,
M.D.; ANDREW SEW Hoy, M.D.; WILLIAM SINCLAIR, c.P.O.; PHILIP SOBOL, M.D.;
RICHARD TARR, M.S.; PAUL YELLIN, M.D.; JOSEPH ZAGORSKI, M.D.; and ARMAND
ZILlOLl, M.D.
Fall 1980 AUGUSTO SARMIENTO, M.D.
References
1. Hospital Record Study. Directed by the Commission on Professional and Hospi
tal Activities. Amber, Pa., Lea, 1971.
2. Kelsey, J.L., Pastides, H., and Bisbee, G.E., Jr.: Musculoskeletal Disorders.
Their Frequency of Occurrence and Their Impact on the Population of the
U.S. New York, Prodist, Div. of Naele-Watson Academia, 1977.
Contents
Chapter 1
The Rationale of Closed Functional Treatment of Fractures 1
1.1 Immobilization is Unnatural 1
1.2 Function is Natural 2
1.3 Function with Rigid Fixation 3
1.4 Minimizing Interference with the Natural Process 4
1.5 Clinical Management . . . . . . 4
1.6 Indications and Contraindications 7
1.6.1 Shortening and Angulation 7
1.6.2 Bracing as an Adjunct to Internal Fixation 8
1.6.3 Open Fractures ........... . 9
1.6.4 Fracture Reduction and Vascular Complications 11
Summary .. 12
Bibliography 13
Chapter 2
The Scientific Basis of Closed Functional Management of Fractures 15
2.1 The Role of Vascularity in Fracture Healing . . . . . . . 15
2.2 Biochemical Changes Related to Endochondral Ossification 20
2.3 Fracture Callus Architecture ........ . 20
2.4 The Effects of Immobilization on Fracture Healing 33
2.5 Stability of Fractures . . 38
2.6 Anatomic Considerations 44
2.7 Material Considerations 53
Bibliography ..... 58
Chapter 3
Fractures of the Tibia 61
3.1 Anatomy and Function 61
3.2 Shortening and Angulation 64
3.3 The Tibial Fracture with an Intact Fibula 71
3.3.1 Angulatory Deformities . . . . . . . . 71
x
Contents
3.4 The Tibial Fracture with an AssQciated Fibular Fracture 73
3.5 Management Protocol 75
3.5.1 Stage One. 75
3.5.2 Stage Two 77
3.5.3 Stage Three 83
3.6 Application of Casts and Braces 84
3.6.1 The Above-the-Knee Cast ... 84
3.6.2 The Functional Below-the-Knee Cast 84
3.6.3 The Plaster-of-Paris Below-the-Knee Functional Brace 84
3.6.4 The Plastic Below-the-Knee Functional Brace 85
3.6.5 Prefabricated Braces 85
3.7 Mechanical Function of the Brace 99
3.8 Brace-Soft Tissue Design. 101
3.9 Materials and Mechanics . . . 103
3.10 Clinical Experience . . . . . . 104
3.10.1 Fractures of the Proximal Tibia 105
3.10.2 Mid-diaphyseal Tibial Fractures with an Intact Fibula 105
3.10.3 Fractures of the Distal Third of the Tibia with an Intact Fibula 120
3.10.4 Fractures of the Proximal Tibia with Associated Fibular Fracture 134
3.10.5 Diaphyseal Tibial Fractures with Associated Fibular Fractures 152
3.10.6 Short Oblique Fractures of the Tibia . . . 165
3.10.7 Distal Metaphyseal Fractures of the Tibia 199
3.10.8 Segmental Fractures of the Tibia 211
3.10.9 Bilateral Tibial Fractures 222
3.10.10 Open Tibial Fractures 236
Clinical Data 262
Bibliography 265
Chapter 4
Tibial Condylar Fractures 267
4.1 The Mechanical Role of the Fibula 267
4.2 Clinical Considerations . 268
4.3 Clinical Management .. 269
4.3.1 Application of the Brace 269
4.4 Clinical Experiences 275
4.5 Bicondylar Fractures with Associated Fibular Fracture 276
4.6 Medical Condylar Fractures ......... . 282
4.7 Bicondylar Fractures with an Intact Fibula 284
4.8 Lateral Condylar Fractures with an Intact Fibula 292
Bibliography ............... . 296
Chapter 5
Fractures of the Femur 297
297
5.1 Femoral Fracture Bracing .....
5.2 Application of the Functional Brace 300
Contents XI
5.3 Clinical Experience 310
Clinical Data 336
Bibliography 338
Chapter 6
Fractures of the Distal Radius 339
6.l Management ..... 347
6.2 Application of the Brace 349
6.3 Clinical Experience 360
Clinical Data 378
Bibliography 380
Chapter 7
Fractures of the Forearm 381
7.1 Fractures of Both Bones of the Forearm 382
7.1.1 Management ........... . 383
7.l.2 Application of the Brace ... . . . . 388
7.2 Clinical Experience with Fractures of Both Bones of the Forearm 397
Clinical Data .... . 425
7.3 Isolated Radial Fractures . . . . . . . . . . . 426
7.3.1 Application of the Brace .......... . 426
7.4 Isolated Fractures of the Radius: Clinical Material 426
Clinical Data . . . . . 459
7.5 Isolated Ulnar Fractures 460
7.5.1 Management ..... 460
7.6 Application of the Ulnar Sleeve 461
7.6.1 Clinical Material . . . . . . . 483
7.7 Bilateral Ulnar Fractures . . . 488
7.8 Segmental Isolated Fractures of the Ulna 490
Clinical Data 494
Bibliography 495
Chapter 8
Fractures of the Humeral Shaft 497
8.1 Humeral Shaft Fractures 497
8.2 Management ..... 497
8.3 Clinical Experience . . . 506
8.4 Bilateral Humeral Fractures 540
Clinical Data 544
Bibliography 545
Chapter 9
Delayed Unions and N onunions of the Tibia 547
9.l Delayed Unions and Nonunions of the Tibia 547
9.2 Clinical Experience . . . . . . . . . . . . 551
XII Contents
9.3 Infected N onunions 551
Clinical Data 580
Bibliography 582
Chapter 10
Fractures in Children 583
10.1 Fractures in Children 583
10.2 Management 584
10.3 Clinical Experience 584
10.3.1 Tibial Fractures 584
10.3.2 Femoral Fractures 596
10.3.3 Forearm Fractures 596
Clinical Data 607
Bibliography 608
