Arch Orthop Trauma Surg (2010) 130:13851396

DOI 10.1007/s00402-010-1082-7
1 3
TRAUMA SURGERY
Early history of operative treatment of fractures
Jan Bartonbek
Received: 29 December 2009 / Published online: 9 March 2010
Springer-Verlag 2010
Abstract Surgery in the Wrst half of the nineteenth century
was primarily dominated by pain and fear of lethal infections.
Therefore, the absolute majority of fractures and dislocations
were treated non-operatively. Development of operative treat-
ment of fractures was inXuenced by three major inventions:
anaesthesia (1846), antisepsis (1865) and X-rays (1895). The
Wrst to use external Wxation is traditionally considered to be
Malgaigne (1843). However, his devices cannot be considered
as external Wxation. Von der Hhe, in 1843, Wxed a non-union
of the femur by inserting into both fragments a couple of
screws transversely connected outside the wound. Von
Langenbeck in 1855 treated a non-union of the humerus with
screws connected by a devise designed for this purpose. A
predecessor of nailing of acute diaphyseal fractures may be
considered to be Wxation of diaphyseal non-unions of the
femur, humerus and tibia with ivory intramedullary pegs, per-
formed by DieVenbach in 1846. Nevertheless, until 1885,
osteosynthesis was still a Cinderella having at its disposal
mainly wires, ivory pegs and very primitive types of external
Wxation. During the following 35 years (18861921), opera-
tive treatment of fractures witnessed an unprecedented revolu-
tion. Radiology became an integral part of bone and joint
surgery. All types of osteosynthesis, i.e. plates (Hansmann
1886), external Wxation (Parkhill 1897) and intramedullary
nails (Schne 1913) were introduced into clinical practice.
Basic experiments were undertaken, surgical approaches
described and the Wrst textbooks on osteosynthesis published.
Keywords History of osteosynthesis Plates
External Wxation Intramedullary nails
Surgical approaches
Introduction
The history of the operative treatment of fractures is a fasci-
nating story that has engaged many authors [37, 1418,
22, 27, 29, 37, 40, 73, 8082, 87, 88, 103, 104]. The recent
50th anniversary of the foundation of AO (Arbeitsgeme-
inschaft fr Osteosynthesenfrage) was the occasion for its
recapitulation. To understand the development of osteosyn-
thesis, it is important not only to become acquainted with
the chronological sequence of individual facts, but also to
analyze the causes, implications and consequences of indi-
vidual events, based on original sources.
Operative treatment of fractures in the Wrst half
of the nineteenth century
In the Wrst half of the nineteenth century, the foundations
were laid for the modern treatment of injuries of bones and
joints, mainly thanks to the textbooks by Pierre-Joseph
Desault (17381795), Sir Astley Paton Cooper (1768
1841) and Joseph Franois Malgaigne (18061865), pub-
lished and translated both in Europe and North America
[19, 20, 23, 24, 6669]. However, but for a few exceptions,
fractures and dislocations were treated non-operatively and
discussions concentrated primarily on the position of the
limb during reduction, the manner of its performance and
immobilization of the injured limb. The main obstacles to
the development of operative treatment were the pain asso-
ciated with surgery and, particularly, concern about infection
J. Bartonbek (&)
Department of Surgery, 1st Faculty of Medicine of Charles
University and Thomayer University Hospital,
Videnska 800, 140 59 Prague 4, Czech Republic
e-mail: bartonicek.jan@seznam.cz
1386 Arch Orthop Trauma Surg (2010) 130:13851396
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and its potentially fatal consequences. As a result, the
most frequent operation at that time was limb amputation,
mainly for war injuries and open fractures, with few cases
of surgically treated non-unions or acute fractures [6, 10,
24, 25, 29, 33, 36, 93]. The absence of anaesthesia and
asepsis were compensated for by the speed and skill of
surgeons.
The Wrst textbook to deal with osteosynthesis Trait de
limmobilisation directe des fragments osseux dans les
fractures was published in 1870 [10]. Its author, Laurent
Jean Baptiste Brenger-Fraud (18321900), the French
chief naval physician and admiral of the French Navy, sum-
marized from literature more than 400 cases of fractures
that were operated on. At that time, the problem of anaes-
thesia had already been solved and the Wrst steps were taken
in the prevention of intraoperative infection. Brenger-
Fraud described, in total, six types of direct Wxation of
bone fragments, the most progressive of which were wire
cerclage and the Wrst prototypes of external Wxation known
at that time. However, in general, operative treatment of
fractures was at that time still in its infancy.
Discovery of anaesthesia, antisepsis and X-rays
(18461895)
Surgery in the Wrst half of the nineteenth century was
primarily dominated by pain and fear of lethal infections. Sur-
geons were, to a great extent, inXuenced by their blindness
resulting from the absence of a method that would allow an
accurate diagnosis of fractures and dislocations, or monitoring
the course of healing, outcomes and complications of the
treatment. All this changed radically within 50 years.
On 16 October 1846, William Thomas Green Morton
(18191868), an American dental surgeon, described for
the Wrst time the administration of inhaled ether vapour as
an anaesthetic during operation. In the space of a few
months, this method had also spread to Europe.
The British surgeon Joseph Lister (18271912), who
lived and worked in Edinburgh and later moved to London,
was inXuenced by Pasteurs teaching and addressed the pre-
vention of surgical infection [14]. In 1865, he treated
successfully an open femoral fracture in an 11-year-old boy
using an antiseptic carbolic acid spray. In 1877, he per-
formed osteosynthesis of a closed fracture of the patella,
under carbolic acid spray, using a silver wire [65]. This
operation became an important part of the history of sur-
gery. In Germany, the Listerian method was actively propa-
gated by Richard von Volkmann (18301889) from Halle
as early as in 1872 and its use quickly spread all over
Germany [37, 102]. In 1886, Ernst Gustav Benjamin von
Bergmann (18361907) from Berlin introduced asepsis
(steam sterilization). Prevention of infection improved also
thanks to the introduction of rubber surgical gloves in the
1890s by William Stewart Halsted (18521922) in the USA
and subsequently by Emil Theodor Kocher (18411917) in
Europe.
Wilhelm Conrad Rntgen (18451923) made his discov-
ery of X-ray imaging on 8 November 1895 and published it
in the Wrst week of January 1896. The Wrst clinical radio-
graph, showing a projectile in the wrist of a 12-year-old
boy, was published in Lancet as early as 22 February
1896!!! One of the Wrst radiographs appeared for instance
in the Atlas of Fractures, published in 1897 by Heinrich
Helferich (18511945) from Greifswald [42]. The Wrst
book on fractures, which had been diagnosed and treated on
the basis of radiographic examination, was published by
Carl Beck (18561911), an American surgeon of German
origin, working in New York, in 1900 [8].
The decisive era of 35 years (18861921)
In 1885, osteosynthesis was still a Cinderella having at
its disposal mainly wires, ivory pegs and very primitive
types of external Wxation. After World War I, the situa-
tion changed radically. During 35 years (18861921),
operative treatment of fractures witnessed an unprece-
dented revolution. Radiology had become an integral part
of the bone and joint surgery. Introduced into the clinical
practice were all types of osteosynthesis, i.e. plates,
external Wxation and intramedullary nails. Basic experi-
ments were undertaken, surgical approaches described
and the Wrst textbooks on osteosynthesis published. This
extremely fruitful period was split by Roentgens inven-
tion into two diVerent parts: the pre-radiological and
radiological eras.
Pre-radiological period (18861895)
Due to the blindness of surgeons, operative treatment Wrst
focused on subcutaneous fractures, i.e. fractures more
easily diagnosed by sight and palpation (patella, olecranon,
tibia, clavicle and mandible), as well as fractures resisting
non-operative treatment (proximal femur, diaphyseal frac-
tures of the forearm). In spite of this blindness, several
signiWcant publications appeared in this period.
Carl Hansmann (18531917), a German surgeon from
Hamburg, was the Wrst to publish in 1886 Wxation of frac-
tures by a plate (Fig. 1) [38].
Heinrich Bircher (18501923), a Swiss surgeon from
Bern, published in 1887 an extensive article on intramedul-
lary osteosynthesis of diaphyseal fractures of the femur and
tibia by means of pegs, and of the metaphyseal fractures of
the tibia by ivory clamps (Fig. 2) [12].
Arch Orthop Trauma Surg (2010) 130:13851396 1387
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Nicholas Senn (18441908), an American surgeon from
Chicago, dealt in detail in 1893 with the then known meth-
ods of osteosynthesis [92]. He studied absorption of asep-
tic ivory and bone in the living tissues and developed a
hollow perforated intra-osseous splint of which he
assumed absorption in a comparatively short time. For
oblique diaphyseal fractures, he designed an extramedul-
lary bone ferrule. He successfully used this absorbable
osseous sleeve, made from ox bone, in three patients with
non-unions of the femoral, humeral and tibial shafts
(Fig. 3). Thus, Senn can be called the father of biodegrad-
able implants. His ferrule was predecessor of the Putti-
Parham bands.
Pietro Loreta (18311889), an Italian surgeon and per-
sonal physician of Garibaldi, was probably the Wrst in the
world to perform, in 1888, an open osteosynthesis of a non-
union of the femoral neck, using multiple cerclage [1].
Julius Dolinger (18491937), a Hungarian surgeon from
Budapest, Wxed an acute extracapsular fracture of the femo-
ral neck by open osteosuture using silver wire, in 1891 [26].
Fig. 1 Hansmanns plate (Verh Dtsch Ges Chir 15:134137, 1886)
Fig. 2 Birchers intramedul-
lary ivory peg and clamp
(Langebecks Archiv 34:410
422, 1887)
Fig. 3 Senns hollow perfo-
rated intra-osseous splint (a)
and an extramedullary bone
ferrule (b, c) (Ann Surg
18:125151, 1893)
1388 Arch Orthop Trauma Surg (2010) 130:13851396
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Willy Meyer (18581932), an outstanding American
surgeon of German origin and Trendelenburgs pupil, was
the Wrst to treat in the USA a non-union of the femoral neck
with two nails in 1892 [71].
Elie Lambotte (18561912), a Belgian surgeon and
brother of Albin Lambotte, was probably the Wrst to treat an
oblique fracture of the tibial shaft with screws, in 1890
[55].
William Arbuthnot Lane (18561943), a British surgeon
from London, advocated in articles published in 18931895
operative treatment of fractures of such a bone as the
patella, tibia, Wbula, clavicle, jaw and olecranon. He Wxed
fractures by wire sutures and later by screws [5759].
Radiological period (18961921)
The discovery of X-ray imaging provided bone surgeons
with a tool for diagnosing fractures and dislocations, as
well as for monitoring fracture healing, evaluation of the
Wnal outcome and of any complications.
Frederic Jay Cotton (18691938) from Boston, the
author of an outstanding textbook, wrote in 1910 [21]: We
are fortunate today not only in having the X-ray as an
accessory method of diagnosis, but in having, as a result of
this diagnostic method and of a vast array of observations
made directly at operation, a material for deductions not
accessible to previous generations. Wisdom did not begin
with this generation, but we have had an unusual opportu-
nity to learn. Similarly, in 1912 Emil H. Beckman stated:
The use of the X-ray Wrst showed us how very inferior our
bone repair work has been [9].
The development of osteosynthesis was gaining momen-
tum and the number of published articles on this subject
was growing, both in Europe and in the USA [9, 13, 28, 31,
32, 34, 35, 39, 4952, 64, 70, 72, 7679, 8385, 89, 94, 95,
97, 98, 100]. Some authors, such as Nienhansen Preston,
Schne and Sherman, became famous in this Weld, on the
basis of only one or two publications [76, 83, 84, 89, 95,
96]. Others such as Lane, Lambotte and Hey Groves dealt
systematically with operative treatment of fractures and
published their work in a book form [44, 46, 55, 56, 60, 63].
This period was symbolically rounded oV with the second
edition of Hey Groves book in 1921 [46].
The development of implants in the late nineteenth
and early twentieth centuries
One of the Wrst problems brought about by the introduction
of operative treatment of fractures was a total lack of suit-
able implants and instruments. Therefore, those who
wanted to treat fractures operatively tended to develop their
own implants. It was a period of testing of suitable materi-
als and the search for adequate surgical approaches.
Materials
EVorts were concentrated on Wnding a suitable implant
material. The oldest implants for internal Wxation of frac-
tures were made from various materials, mainly ivory, bone
and metal (bronze, lead, gold, copper, silver, brass, steel,
aluminium). Ivory and bone pegs were used for intramedul-
lary Wxation [2, 11, 25]. Silver was used for cerclage wires,
plates and intramedullary pins. However, the Wrst plates
were made from nickel-coated sheet steel [38], and later
from silver [98], high carbon steel [60, 63], vanadium steel
[95], aluminium [55, 56] or brass [13]. Nevertheless, all the
metals were highly problematic from the viewpoint of their
mechanical properties and corrosion. This problem was
solved by the use of stainless steel. Although it was
invented before WWI, it was not used for the production of
implants until much later [101].
Experiments
Many authors tested their ideas experimentally. One of the
Wrst was Ferdinand Riedinger (18441918), a German sur-
geon from Wrzburg. His article of 1881, dealing with non-
unions of the forearm, included a number of experiments
on rabbits and dogs [86]. While the implanted intramedul-
lary ivory pegs and bone blocks integrated into the bone
without problem, the wooden and rubber implants caused
infections. The article was supplemented also with micro-
scopic drawings not only of integrated ivory pegs, but also
of the adjacent physis (Fig. 4).
An outstanding researcher was Nicholas Senn, who in
1889 published a book on experimental surgery [91]. He
not only studied the healing of intracapsular fractures of the
femoral neck [90], but veriWed in dogs the feasibility,
safety and utility of direct fracture Wxation with bone fer-
rules [92].
Harry M. Sherman (18541921), an American surgeon
from San Francisco, studied experimentally in 1914 several
signiWcant issues, including: Are screws and plates toler-
ated inside a joint? and What are the early and late eVects
of well, and insuYciently, countersunk screws. Among
other things, he found out that The use of two diVerent
metals in these screws and plates does not change the
results in the articulation, except so far as the possible elec-
trical reaction is concerned in the staining of the tissues
[94].
The most extensive and comprehensive experiments
were made from 1914 by Hey Groves [44]. In most of his
100 experiments, he studied on the cat tibias and femurs the
healing of fractures Wxed by plates, intramedullary pegs
Arch Orthop Trauma Surg (2010) 130:13851396 1389
1 3
(ivory, steel, metallic magnesium, wire spirals, bone, decal-
ciWed bone) and external Wxators. He also studied Wlling of
bone defects with bone pieces or chips and regeneration of
bone after subperiosteal removal of a piece of its entire
thickness. The results of his experiments were illustrated by
skiagrams, and photographs of microscopic specimens
and microscopic sections. His conclusions are valid to this
day. He thereby anticipated much of the experimental work
of AO by more than 40 years.
Cerclage
Wire cerclage was one of the earliest methods of internal
Wxation [1, 10, 26, 29, 65, 71, 81, 82]. Improvement of this
technique was published almost simultaneously by three
authors. Robert Milne, an American surgeon, described in
1912 cerclage using Xexible threaded pins [72]; Vittorio
Putti (18801940), an Italian orthopaedic surgeon, pre-
sented in 1914 cerclage with a narrow metal band [85].
Two years later (1916), a similar method was published by
Frederick William Parham (18561927), an American sur-
geon from New Orleans [77]. The implant spread world-
wide under the name Putti-Parham bands and in various
modiWcations it is occasionally used today.
Plates
The Wrst to publish his experience with plate osteosynthesis
was Carl Hansmann, in 1886, as mentioned above [39].
Hansmann used plates from nickel-coated sheet steel in 20
cases, 15 times in fractures (8 fractures of the tibia, 3
fractures of the femur, 1 fracture of the radius, 1 olecranon
fracture and 2 fractures of the mandible) and 5 times in
non-unions (humerus, ulna, radius, femur, tibia). Part of the
plate, and the shanks of the screws that Wxed it to the bone,
protruded from the wound and could be therefore removed
percutaneously. Hansmann kept the surgical wound strictly
aseptic and used washable external rubber splints. He did
not mention any complications and removed the plates after
48 weeks. Neither in Germany nor elsewhere in Europe
did Hansmann have a successor for a long time. It was only
after a 14-year interval that other publications in this Weld
appeared, mainly in the USA.
Lewis W. Steinbach (18511913) from Philadelphia in
1900 treated four cases of fracture of the tibia with a silver
plate of his own design, Wxed to each of the fragments by
two steel screws [98]. He also described in detail the opera-
tive technique, including the use of drainage tubes. It was
the Wrst publication to use radiography to document the
injury, the plate Wxation and the Wnal outcome after implant
removal.
Edward Martin (18591938), also from Philadelphia,
published in 1906 radiographs of fractures of the femoral
shaft, and the tibial shaft and metaphysis, treated with
plates and monocortical screws [70]. Among radiographs
published by Martin was also a healed fracture of the distal
shaft of the radius treated with plate and bicortical screws
by John Ashhurst (18391900) 7 years before publication
of Martins article, i.e. in 1899!
William Lawrence Estes (18551940), from South
Bethlehem, in 1912 in an article on fractures of the femoral
shaft, discussed in detail the operative technique, stating:
In 1886 the writer devised a plate for direct Wxation of
fractured bones. It has been used in his clinic with good
results ever since. It is a modiWcation of the early Schede
plate. It is made of soft steel, nickel plated. It has been
known to bend a little but has never broken while in use
[28]. This indicates that Estes developed the plate simulta-
neously with Hansmann! Unfortunately, no details could be
traced.
Joseph Augustus Blake (18641937) of New York
reported 106 surgically treated fractures in 1912 dealing in
detail with plate osteosynthesis [13]. From 1905, he used
plates of his own design, made mostly of silver, and also
occasionally of brass or steel. He later applied the Lane
plates to the treatment of fractures of the shafts of the
humerus, ulna, radius and femur.
Emil H. Beckman (18721916) from the Mayo Clinic in
Rochester was probably the Wrst to publish, in 1912, a
radiograph of a fracture of the medial malleolus Wxed with
a plate [9].
William ONeil Sherman (18801979) from Pittsburgh
was a strong proponent of internal Wxation in the USA and
contributed to signiWcant improvements in plate design. As
he worked for Carnegie Steel Company, he had optimal
conditions for experimenting with both the material and
Fig. 4 Riedingers experi-
ments: a ivory peg (a) incorpo-
rated in medullary channel,
b physis of operated on bone,
c physis of control contralateral
bone, the diVerence in the height
of both physes is clearly visible
(Arch Klin Chir 26:985993,
1881)
1390 Arch Orthop Trauma Surg (2010) 130:13851396
1 3
design of plates. He published his results in 1912 [95]. His
sophisticated plates, designed on the basis of mechanical
principles, were made of vanadium steel, using self-tapping
monocortical screws. Later, in 1926, he dealt in detail with
plate osteosynthesis of diaphyseal fractures of the femur,
attaching the plates with bicortical screws [96].
In 1914, Miller Edwin Preston (18791928) from Denver
designed the Wrst angled blade plate for osteosynthesis of
femoral neck fractures, although he used it probably only in
a few cases [83].
At the beginning of the twentieth century, plate
osteosynthesis started spreading in Europe, mainly due to
William Arbuthnot Lane and Albin Lambotte, who were
followed several years later by Ernest William Hey Groves.
Albin Lambotte stated in the 1907 Wrst edition of his book
that from 1900 he had treated various diaphyseal fractures
with plates made of aluminium, which he Wxed by self-tap-
ping monocortical screws [55]. In the second edition of his
book, published in 1913, he described three diVerent types of
plates, one of which was contoured [56]. Albin Lambotte
also used plates for the Wxation of fractures of the distal
humerus, distal femur, proximal tibia and the mandible.
William Arbuthnot Lane published, in 1907, a successful
Wxation of diaphyseal fracture of the femur using a pair of
plates [61]. The second edition of his book in 1914 was
devoted primarily to plate osteosynthesis [63]. Lane Wxed
carbon steel plates of his own design with monocortical
screws. Their disadvantage was their Ximsiness and the
necessity to immobilize postoperatively the limbs with exter-
nal splints. Lane used plates for the Wxation of all diaphyseal
fractures of the clavicle, humerus, radius, ulna, femur, tibia
and Wbula, and also of both malleoli, olecranon and scapula.
Henry S. Souttar (18751964), an outstanding surgeon
from London, who later became famous for his operation for
mitral stenosis, published in 1913 his own design of a plate
Wxed with a Wnely threaded screw [97]. He considered the
vascular impact of the plate on the bone and tried to reduce
its footprint on the bone in order to not impair healing.
Ernest William Hey Groves dealt in detail with plate
osteosynthesis, including experiments on animals [44]. For
instance, he designed curved plates or plates with T-shaped
ends. He compared the mechanical properties of the Lane
and Lambotte plates, as well as Wxation properties of
wood and metal screws. Hey Groves also used inter-
fragmentary Wxation and bolted plates.
Due to the eVorts of the above-mentioned authors, plates
became, at the beginning of twentieth century, the most fre-
quently used implants for internal Wxation of fractures.
External Wxation
The Wrst to use external Wxation is traditionally considered
Malgaigne (Fig. 5) [16, 81, 82]. In 1840, Malgaigne used
and in 1843 published pointe mtallique, by which he
percutaneously Wxed fractures [66]. However, this device
cannot be considered as external Wxation [18]. The same
applies to griVe mtallique, which Malgaigne designed in
1843 and described in 1847 [66]. GriVe mtallique was
subsequently modiWed by Rigaud in 1850 and Chassin in
1852 [10]. It was not a typical external Wxator and was
intended only for fractures of the patella [10, 18, 66].
Povacz [82] in Historie der Unfallchirurgie ascribed
the Wrst application of external Wxation to Carl Wilhelm
Wutzer (17891863) from Bonn, Germany. In 1843, Wut-
zer allegedly used the Wrst external Wxator to treat a non-
union of femur persisting for 11 years [82]. But the reality
is diVerent. Geller [33] in his dissertation thesis in 1847
brieXy mentioned that C. Claus von der Hhe Wxed in 1843
at Wutzers clinic a non-union of the femur by inserting
into both fragments a couple of screws transversely con-
nected outside the wound. However, the patient died.
Therefore, Wutzer in 1846 treated a non-union of the femur
by resection of the ends of the fragments and use of a gold-
wire cerclage, and the operation was successful [33].
Bernhard Rudolf Konrad von Langenbeck (18101887)
from Berlin in 1855 treated a non-union of the humerus
with screws connected by a devise designed for this pur-
pose [30]. Due to infection, the Wxator had to be removed
after 12 days and the non-union was left to heal conserva-
tively.
Fig. 5 Malgaignes external Wxators: a pointe mtallique, b griVe
mtallique (Trait des fractures et des luxations. JB Baillire, Paris
1847)
Arch Orthop Trauma Surg (2010) 130:13851396 1391
1 3
An original and today quite unknown concept of external
Wxation was developed by Carl Wilhelm v. Heine (1839
1877), who worked in Innsbruck and later in Prague [41].
In 1872, Heine Wxed a non-union of the femur by two ivory
pins inserted transversely through both cortices of each
fragment, threaded at the end to accommodate the end cap.
Each of the pins was transversely connected to the bar. The
other end of the bar was Wxed in an arch, the arms of which
were integrated into the plaster bandage (Fig. 6). However,
this Wxation proved to be inadequate. Therefore, in the
patients with non-union of the humerus, tibia and femur,
the fragments were directly Wxed by bone clamp jaws
resembling a pin-less external Wxator. The clamp protruded
from the surgical wound and was connected by a transverse
bar Wxed again in the plaster bandage (Fig. 6). In this way,
Heine healed only the non-union of the humerus, while the
other cases required amputation.
External Wxation, as we know it today, started to develop
as late as at the turn of the twentieth century. In the USA, in
18971898 Clayton Parkhill (18601902) from Denver
designed external Wxation clamps and used them for diVer-
ent types of fractures (Fig. 7) [78, 79]. His early death,
caused by acute appendicitis when he refused operation,
prevented him from developing this method, which was
then further developed by his colleague Leonard Freeman
(18601935). In 1911, Freeman described the detailed
operative technique, including various tips and tricks [31].
In 1919, he introduced the turnbuckle to facilitate reduc-
tion, which was a highly sophisticated precursor of the AO
femoral distractor [32]. Howard Lilienthal (18611946),
from New York, who later became an outstanding thoracic
surgeon, used external Wxation of his own design in diaphy-
seal fractures, including the infected ones in 1912 [64].
In Europe, Albin Lambotte became the father of external
Wxation. He developed his own external Wxator clamps,
independently of Parkhill. The design of the Lambotte Wxa-
tor was highly sophisticated and was very similar to the
current AO tubular Wxator. The screws were self-threading
and self-tapping and the clamps provided the Wxator with
diVerent degrees of freedom. Lambotte used it successfully
from 1902 for all diaphyseal fractures [55, 56].
In 1916, Ernest Hey Groves described diVerent types of
external Wxator clamps for intraoperative reduction of frac-
tures, allowing both distraction and compression of frag-
ments. For stabilization of diaphyseal fractures of the femur
and tibia, he used external Wxator frames [44].
Although external Wxation was not used as frequently as
plates, it was relatively widespread both in Europe and the
USA during the study period.
Intramedullary nailing
A predecessor of nailing of acute diaphyseal fractures may
be considered to be Wxation of diaphyseal non-unions of the
femur, humerus and tibia with ivory intramedullary pegs,
performed by the prominent Berlin surgeon Johann Fried-
rich DieVenbach (17921847) and published in 1846 [25].
The same method for a non-union of tibia was used in
1861 by the German surgeon Theodor Bilroth (18291894),
Fig. 6 Heines external Wxators: Fig. 1 and 2 ivory pins Wxator,
Fig. 3 and 4 pin-less external Wxator. (Langebecks Archiv 22:472
495, 1878)
Fig. 7 Parkhills external Wxator (Ann Surg 28:552570, 1898)
1392 Arch Orthop Trauma Surg (2010) 130:13851396
1 3
who worked at that time in Zurich [11]. He removed the
ivory grafts 2 weeks after operation, examined them micro-
scopically and found their partial resorption. His method
consisted in opening the medullary cavity of both diaphy-
seal fragments with a drill.
The ivory grafts inserted subsequently served as biologi-
cal stimulators, rather than as mechanical Wxation. Antisep-
sis was not known at that time and thus the wound always
became infected and the pegs had to be removed after
13 weeks. However, the subsequent inXammatory hypera-
emia often resulted in healing of the non-union.
The superWcial resorption of ivory pegs by macrofags
was described also by Emanuel Aufrecht (18441933),
from Magdeburg. In 1877, Aufrecht microscopically exam-
ined ivory pegs, which an outstanding German surgeon
Werner August Hagedorn (18311894), had used to Wx a
non-union of the tibia under antiseptic conditions [2].
Carl Wilhem v. Heine described in 1878, in an article
published after his death [41], a successful Wxation of
diaphyseal non-union of humerus and ulna with ivory pegs.
Ferdinand Riedinger studied experimentally internal Wxa-
tion with ivory pegs in 1881 [86]. Heinrich Bircher treated
successfully in 1887 diaphyseal fractures of the femur and
tibia with intramedullary pegs [12]. A similar type of intra-
medullary Wxation was the intraosseous splint described by
Nicolas Senn in 1893 [92].
Metallic nails were initially used to Wx fractures of the
articular ends of bones, particularly in fractures of the fem-
oral neck [71, 74, 93]. The Wrst operation in this respect
was performed by Langenbeck in 1858 [93]. Paul Niehans
(18481912) from Bern, in 1904, described treatment of a
supracondylar humeral fracture in a child [76]. The author
performed open reduction and nailing in six cases, from the
Kocher radial approach after temporary osteotomy of the
olecranon!
The Wrst successful closed nailing of a diaphyseal
fracture was described by Georg Schne (18751960)
working in Greifswald in 1913 [89]. Under Xuoroscopic
control, he treated a total of seven diaphyseal fractures of
the ulna or radius, using percutaneously inserted silver
pins (Fig. 8).
A highly signiWcant, although until now not fully recog-
nized, contribution to intramedullary nailing was made by
Ernest William Hey Groves. He conducted a series of
experiments with intramedullary pegs and nails made of
bone, ivory and metal [44, 46]. Hey Groves also tested
diVerent designs of nails. In 1918, he treated two cases of
gunshot fracture of the femoral shaft by a steel nail [45].
Unfortunately, Hey Groves remarkable contribution to
intramedullary osteosynthesis has been rather overshad-
owed by the eminence accorded to Gerhard Kntscher.
Despite all eVorts, nails did not win recognition in the
treatment of diaphyseal fractures at the beginning of the
twentieth century. One of the main obstacles was the lack
of a suitable material.
Surgical approaches
It is surprising that the authors of this period paid such little
attention to operative approaches in their books and arti-
cles. The Wrst book containing a more detailed description
and Wgures showing operative approaches was Operation-
slehre (Textbook of Operative Surgery) published in 1907
by Theodor Kocher, a Swiss surgeon from Bern [50].
Kocher described therein a number of approaches that
today bear his name (hip, elbow and calcaneus).
The very Wrst publication dealing in detail with operative
approaches to long bones was the 1918 article by James
Edwin Thompson (18631927) [99]. This English surgeon
and anatomist, who moved to Galveston in Texas [17], deW-
ned the requirements for operative approaches that are valid
till today:
ease of access,
preservation of all nerves, both sensory and motor,
prevention of unnecessary injury to muscles,
preservation of the vascular supply.
Subsequently, he described a number of approaches to all
the long bones, including their articular ends. Of the whole
article, history remembers merely the posterolateral
approach to the radial shaft that is today named after him.
It was not until 1945 that the Wrst two comprehensive
textbooks of operative approaches were published. The Wrst
of them was Extensile exposure applied to limb surgery
written by Arnold Kirkpatrick Henry (18861982) [43].
This Irish surgeon and anatomist, an outstanding represen-
tative of the Dublin surgical school, formulated the concept
of extensile approaches in internervous planes. In addition
to general principles, he described also a number of
approaches, the best known of which is Henrys volar
approach to the radius. A comprehensive Atlas of surgical
Fig. 8 Schnes intramedullary nailing of forearm fractures (Mnch
Med Wschr 60:23272328, 1913)
Arch Orthop Trauma Surg (2010) 130:13851396 1393
1 3
approaches to bones and joints containing also approaches
to the spine, pelvis, mandible and temporomandibular joint
was published by TouWck Nicola (18941987), an Ameri-
can orthopaedic surgeon from New York [75].
Luminaries of bone surgery of the Wrst half
of the twentieth century
Outstanding from the above-mentioned authors, who more
or less contributed to the development of osteosynthesis,
are three extraordinary personalities especially worthy of
mention.
William Arbuthnot Lane (18561943), the British sur-
geon working in London, was a pioneer of internal Wxa-
tion who treated closed fractures operatively from 1892.
His Wrst publications may be considered as the Wrst decla-
ration rationally defending operative treatment of frac-
tures [5759]. In 1905, he published the book The
operative treatment of fractures [60]. In 1907, he added
also plates of his own design [61]. These plates appeared
as a preferred method only in the second edition of his
book in 1914 [62]. Lane was an excellent surgeon with a
profound knowledge of anatomy. He was the originator
and a strong proponent of the no touch technique, for
which he developed a number of dedicated instruments
[15, 70, 78]. As a result, he had a very low incidence of
infective complications. He was in close contact with the
German Surgical Society, and regularly attended its
congresses at the beginning of the twentieth century. His
concepts became very popular, particularly in the USA
[39, 62].
Albin Lambotte (18661955), a Belgian surgeon from
Antwerp, was a true genius of bone surgery, who at the
beginning of the twentieth century extraordinarily inXu-
enced its development [27, 73, 81]. His contribution is
remarkable mainly due to the comprehensiveness of the
methods he used. Plates, external Wxation, cerclage, screws
and nails, all of which he used for various types of frac-
tures. In addition, he invented or improved a number of
instruments. In 1907, he published the book Linterven-
tion opratoire dans les fractures rcentes et anciennes
envisage particulirement au point de vue de losto-syn-
thse [55] the title of which presents for the Wrst time the
term osteosynthesis. The revised edition of 1913 is a
work, which to date remains fascinating by virtue of its
scope of coverage [56]. Unfortunately, it has been trans-
lated into neither English nor German.
Both editions contain a detailed documentation of a great
number of his surgical cases. Lambotte used radiographs as
a standard for diagnosis, as well as for monitoring the
course of healing. He carefully recorded the radiograph
documentation of each of his patients in the form of sche-
matic drawings made from X-rays using a pantograph,
sometimes including functional results. The technique of
his operations and their results were well ahead of his time.
Although Lambotte was well known in the English-speak-
ing surgical world, due to the language barrier his ideas
could not spread as did those of Lane.
Ernest William Hey Groves (18721944) from Bristol is
nowadays unjustly neglected in the history of osteosynthe-
sis. During World War I, in 1916, he published a textbook
that is almost unknown today On modern methods of
treating fractures [44]. A second edition followed in 1921
[46]. The textbook surprises by its comprehensive coverage
of the given issue and many of its concepts are almost the
same as in current textbooks on bone trauma. The reader
will also Wnd here three extensive chapters dealing with
operative treatment, showing in detail how the author used
plates, nails and external Wxation. His extensive experi-
ments on animals using all these implants are unique. A
large space was devoted to mechanical properties of diVer-
ent types of plates and screws suitable for the cortical bone.
In fractures of the femur, he introduced nailing from the tip
of the greater trochanter, as well as retrograde nailing from
the fracture site [45]. In some cases, the author Wxed intra-
medullary pegs by transversely inserted screws, which
anticipated the concept of locking nailing. Hey Groves was
a universal bone surgeon. He studied also the application of
solid bone grafts and used them to treat fractures of the
femoral neck [48]. He signiWcantly inXuenced reconstruc-
tive surgery of the hip and, in 1927, designed an ivory hip
replacement, similar in form to the later Judet prosthesis
[47]. In spite of this, Hey Groves historical contribution to
operative treatment of fractures has not yet been fully
appreciated.
Contribution of individual surgical schools
British surgical school
Throughout the nineteenth century and in the early twen-
tieth century, British surgeons were pioneers in the Weld
of closed and operative treatment of fractures. Lister,
Lane and Hey Groves could rely on the foundations laid
by Sir Astley Cooper, and the Dublin and Edinburgh sur-
gical schools [46, 19]. Lister succeeded in reducing
infection [14]. Lane became a respected proponent of
osteosynthesis and the no touch technique, not only in
Great Britain, but also in Germany and the USA [15].
Hey Groves studied all types of osteosynthesis, including
experimental ones; he published the Wrst modern text-
book on closed and operative treatment of fractures and
contributed also to the development of reconstructive hip
surgery [4448].
1394 Arch Orthop Trauma Surg (2010) 130:13851396
1 3
German surgical school
In the second half of the nineteenth century, the German-
speaking surgeons became strong advocates of the operative
treatment of fractures and promptly accepted the Listerian
principles as early as in 1872 [14, 37]. In addition, many
of them gained experience from the PrussianAustrian
(1866) and GermanFrench (1870) wars. As a result, in the
70s and 90s of the nineteenth century, German surgery had
the edge over the rest of the world. In 18471913, German
surgeons published key original articles on external Wxa-
tion, plate osteosynthesis and intramedullary nailing
[25, 30, 33, 38, 41]. Unfortunately, none of these German
authors dealt systematically with operative treatment of
fractures. This was the main cause for the gradual decline
of German bone surgery from its position of pre-eminence
at the beginning of the twentieth century. The only signiW-
cant proponent of operative treatment in Germany in the
Wrst decades of the twentieth century was Fritz Knig
(18661952), the son of the well-known German surgeon,
Franz Knig (18321910) [5154, 104]. Fritz Knig was
also the author of the Wrst German book on osteosynthesis,
published as late as in 1931 [54].
French surgical school
In the Wrst half of the nineteenth century, the French school
of bone surgery, represented by Dupuytren, Larrey and
mainly Malgaigne, reached its climax. However, Branger-
Frauds book of 1870, dealing with osteosynthesis, was an
epilogue of this era [10]. Its author had no successor in
France for many years. The situation radically changed
with Albin Lambotte, a Belgian surgeon with links to
French surgery and writing in French, whose contribution
was cardinal [55, 56].
American surgical school
At the beginning of the nineteenth century, surgeons in
the USA had established close contacts with the English,
German and French surgical communities. Clayton Parkhill
signiWcantly inXuenced the development of external Wxa-
tion, both in the USA and around the world. Also, the
development of plate osteosynthesis was extraordinary in
the USA, from the very beginning of the introduction of
this method. It is amazing how many interesting articles
dealing with operative treatment of fractures, published by
a signiWcant number of authors, appeared in the Wrst few
years of the twentieth century [9, 13, 28, 34, 49, 64, 83, 94,
95, 100]. Writers discussed in detail operative techniques
and many other related topics. Most of the articles were
amply documented by radiographs and drawings. This
period culminated around 1912. Sherman plates subse-
quently spread all over the world. Many of the above-men-
tioned authors excelled also in other surgical disciplines
(thoracic surgery, neurosurgery, andrology), but in fact
none of them was a full-time specialist in bone and joint
surgery. This was probably one of the reasons why a text-
book on internal Wxation of fractures did not appear in the
USA until as late as 1947 [101].
Epilogue
It is fascinating how aptly Preston deWned the main prob-
lems of internal Wxation of fractures as early as in 1916
[84]: There is no branch of surgery in which nature is
more exacting then bone work. To be successful in this
Weld, the cases must be carefully selected, the most rigid
asepsis should be observed, the surgeon must possess a
good working knowledge of anatomy and fully appreciate
the laws of stress, strain and leverage. The internal Wxation
of a fracture is decidedly an engineering problem, as well
as a surgical procedure, and it is probable that a larger per-
centage of failures have resulted from violation of
mechanical laws than have been due to faulty surgical
asepsis.
After World War I, the way opened for operative treat-
ment of fractures to spread successfully all over the world.
Plate osteosynthesis, particularly, became highly popular
both in Europe and in the USA. However, the Wrst genera-
tion of advocates of osteosynthesis was no longer as active
in publishing works on bone surgery as hitherto. As a
result, internal Wxation of fractures, in many cases, passed
into the hands of unprepared surgeons, whose knowledge
was insuYcient to understand the principles deWned and
respected by their predecessors. Over a short period, a large
number of catastrophes occurred to swing the pendulum of
specialized public opinion in favour of conservative treat-
ment, for many years. This, however, cannot change the
fact that in a historically very short period of 50 years
(18701921), solid foundations were laid for operative
treatment of fractures, many of which we continue to
respect to this day.
Acknowledgments This article could not have appeared without
the extraordinary help in collecting original sources, oVered by
Ms. Ludmila Frajerov from the Klementinum (Czech National
Library) and Ms. Mirka Plecit from the 3rd Faculty of Medicine,
Charles University, Prague and Arsen Pankovich, MD. I also wish to
thank Ms. Ludmila Bbarov and Chris Colton, MD for editing the
English version of the manuscript.
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