Treatment of Elbow Fractures: A historical Perspective
Job Doornberg, MS, Jesse Jupiter, MD
MASSACHUSETTS GENERAL HOSPITAL
"There is no class of injuries so frequently productive of
discontent, and perhaps so often the cause of litigation, as traumatic lesions
of the elbow joint"
Henry Jacob Bigelow, Massachusetts General Hospital, Boston 1868 Introduction
The contemporary difficulties in the management of traumatic
and reconstructive problems involving the elbow are equally reflected through
antiquity as one investigates the history of medical and surgical care of
musculoskeletal problems. As with so many areas of orthopaedics, the literature
of the past reflects the ingenuity, frustrations, ego, and personal
self-aggrandizement of physicians, irrespective of the era in which they
practiced the art and science of medicine.
Closed Reduction and Splinting
 Some of the earliest examples of traumatic injuries involving
the upper limb were found in the archeological efforts in the Nubian Desert by
Sir Grafton Elliot Smith (1871-1937)1. Fractures were common findings
and splints were recovered made of bamboo, reeds, woods or bark and padded with
linen. It is of interest that several thousand years later similar splints were
described in Europe known as Joncs (reeds)1.
In 1862, a papyrus was found in a tomb in Thebes and sold to an
American Egyptologist, Edwin Smith. It is thought to be the work of Imhotep, an
architect and chief minister to king Zoser (c. 2800 BC). It represents a
collection of 48 clinical records including careful description of reduction
and splinting of fractures of the upper arm.2
 Much of the discussion related to elbow trauma in early
writings including those of the Greeks, Romans, Chinese, and Japanese were
related to methods of reductions of dislocations and immobilization.
Undoubtedly, more then a few elbow dislocations were in reality fractures!
Hippocrates observed that an elbow dislocation, after reduction, should be
bandaged slightly greater than at a right angle as this should be the most
functional position should ankylosis occur6. Hippocrates noted:
"If ankylosis should eventually develop, an arm ankylosed in the extended
position would be better away (i.e. amputated) for it would be of great
hindrance and of little use to the patient."
Hippocrates' text warned of the fact that elbow dislocations
could be difficult to reduce, with complications being commonplace: "Sometimes
the head of the humerus itself is fractured at the epiphysis, yet this, though
it may seem a very serious injury, is much less so than injuries of the
elbow joint."
Plaster
In 970 A.D., the Persian Abu Mansur Muwaffak suggested that
fractures and other bony injuries should be coated with plaster. The Arabic
physicians had discovered that the addition of water to a soft powder of
anhydrous calcium sulfate produced the firm hydrated crystalline form. This
was observed centuries later by William Eton in 1798, former British consul
to Turkey and soon became standard in Europe.2,7 A Dutch Army
surgeon Antonius van Mathysen developed the plaster bandage with his book
published in 1852.8, 9 A precursor of the plaster bandage was
recorded by the famous English surgeon and anatomist William Cheselden, who,
as a schoolboy sustained an elbow fracture that was treated in this
manner:1
"I thought of a much better bandage which I learned from
Mr. Cowper, a bone setter at Leicester, who set and cured a fracture of
my own cubit when I was a boy at school. His way was, after putting the
limb in a proper posture, to wrap it up in rags dipped in the whites of
eggs and a little wheat flour mixed. This drying grew stiff and kept the
limb in good posture. And I think there is no way better than this in
fractures, for it preserves the position of the limb without strict (tight)
bandage which is the common cause of mischief in fractures."7
 Yet the plaster support was not universally accepted in
the 19th century, particularly in England and America. Hugh Owen Thomas
and Robert Jones thought it risky. Jones suggested: "Nothing so barbarous
as Plaster-of-Paris is used any longer".
Splinting
Thus the 19th century saw the continued use of splints,
many custom made for the elbow joint and advocated with zeal by its
developer. Some splints such as that devised by Rose, Kirkbride, or Welch
offered adjustable hinges which could be used to stretch out elbow contractures.
Of interest is perhaps the earliest turnbuckle splint,
devised as early as 1517 by Hans von Gersdorff, who termed his splint
the "appliance for the crooked arm".11
Recognition
The pre-roentgenogram nineteenth century also witnessed a
more widespread recognition that many elbow injuries involved fractures
rather than dislocations. Dupuytren noted this in the early part of the
century:12 "There is nothing so common as to see a fracture of
the lower end of the humerus, immediately above the elbow joint, mistaken
for a dislocation backward." He advised: "The principal sign by which
fracture may be distinguished from dislocation is crepitus". This "valuable
sign … is often very much masked, or even hidden, by the presence of swelling".
Malgaigne also noted that "In dislocations the articulation
is destroyed, and flexion or extension are impracticable, whereas in fracture
it is intact, and the movements are probably in part preserved".
Dupuytren described numerous cases of management of distal
humerus fracture illustrated well in this example:13
"All the signs which resembled dislocation were easily
explained by the seat of the fracture: for, the continuity of the humerus
being broken, its lower articulating extremity no longer presented their
natural support to the radius and ulna, and the olecranon consequently
drawn upwards by the tonic contraction of the triceps...
"On the day that the above accident happened it was found
impracticable to obtain entire reduction, on account of the pain which the
attempt produced, and especially in consequence of the great swelling. I
was, therefore, obliged to place the arm, semiflexed, on some pillows, which
were placed horizontally; and directed that the affected parts should be
kept wet with Goulard's wash. The patient was also largely bled, and low
diet and an anodyne draught prescribed...
"Second day. The reduction being accomplished, the arm was
again placed on pillows as before: some graduated compresses were applied
around the lower extremity of the arm, so as to correspond to the two osseous
prominences, and to replace the fingers, by the pressure of which they had
been forced into position. Support was also afforded by two long compresses,
and other parts of the apparatus, which had been prepared by being wetted
with a solution of acetate of lead in cold water. Lastly, the two lateral
pads were folded on themselves at their lower extremity, so that in tightening
the apparatus the splints might be forced against the graduated compresses,
and thus press in opposite directions the olecranon process and the upper
extremity of the lower fragment."
"On the thirty-third day the apparatus was finally removed,
there being a good union, unattended by deformity; and on the forty-fifth,
D. left the hospital having already considerable power in flexion and extension
of the joint".
 It is noteworthy that during Dupuytren's era not all eminent
physicians agreed regarding differential diagnosis. Bigelow at the Massachusetts
General Hospital stated:
"I have found an opposite error, however, by far the most
frequent, namely - a dislocation of both bones backwards has been supposed
to be a fracture. The sources of embarrassment are found in the proximity
of the fracture to the joint, in the rapidity with which swelling occurs,
and in the striking similarity of the symptoms which characterize the two
accidents".
Bigelow himself favored custom splints created in a manner
not too dissimilar to those decribed by Arab physicians centuries before
which was termed gutta percha:
"Whatever material is employed, a pretty large pledget of
fine cotton batting ought to be laid in front of the elbow joint to prevent
the roller from excoriating the delicate and inflamed skin and great care
should be taken to protect the bony eminence..."
"At a very early day, so early, indeed as the seventh or
eight day, the splint should be removed, and, while the fragments are
steadied, gentle passive motion should be inflicted upon the joint".
Bigelow also documented examples of cases treated:
"A woman, living in this city, age 44, fell upon the
sidewalk in January, 1850, striking upon her right elbow. I saw her a
few minutes after the accident, but the parts about the joint were
already considerably swollen, and it was not without difficulty that
the diagnosis was made out. The forearm was slightly flexed upon the
arm, and pronated. On seizing the elbow firmly, a distinct motion was
perceived above the condyles, and a crepitus. I could also feel,
indistinctly, the point of the upper fragment. While moderate extension
was made upon the arm, the condyles were pressed together, when it was
apparent that they had been separated. On removing the extension they
again separated, and the olecranon drew up. She was in a condition of
extreme exhaustion, and the bones were easily placed in position.
"An angular splint was secured to the limb, and every care
used to support the fragments completely, but gently.
"From this date until the conclusion of the treatment,
the dressings were removed often, and the elbow moved as much as it was
possible to move it.
"Seven months after the accident, the elbow was almost
completely anchylosed at a right angle. The fingers and wrist also were
quite rigid. Six years later, the anchylosis had nearly disappeared; she
could now flex and extend the arm almost as much as the other; the wrist
joint was free, and the fingers could be flexed, but not sufficiently to
touch the palm of the hand. The line of fracture through the base could
be traced easily, but the humerus was not shortened. There was, moreover,
much tenderness over the point of fracture through the base, and at other
points. Occasionally, a slight grating was noticed in the radio-humeral
articulation. She experienced frequent pains in the arm, and especially
along the back and radial border of the ring finger. During the first
year or two after the accident, the arm perished very much, but although
the hand remained weak, the muscles were now well developed".
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The nineteenth century brought one of the major advances
in medicine, namely the development of ether anesthesia which was first
demonstrated at the Massachusetts General Hospital in 1846.14
This not only permitted operative treatment but also led to the recommendation
of some to consider manipulation as a management option for the elbow rendered
stiff following traumatic injury and resultant treatment. Bigelow noted:
The third scientific advance of the nineteenth century,
which led to major developments in elbow injuries, was that of antisepsis.
Prior to this, surgery was primarily performed for open fractures and in
most cases for removal of fragments, illustrated by Dr Stone with this
case of a 26-year old woman with open intercondylar comminuted fracture
of the distal humerus:16
Antisepsis, anesthesia, and the x-ray enabled ingenious
surgeons such as Dr. Albin Lambotte to bring us into the modern era of the
management of elbow trauma. His carefully documented case studies reveal
operative approaches and implants very much resembling those of today.17-19
We are fortunate to be able to have had the wisdom and experience of all of
these giants of medicine who have established the approaches to diagnosis
and management which we use today. Lambotte coined the term osteosynthesis
and led us into the twenty first century, the era of open reduction and
internal fixation.