The Classic: Early versus Delayed Stabilization of Femoral Fractures: A Prospective Randomized Study

Lawrence B. Bone (Fig 1), the author of this classic paper currently serves as Chairman and Program Director of the Department of Orthopaedic Surgery at the State University of New York Buffalo, School of Medicine and Biomedical Sciences. Born and raised in western New York in the family of a rural general surgeon he also earned his MD there. He took a general surgical residency at the same institution during which time general surgeons routinely took Trauma Call. As a result he gained wide experience in the treatment of fractures. This experience led to further training as an AO Fellow in Davos, Switzerland and eventually to an orthopaedic residency in Dallas, Texas at Southwestern and Parkland hospitals. During all of this Dr. Bone came to recognize that the then current wisdom of treating femur fractures with weeks of skeletal traction did not preclude shock lung, fat embolism, and adult respiratory distress syndrome. He observed that patients did better when they had their femoral fractures treated with prompt reduction and intramedullary fixation performed atraumatically with percutaneous techniques. In this paper Dr. Bone documents the importance of this type of treatment in a prospective study. In 46 multiply injured patients with femoral fractures treated with prompt internal fixation, 16 pulmonary complications occurred. In 37 such patients treated with prolonged skeletal traction there were 50 complications. Other parameters such as length of stay, blood gas values, and total cost supported his conclusion: The overwhelming recommendation is that early stabilization of long bone fractures should be performed in multiply injured patients. Dr. Bone's paper contrasts starkly with that of Dr. A. H. Stephens published in 1837. Dr. Stephen's femur fracture patient upon whom A bank of earth had fallen burying him beneath had treatment with prompt venesection with removal of blood followed by medication with ammonia and camphor and arrow-root with brandy. The limb was smeared with balsam of Peru, covered with a yeast poultice and wrapped in cotton. Several days later the leg was amputated. Death, amputation, and deformity routinely followed femoral shaft fractures in the era that preceded the rise of modern medicine and Dr. Bone's seminal paper documents scientifically a major step in the evolution of trauma surgery.