Management of proximal humeral fractures in the nineteenth century: an historical review of preradiographic sources

Abstract

Background: The diagnosis and treatment of fractures of the proximal humerus have troubled patients and medical practitioners since antiquity. Preradiographic diagnosis relied on surface anatomy, pain localization, crepitus, and impaired function. During the nineteenth century, a more thorough understanding of the pathoanatomy and pathophysiology of proximal humeral fractures was obtained, and new methods of reduction and bandaging were developed.

Questions/purposes: I reviewed nineteenth-century principles of (1) diagnosis, (2) classification, (3) reduction, (4) bandaging, and (5) concepts of displacement in fractures of the proximal humerus.

Methods: A narrative review of nineteenth-century surgical texts is presented. Sources were identified by searching bibliographic databases, orthopaedic sourcebooks, textbooks in medical history, and a subsequent hand search.

Results: Substantial progress in understanding fractures of the proximal humerus is found in nineteenth-century textbooks. A rational approach to understanding fractures of the proximal humerus was made possible by an appreciation of the underlying functional anatomy and subsequent pathoanatomy. Thus, new principles of diagnosis, pathoanatomic classifications, modified methods of reduction, functional bandaging, and advanced concepts of displacement were proposed, challenging the classic management adhered to for more than 2000 years.

Conclusions: The principles for modern pathoanatomic and pathophysiologic understanding of proximal humeral fractures and the principles for classification, nonsurgical treatment, and bandaging were established in the preradiographic era.

Fig. 1

The Hippocratic mode of reduction for fractures of the humerus is illustrated. (Reprinted from Richter AL. Theoretisch-praktisches Handbuch der Lehre von den Brüchen und Verrenkungen der Knochen. Berlin, Germany: Verlag von TCF Enslin; 1828).

Fig. 2

A posterior view of a left shoulder with a displaced four-part fracture is shown. (Reprinted from Malgaigne JF. Traité des fractures et des luxations. Paris, France: JB Baillière; 1847).

Fig. 3

In Robert Liston’s bandage, the entire arm is bandaged to prevent soft tissue swelling and a valgus pressure could be applied over the fracture. (Reprinted from Liston R. Practical Surgery. 2nd ed. London, England: John Churchill; 1838).

Fig. 4

Middledorpf’s triangle is illustrated. (Reprinted from Stimson LA. A practical treatise on fractures and dislocations. New York, NY: Lea Brothers & Co; 1899).

Fig. 5

Hamilton’s bandage with permanent skin traction is shown. (Reprinted from Hoffa A, Grashey R. Verbandlehre (first published 1896). 5th ed. Munich, Germany: JF Lehmans Verlag; 1914).

Fig. 6

Bardenheuer’s apparatus for permanent traction treatment is shown. (Reprinted from Hoffa A. Lehrbuch der Frakturen und Luxationen für Ärzte und Studierende (first published 1888). Würzburg, Germany: Stahel; 1891).

Fig. 7

Hennequin’s plaster splint is shown. (Reprinted from Stimson LA. A practical treatise on fractures and dislocations. New York, NY: Lea Brothers & Co; 1899).

Fig. 8

Desault’s bandage is shown. (Reprinted from Hoffa A, Grashey R. Verbandlehre (first published 1896). 5th ed. Munich, Germany: JF Lehmans Verlag; 1914).

Fig. 9

Velpeau’s bandage is shown. (Reprinted from Hoffa A, Grashey R. Verbandlehre (first published 1896). 5th ed. Munich, Germany: JF Lehmans Verlag; 1914).

Fig. 10

The mechanism of displacement in fractures of the surgical neck is shown. (Reprinted from Hoffa A. Lehrbuch der Frakturen und Luxationen für Ärzte und Studierende (first published 1888). Würzburg, Germany: Stahel; 1891).

An anterior view of a right shoulder with a fracture of the anatomic neck with rotational displacement of the humeral head is illustrated. (Reprinted from Smith RW. A treatise on fractures in the vicinity of joints and on certain forms of accidental and congenital dislocations. Dublin, Ireland: Hodges & Smith; 1847.)