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It was five years after the end of the second world war. A young lecturer in orthopaedics from Manchester published a book titled The Closed Treatment of Common Fractures—a slim volume with a modest aim: “to re-emphasise the non-operative method.” His target readership was primarily junior trainees in accident and emergency and orthopaedics. His years of service as a military surgeon in the war almost certainly provided him with ammunition for his work. He had an important message for the hapless doctor left unsupervised to treat common fractures concerning why and how fractures displace and how best to reduce and hold them. His was a unique message, he thought, because after the description of detailed theory, larger textbooks had generally neglected to teach this small matter of practical treatment.
John Charnley (1911-82) was a surgeon gifted with a superb technical mind. Within a decade he was set to forever transform the practice of hip replacement surgery. With this publication he attempted to bring the ill defined art of fracture manipulation into the realms of practical science. He brilliantly explained fracture deformity and the soft tissue hinge by clever use of wooden blocks and leather strips. He was also not shy of borrowing from the industrial heritage of his Mancunian upbringing, using the analogy of gear wheels and crank and connecting rod.
Some of his line drawings might be accused of oversimplification yet are useful to help understand and treat fractures. His no-nonsense style of writing is a pleasure to read. He made his arguments confidently, deploying occasional bits of evidence based medicine from his own practice. With each common fracture he tried to present a “mental picture” of the deformity to the reader; once the mechanics of displacement were understood the reader could solve the puzzle of reduction. A well reduced fracture will often redisplace in a poorly applied cast. He then turned the reader's attention to the proper application of casts. The chapters on treatment of particular fractures are full of practical tips. It is also instructive to see the respect he had for soft tissue preservation—he was, after all, advocating closed treatment mainly to avoid the unhappy consequences of poor handling of soft tissue. His interest in the non-operative treatment of fractured neck of femur and the like may be of historical interest, but more than 50 years, four editions, and three reprints later his work is still essential reading for anyone involved in managing fractures.
In many parts of the world today the prohibitive costs of orthopaedic implants mean that non-operative treatment is the only option left to the treating surgeon. However, even in the West, where internal fixation has supplanted non-operative treatment of many of the common fractures that Sir John describes so well, the message is still very pertinent. His interest was in highlighting the “principles,” and in so doing he set a standard that half a century later is still hard to beat.
The Closed Treatment of Common Fractures
By Sir John Charnley
First published in 1950