History of Orthopaedics
Ancient Fracture Management
| Gandhi Nathan Solayar |
The ability of humans to heal broken bones has contributed to the longevity of our species. Archaeological findings have shown evidence of healed fractures in Neanderthal bones dating back to 130,000 years ago. This article briefly looks back at the various methods used to treat fractures with particular attention to what the Ancient Egyptians and Greco-Romans had in their orthopaedic repertoire.
By far, the most impressive literature pertaining to ancient methods of treatment derive from the Edwin Smith Papyrus. It dates back to the Second Intermediate Period in Egypt, circa 1600 BC. Unlike contemporary documents of its era (i.e. Ebers papyrus) which emphasise magic, it presents medical management from a scientific standpoint. There are 48 cases mentioned, however, only a handful are complete which describe various fractures of the humerus. It details methods of traction using “something between the shoulder blades” and pulling till the fracture reduces. It appears that the immobilisation method is akin to modern day plaster techniques where the ancient physician applied bandages of cloth and alum. They appear to favour honey as an adjunct towards fracture treatment and would change the bandages regularly.
One description on the Edwin Smith Papyrus may well be the earliest documentation of open fracture reduction. It mentions a technique called “nekhebkheb” which means to “move, wiggle or crepitate the fracture under the fingers of the physician”. Superficial wounds were treated similarly with bandages of alum, honey and oil. Severe injuries with exposed bone through skin and muscle were described as hopeless regardless of treatment.
Archaeologists have found several skeletal remains with healed fractures dating from Ancient Egyptian times which stand as evidence to the success of orthopaedic management in antiquity. There is also evidence of splints and bandages found on mummies illustrating the technique as mentioned on the Edwin Smith Papyrus which suggests that the people of the day learnt from prior experiences and current literature and may well be the first evidence we have of Orthopaedic CMEs!
This article would not be complete without a mention of Hippocrates (460BC-370BC). The Hippocratic method of shoulder relocation following dislocation is still taught in modern medical schools and stands testament of its legacy where traction is applied with the foot in the axilla providing counter-traction. He is also recognised for describing a method for reducing humeral fractures where the patient is seated with a rod in the axilla, having had traction applied to the arm in the form of weights. The physician reduces the fracture manually and immobilises with the use of bandages. Of note, the bandages are either soaked in oil, resin, wax or cerate to provide stiffness. It mentions that the bandages should be changed regularly to make it tighter which attests to the Greeks' understanding of soft tissue inflammation. Testament of the success of the Hippocratic school of thought manifests itself through the writings of following physicians namely Galen (129-215AD) and Celsus (25BC-50AD).
Celsus (25BC-50AD) was a Roman and is credited for his compilation known as “De Medicina” which comprises articles ranging from medicine, philosophy, law and military tactics. He is known for his anatomical description of fractures (proximal, shaft, distal) and their respective treatment and prognosis. His contributions include descriptions of the type of bandages and how the use of different techniques in their application would suit various types of injuries (e.g. using longer bandages for the proximal humerus as compared to distal/shaft fractures). He differs from Hippocrates in that his bandages were soaked with wine and oil as opposed to cerate.
Another person of note is Oribasius (325-397AD) who is credited for the compilation of medical writings and books thought to have been, at one time, at the great library of Alexandria. Among his many accounts includes a description of reducing the shoulder joint in fracture-dislocations of the humerus prior to setting the fracture. Oribasius recommended the Hipprocratic bench “scamnum” for the treatment of such fractures.
It is important to appreciate that Orthopaedics is an ever-expanding field with new discoveries, knowledge and techniques being discovered and improved with time. Ancient methods have been refined throughout the generations which has enabled us to improve our management of open fractures, complex dislocations and establish the field of arthroplasty. This brief article only mentions but a few contributions from earlier times. Other civilisations, past and present, have had their share of knowledge pooled including the medieval Arabs, ancient practices from India and China, and the centuries following the dark ages in Europe. We have but a scattering of written accounts from times past about fracture management but stand grateful as these have been the foundation of our modern day orthopaedic practice.
- Breasted JH. The Edwin Smith Surgical Papyrus: Published in Facsimile and Hieroglyphic Transliteration with Translation and Commentary in Two Volumes. Chicago, IL: The University of Chicago Press; 1930
- Lawrence G. Surgery (traditional). In Bynum WF, Porter R, eds. Companion Encyclopedia of the History of Medicine. London, UK: Routledge; 1993:961
- Brorson S. Management of fractures of the humerus in Ancient Egypt, Greece, and Rome: an historical review. Clin Orthop Relat Res. 2009 Jul