Early examples of nonoperative fracture management can be traced back to the ancient Egyptians. Archaeologic artifacts of fractured extremities splinted with longitudinal wooden boards were discovered by A.C. Mace during the Hearst Egyptian expedition of the University of California in 1903.¹, ², ³, ⁴, ⁵, ⁶ and ⁷

Prior to the development of plaster-of-Paris and modern day plaster techniques, an Arab physician named Rhazes described a recipe for a casting material using clay gum mixtures, flour, and egg whites.⁸,⁹ Variations of this recipe, including the addition of lime, honey, pork fat, vinegar, and powder of Armenian clay or plaster were concocted up through the late 18th century.³,⁸, ⁹ and ¹⁰ The benefit of this method of immobilization touted by Rhazes Athuriscus was that “… it will be much handsomer and will not need to be removed until the healing is complete.”⁸

In 1852, the plaster-of-Paris bandage, derivates of which are still used today, was introduced by a Russian military surgeon, Antonius Mathijsen.¹¹ This revolutionized the stabilization of healing fractures, providing a material which was durable and could be maintained for the duration of healing. Many subsequent methods of immobilization were invented including the copper limb curirasse described by Heister¹² and what Malgaigne called “the great machine of La Faye.”¹³,¹⁴ The drawback of these extensive and heavy devices, however, was that they essentially confined the healing patient to the bed for the entirety of their rehabilitation. In turn, Seutin devised the amidonné, or starched bandage,¹⁵ allowing for earlier mobilization of the fractured extremity. Hence the debate over immobilization versus early mobilization of the fractured extremity was born. Most European surgeons favored total immobilization, with others such as Sir James Paget and Lucas-Championnière favoring Seutin’s déambulation regimen.¹⁶ In 1907 Championnière wrote, “the necessity for immobilization is only relative … [W]hile authors attach great importance to the immobilization of a compound fracture, we find here that with small movements and an apparatus moderately immobilizing, consolidation goes on well, and no inflammatory complications result.”¹⁶

Descriptions of traction applied for the treatment of fractures can be found as early as AD 130 in the writings of Galen.²,¹⁷ He described an extension apparatus, or glossocomium (Fig. 1.1), used to temporarily treat fractured extremities until splinting could be performed by turning a handle to provide distraction. Continuous traction intended for primary fracture treatment can be found in the early writings of Guy de Chauliac (1300 to 1367);¹⁷,¹⁸ however, it was not widely practiced until the mid-19th century. Borrowing from the traction techniques of Bardenheuer, Albert Hoffa of Wurzburg published in his book of fractures and dislocations in 1888 the use of traction for many different types of fractures including those of the femur and humerus.¹⁹ Josiah Crosby of New Hampshire also described the use of continuous skin traction using a combination of adhesive plaster secured with a spiral bandage and weight applied to the end for the management of a femur fracture, an open tibia fracture and in two cases of clavicle fractures in children.²⁰ Codivilla of Bologna was the first known to apply skeletal traction via the use of an intraosseous pin, with Fritz Steinman popularizing the technique in the treatment of acute fractures.²¹ Steinman, frustrated with the complications of skin traction, described using two pins driven through the femoral condyles to pull in-line traction for midshaft femur fractures in 1907.²² Two years later, Martin Kirschner of Greifswald would describe skeletal traction using wires of a much smaller diameter.²²

Traction, though more likely to decrease the risk of malunion in healing fractures, came at the expense of prolonged periods of immobilization, as well as the risks inherent to the placement and maintenance of traction devices themselves. Aside from the obvious external drawbacks of immobilization, including bed sores, soft tissue and bone infections, and delay in return to work or war, there
were other less conspicuous effects including internal signs of decompensation, such as muscle atrophy.²³

Recognizing these limitations, Professor George Perkins of London advocated for straight simple in-line traction through a proximal tibial pin in the 1940s and 1950s, which would also allow for early mobilization of the knee using a Pyrford traction system.¹⁵,²⁴ Also aware of the difficulties of immobilization in healing fractures was Dowden, who in the opening sentence of his 1924 article wrote, “The principle of early active movement in the treatment of practically all injuries and in most inflammations will assuredly be adopted before long… .”^* Both Perkins and Dowden were among the many early advocates of mobilization of all joints of the injured limb, believing it to be even more important than precise skeletal reduction. To such pioneers it became clear that a more sophisticated means of maintaining function while the healing process occurred was needed.