Orthopaedics Through the Ages
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ORTHOPAEDICS IN ANCIENT EGYPT 
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Mummified bodies, wall paintings and hieroglyphics depict some of the orthopaedic practices used by the people of ancient Egypt. There is evidence of the use of crutches on a carving made in 2830 BCE on the entrance of a portal on Hirkouf’s tomb - it depicts a figure leaning on a crutch-like staff.  The Edwin Smith Surgical Papyrus is an ancient Egyptian medical text. Named after the American who bought it in 1862, it is the oldest known surgical treatise on trauma. This papyrus, which was found in a tomb, is 5 meters in length, and is thought to date back to at least 1600 BCE. It describes 48 cases of injuries, fractures, wounds, dislocations and tumours.  Among the treatments are closing wounds with sutures, bandaging, splints, poultices, preventing and curing infection with honey, and stopping bleeding with raw meat. Immobilisation is advised for head and spinal cord injuries, as well as for other lower body fractures.  Splints were used to assist bone fractures to heal. They were made of bamboo, reeds, wood or bark, and were padded and wrapped with linen - and have been found on mummies. It is thought that the use of stiff bandages for support probably derived from embalming techniques.

The below is from THE EDWIN SMITH SURGICAL PAPYRUS CASE 36: A FRACTURE OF THE HUMERUS

Translation: Thou shouldst place him prostrate on his back, with something folded between his two shoulder blades; thou shouldst spread out with his two shoulders, in order to stretch apart his upper arm until that break falls into its place. Thou shouldst make for him two splints of linen, (and) thou shouldst apply for him one of them both on the inside of his arm (and) the other of them both on the underside of his arm. Thou shouldst bind it with ymrw, (and) treat afterward (with) honey every day until he recovers. 

ORTHOPAEDICS FROM 300BC TO 1500AD  

The non-surgical management of orthopaedic injuries such as fractures remained remarkably constant through the ages until the late nineteenth century when the introduction of anaesthesia and radiology enabled surgeons to plan and perform surgery in a more modern sense. 

The use of splints and bandaging to assist in the healing of bone fractures is recorded in ancient times, as it was realised that immobilisation of an injury led to reduced pain, swelling and ultimately better healing. Splinting involved the laying of rigid materials on the skin, alongside the bone. Ancient Hindus treated fractures with bamboo splints. Hippocrates of Greece, known as the founder of modern medicine, had a thorough understanding of fractures. He knew of the principles of traction, and developed special splints for fractures of the tibia (shinbone). He also advocated wooden splints plus exercise to prevent muscle atrophy or wasting during the immobilisation. In the 'Corpus Hippocrates', collated between 430 and 330 BCE, there is a volume on joints. Here dislocations of the shoulder, knee, hip and elbow were described, as were various methods used in treating them. The ancient Greeks used waxes and resins to create stiffened bandages. Similarly the Roman Celsus, writing in AD 30, describes how to use splints and bandages stiffened with starch. 

The use of plaster to form a shell to encase a limb to stabilise and support a broken bone, forming a similar function to a splint, was first recorded in 980 AD, based on the writings of an Arabian surgeon, Paul of Aegina. Arabian doctors used lime derived from sea shells and albumen from egg whites to stiffen bandages. 

The Italian School of Salerno in the twelfth century recommended bandages hardened with a flour and egg mixture as did Medieval European bonesetters, who used casts made of egg white, flour and animal fat. 

During the wars of the Middle Ages field surgeons would use clothes dipped in horse blood to apply early splints to wounded limbs. When the clothes dried, they would stiffen and provide support to broken or damaged limbs. While the usual method for the healing of fractures was bed rest and restriction of activity many orthopaedic injuries necessitated immobilisation - simply because the splinting materials were so heavy! 

THE DEVELOPMENT OF ORTHOPAEDICS FROM THE 18TH TO 20TH CENTURIES
 
 Surgery and medicine were very separate in the West until the 18th century. Physicians were university trained, whereas surgeons learned their craft by apprenticeship - under the auspices of the trade guilds. During the 18th century many developments occurred as academic teaching and practitioner regulation were introduced for surgeons and the links between surgeons and the trade guilds were severed. British surgeon, John Hunter (1728-1793), was skilful and influential; he insisted that surgery should be a science with a secure base of theoretical knowledge. When orthopaedics began to be practised as a specialist branch of surgery, it most frequently dealt with the care of crippled children, often with spine and limb deformities. The first orthopaedic institute was established at Orbe in Switzerland in 1780, treating the skeletal deformities of crippled children. At that time, patients suffering with musculoskeletal disease and deformities were most often prescribed rest and their limbs were immobilised with braces. 

Prior to the 19th century, surgical intervention was usually undertaken only out of dire necessity. Actual everyday practice was most often simple and conservative, consisting mainly of wound treatment and bandaging. Large numbers of children during the middle to late years of the 19th century were afflicted with musculoskeletal manifestations of tuberculosis which prompted a demand for skilled physicians to treat them. Later, as the prevalence of tuberculosis declined, the waves of polio epidemics began. Polio infected thousands of adults and children - many of whom required orthopaedic care. 

The 20th century can be seen as a great turning point for orthopaedics as a surgical specialty. The need to rehabilitate soldiers injured in war, the discovery of the X-ray and in later decades the development of penicillin and other antibiotics, as well as technologies for joint replacement and diagnostic tools all contributed significantly to the development of orthopaedics as the specialty we know today in Australia. 

ORTHOPAEDICS IN WORLD WAR I 

In August 1914 Germany declared war on France. The British government had committed military support to France, so Britain entered the war. Australia soon pledged its full backing to the allied forces. With a population of under five million, Australia contributed 416,809 volunteers to the war. This was 38.7% of Australian males aged from 18 to 44. Most served in the Gallipoli campaign and then went to the Western Front. The four years of trench warfare in Europe took an extremely heavy toll. By the end of the war Australia had suffered 58,961 deaths and more than 150,000 wounds and injuries. 

Due to the extensive use of high-speed projectiles, especially machine gun bullets and artillery shells, a high proportion of injuries were shrapnel and bullet wounds. These damaged both flesh and bone. Orthopaedic injuries, “injuries of the extremities”, are said to have accounted for 60%-70% of wartime injuries. 
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All Australian soldiers who went to the frontline were issued with an iodine ampoule, and dressings which they carried in a special pocket inside their tunic. Those whose limbs were seriously injured used the dressings - which included an absorbent pad - to pack their wounds until they could reach medical assistance. Iodine tincture - a mixture of ethanol, water, iodine and potassium iodide - was used as an antiseptic. The terrible wounds which were inflicted by shell fire and grenades sometimes required immediate amputation of limbs to save a life. 

A Satterlee bone saw. These saws were made of stainless steel so they could be easily sterilised. They were designed to cut quickly through flesh and bone. During the war many men owed their lives to the doctors who were willing to take quick action to amputate gangrenous limbs.


WORLD WAR l's LEGACY OF ORTHOPAEDIC LEARNINGS 
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During 1914, at the beginning of World War I, open fractures of the femur (hip) were prevalent and the mortality rate was 80%. 
Plaster and splints were usually available at the Casualty Clearing Stations or Stationary Hospitals. However the splint that was available, a long single board to which the damaged limb was bandaged, caused bleeding from the fracture site and damaged soft tissues. Traction was not able to be applied. Soldiers often had to wait a long time to be moved. If the injury was open infection was rife - amputation was often the only hope of relief and survival. Operating on injured and shocked patients was often fatal.
 
Thanks largely to the work of Hugh Owen Thomas, known as the father of British Orthopaedic Surgery, and the advocacy of Sir Robert Jones, who opened an experimental orthopaedic unit in Liverpool in 1915, a new form of splint was developed. The 'Thomas splint' stabilised and immobilised the femur and reduced bleeding during transportation. During the second half of World War I its impact on the mortality rate was enormous.  Additionally as World War I ensued, it was realised that early treatment of orthopaedic injuries was imperative. 

The Thomas Splint

By 1918 teams of experienced surgeons with an anaesthetist would go forward close to the front, taking the medical services to those in need. Most of the major limb and life-saving surgery took place at Casualty Clearing or Advanced Dressing Stations. The long evacuation back to base hospitals no longer occurred until after operative intervention had occurred.

The application of Pare and Larrey's teachings on wound debridement also became vital in reducing mortality from fractures. This involved removal of all dead tissue and foreign material - shell fragments, clothing driven into the wound, and all the dirt and debris from the battlefield that went into the body tissues Only healthy, bleeding tissue was left behind so that the organisms responsible for gangrene were deprived of oxygen and the opportunity to grow.

By the end of World War I, as a result of these orthopaedic developments, mortality from femur fractures dropped from 80% to 8%. Further, the incidence of complications from open fractures - including infection, septicemia, gas gangrene and nonunion - declined dramatically. 

REHABILITATION POST-WAR 
 
Out of every 10 Australian soldiers who served in World War I, two were killed and three were disabled. 3500 Australian soldiers returned home without a limb; modern warfare literally shattered soldiers' bodies. After the First World War there was an urgent need for hospital facilities for wounded soldiers, particularly with the evacuation and repatriation of those from the Gallipoli campaign. The History of Orthopaedics in South Australia notes that: 
'A major impetus to the establishment of orthopaedics was the need to rehabilitate South Australian soldiers injured in the two world wars. Much of their treatment centred around the Repatriation Hospitals.' 

In July 1917, the Seventh Australian General Hospital was opened at the Keswick Barracks to cope with the patients who were mainly affected by long term orthopaedic conditions, including amputees. A Rehabilitation Wing was opened on 3 May 1918 and was supported by extensive physiotherapy, hydrotherapy and massage treatment. 

By the end of the Second World War, repatriation hospitals had been established in each state of Australia to provide care and rehabilitation to those returning from war. Opportunities for clinical research and application of scientific discoveries also occurred due to the scale of those injured. Many advances in medical treatment and surgery were made. 

ORTHOPAEDICS IN THE SECOND HALF OF THE 20TH CENTURY

After a Polio vaccine became effective and with the advent of antibiotic management of infectious diseases, orthopaedics developed in new directions as these two areas of orthopaedic care became less prominent. The 1940s saw developments in methods of internal fixation of fractures - in particular the use of metallic pins, nails, plates, screws and wires. 

After World War II orthopaedics progressed to total joint replacements, minimally invasive surgeries using the arthroscope, and treatment of soft tissue problems of the extremities - especially hand and sports injuries. The surgical management of orthopaedic trauma developed in response to the increase in road trauma with the widespread use of cars. 

New areas of research, revolutionary diagnostic devices, robotics, 3D printing and stem cell therapy all created new frontiers for supporting the orthopaedic well-being of the Australian community.


Credit to the Australian Orthopaedic Institution for all content.