the Management of Fractures

It is often difficult to procure evidence upon which a definite answer to the numerous facets of progress of human advancement can be based. However, it is in general acceptance that advancement in knowledge is achieved through a process of continuous occurring of data from all available sources at different times. What is termed Islamic Medicine may be considered to be essentially an amalgam of philosophical theorems and numerous materia medica that had prevailed or were available in areas around the Mediterranean and the adjoining countries of Asia.

 

With the unparalled progress that accompanied Islam, the Arabs chose to develop their medical heritage based largely. upon the accumulated data available within the Greek system of medicine. Islamic medicine did not grow wholly upon Arab soil nor were all great Islamic physicians Arabs. Islamic medicine is better considered as a cultural force which absorbed many different currents within itself and having integrated developed them.

 

The cultural Islamic respect for the dead is said to have dissuaded the Islamic physicians from undertaking dissection of the human body. Hence, it has been alleged that the anatomical knowledge, so essential to the art of surgical practice, was neither considerable nor original. Enmity, rivalries and prejudices have distorted the truth.

 

The study of osteology by Abdel Latif el-Baghdadi (1161-1231) on a remarkably large number of human skeleton led him to write his book on 'Improved Anatomy'. Unfortunately, this is no longer available. By providing factual observations he concluded that Galen was wrong in many ,important aspects 5 .

The object of this presentation is to give, in as concise a form as is compatible with clarity and accuracy, (and to summarize) the contributions of Abul Qasim al-Zahrawi in the management of fractures. His contributions to medicine in general must not be constrained by a too narrow interpretation of thf title of this essay. Most physicians of the time occupied themselves with the science of medicine, of internal medicine as it is known today. There were also those who even considered the surgical art to be inferior and a separate branch of medicine. And orthopedic was not yet separated from surgery 2 . Hence, with personal interest in orthopedic and the sustained increase in fracture incidences it seems pertinent to recapitulate the contributions of Abul Qasim, a doyen among the Islamic physicians in fractures; and attempt to evaluate its relevance in the light of contemporary medicinal practice.

 

Abul Qasim Khalaf Ibn al-Abbas al-Zahrawi, known as Albucasis in Latin Europe, was a practicing physician in Cordova at the time of Caliph Abd-ar-Rahman III. He was born in al-Zahra in 936 and died in 1013 .His great work, the Kitab-al- Tasrif in thirty parts dealing with surgery and medicine has become especially well known. A plethora of information is available in this well illustrated medico-surgical encyclopedia. The information presented in this article is acquired from this book taken from the chapter on Surgery and Instruments, Book 3 on Bone setting.

 

He defined a fracture as a separation or fragmentation of a bone. This may be a clean break without splintering, or along the bone, or with splinters or may involve a wound. Hence, among its clinical features he included, distortion, protrusion and palpable crepitus. In its absence, however, and if pain is not elicited on attempted movement of the affected bone he advised to suspect a crack in the bone, the greenstick fracture in current terminology. He mentioned that there were various types of fractures and well described the two most common clinical types namely the closed and the open fractures.

 

Bone healing, he believed, was due to the production of something like a glue around the fracture site, with a certain viscosity which helps it join and binds it so as to ensure a firm linkage. This is perhaps what he alluded to the formation of callus through its stages well before the discovery of the microscope. His observations that fractures in the mature and the old cannot mend into original condition on account of the dryness and hardness of the bones; though soft bones, like those of infants unite and heal readily is in consonance with the current understanding of osteoporosis in the aged and the exuberant remodeling ability in the young. His remarkable conclusion that cranial and extremity bones healed differently is in concurrence with our understanding of cartilaginous and membranous bone healing.

 

In his recommendations on the managements of fractures he advocated manipulative reduction with external immobilization. If the bones were parted, he said, reduction was to be effected by traction, and counter-traction, using diligent manipulation in order to secure exact reposition of the bones and avoiding violent compression. His classical method of resetting a fractured cocky was by exerting corrective pressure by a finger introduced through the rectum, a practice not un-commonly used today. In green- stick fractures he practiced immobilization without manipulation. As to the method of immobilization Abul Qasim suggested the use of either bandages, plasters or splints. Bandages were cut in different sizes to suit the size of the fractured part. It was used as slabs or applied circumferentially exerting gentle and even pressure, often in two or three layers and extending beyond the level of the fracture site. Between the layers of the bandage enough soft tow or rags were inserted to help correct any curves of the fracture and mellow the pressure. The current Robert Jones bandage seem to simulate this very closely.

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