Stanley Hoppenfeld and Vasantha L. Murthy, editors.
Philadelphia: Lippincott Williams and Wilkins; 2000. 606 pages. $59.00.
Stanley Hoppenfeld’s familiar texts on physical diagnosis
and surgical anatomy have helped to educate several generations of
North American orthopaedic surgery residents. The current book,
which Hoppenfeld coedited with his colleague, Vasantha Murthy, MD,
who is an assistant clinical professor of rehabilitation medicine
at Albert Einstein College of Medicine, represents an interesting
attempt to merge the disciplines of rehabilitation and orthopaedic
surgery in order to promote optimal treatment of fractures.
The intended audience is not clearly specified, but the text presumably
is geared toward residents in orthopaedic surgery and physiatry.
It might also be a useful addition to a departmental library.
The book begins with an introductory section reviewing fracture-healing,
biomechanics, and treatment options, including exercises, modalities,
assistive devices, braces, and splints. Chapters on gait and open
fractures are also included in this section. The remainder of the
text is devoted to systematic discussions of fractures of the upper
and lower extremities and the spine; pelvic and acetabular fractures
are not covered. The editors suggest reading these sections "fracture
by fracture on an as-needed basis."
Treatment is discussed in sections organized according to the number
of weeks elapsed since the injury. Each section includes comments
on bone-healing and offers recommendations for rehabilitation. Coverage
of the same issues at multiple points in time necessarily leads
to some repetition. Each chapter closes with summary tables, organized
by time-period and treatment method. These tables provide information
on fracture stability, "orthopaedic" management,
and "rehabilitation" management.
A detailed consideration of gait is one of the strong points
of the text. Normal gait is well described and analyzed in the introductory
section, as are various crutch-walking gaits and transfers. The
fracture-specific chapters discuss involvement of individual muscle
groups, functional consequences, and appropriately focused rehabilitation.
The text is copiously illustrated with line drawings and radiographs,
which are generally of good quality. There are limited references,
mostly from the 1980s and early 1990s.
The editors and chapter authors attempt to supply information that
a relatively inexperienced physician needs in order to
provide follow-up fracture care. However, the fracture-fixation techniques
that are described are not all state-of-the-art,
and the advice that is given is sometimes inconsistent with that found
in other authoritative sources. Rehabilitation of the multiply injured
patient is not addressed. Functional fracture treatment, as advocated
by both the AO/ASIF and the functional cast and brace school
of Sarmiento et al., is not well articulated. Techniques of stable
internal fixation consistent with protected functional use are now
well established, and the fracture surgeon should be familiar with
them and be able to assess the degree of stability that is achieved
surgically, as this assessment guides rehabilitation. Optimal care
depends on the surgeon being actively in charge of rehabilitation
rather than delegating it to others. This text does not adequately cover
the assessment of fixation stability on a patient-by-patient
basis. Depending on the implant used, fixation is categorized as "stress
sharing" or "stress shielding," but the
text does not clearly indicate how these concepts can be used to
guide patient management.
Insufficient consideration also is given to the mechanics and biology
of plate fixation as well as to comminution, bone quality, and the
effects of repetitive loading. The discussion of nonoperative fracture
care would have been improved by increased emphasis on the patient’s
rapid return to use of an injured limb within appropriate constraints
and by greater coverage of the specifics of fracture-brace
fitting and use. There should also be a discussion of pain management,
a frequent source of concern to patients. More attention might also have
been directed to cardiopulmonary rehabilitation and energetics.
Despite these shortcomings, I applaud the authors’ efforts
to improve fracture care. Given the lack of systematically proven knowledge
in our field and the resulting role of often-divergent expert opinions
about broad spectra of injuries, treatments, and patients’ biological
and behavioral responses, it is not possible for a text such as
this one to please every reader. The text makes a useful contribution
by alerting the trainee in rehabilitation medicine or orthopaedic
surgery to many of the issues that arise during the treatment of
a patient who has a musculoskeletal injury. As the editors state, "A
book cannot presume to replace the hands-on process of
learning to treat a fracture under the guidance of a seasoned physician." I believe
that they should have emphasized the importance of continuity of
fracture care by a single treating surgeon rather than offering
the impression that care can be separated into "orthopaedic" and "rehabilitation" phases.