The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 3

The Orthopaedic Forum | March 01, 2007

Raoul Hoffmann and His External Fixator*

Evan M. Schwechter, MD¹; Kenneth G. Swan, MD²

¹ Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, 6th Floor, Bronx, NY 10467. E-mail address: eschwec@gmail.com
² Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, 185 South Orange Avenue, G-590, Newark, NJ 07103. E-mail address: pedretdl@umdnj.edu

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Read in part at the Annual Spring Meeting of the Medical History Society of New Jersey, Princeton, New Jersey, May 24, 2006.

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Mar 01;89(3):672-678. doi: 10.2106/JBJS.F.01177

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Extract

A wealth of information exists concerning the biomechanics, indications, and outcomes associated with the use of the Hoffmann external fixator. Likewise, much has been written about the history of external fixation of fractures. However, little is known about the fascinating life of one of the major figures in its development, Raoul Hoffmann. The purpose of this report is to fill that void and bring to the attention of those who use his device, or its variations, the extraordinary career of this very talented surgeon.

Figures in this Article

Born in Berlin to Adolphe and Aline on April 5, 1881, Raoul Hoffmann was one of three brothers (René and Roger were the others). He also had one sister, Rose. Having received an offer to serve as the minister of the German-speaking Lutheran Church in Geneva, Adolphe moved his family to Switzerland when Raoul was six months old. Only a year later, Adolphe presided over the church's celebration of the 400th anniversary of Martin Luther's birth¹.

Raoul's mother, a minister's daughter, was a well-known Swiss-French author whose writing focused especially on issues of interest to women of her era, including home education, gender relationships, child education, women's rights, and religion².

While Hoffmann's early school years were unremarkable, signs of intellectual prowess, and a strong work ethic, were evident². These traits contributed to Hoffmann's academic success in high school at the College of Geneva, where he graduated first in his class in 1899³. Hoffmann continued his education at the University of Geneva, earning a baccalaureate degree in Letters in 1899 and in Physical and Natural Sciences in 1902⁴.

Hoffmann then took a short break from academia and served an apprenticeship as a furniture maker in La Place du Bourg-de-Four, a charming, historic square in Geneva's old city⁵. He traveled to Paris in search of more challenging employment as a furniture maker but was unsuccessful because of the fierce job competition in Paris at the time^2,4. This early experience in craftsmanship, requiring sophisticated manual dexterity and an understanding of engineering, became the basis for Hoffmann's later work designing and constructing his ingenious external fixator. He abandoned furniture making and focused on a greater calling that he had long nurtured—medicine.

Hoffmann began his medical education at the University of Berlin but soon returned to Geneva, where he earned a diploma in medical physiology and anatomy. A young man with eclectic interests, Hoffmann concurrently studied theology. Considering his religious upbringing, this was not an unusual pursuit. In 1908, he received his degree in theology from the University of Geneva after writing his thesis on Søren Kierkegaard, the nineteenth century Danish existentialist philosopher and theologian^4,6. Hoffmann briefly served apprenticeships as a minister at churches in Geneva, Switzerland, and Borinage, Belgium⁴.

Returning to his medical studies in 1909, Hoffmann completed an externship at the University of Greifswald in Germany, before again returning to Geneva to finish medical school. In 1909, he passed both oral and practical medical board examinations⁴. Hoffmann conducted clinical and anatomical research at the Institut Pathologique de Genève, and he wrote his thesis on Théories Actuelles sur la Neurofibromatose et ses Complications (Current Theories on Neurofibromatosis and its Complications)⁷. On January 5, 1911, the University of Geneva awarded Hoffmann a Diploma for a Doctorate in Medicine (M.D.)⁸.

Hoffmann interned at the Cantonal Hospital of Geneva (Fig. 1) and, in 1912, pursued further studies at the London School of Tropical Medicine⁹. He interned, again, at Falun Hospital (Sweden), a well-regarded medical training institution, as well as the location of one of his cousins who was a surgeon at the hospital². It was there that he met his future wife, Elsa Holmdahl, a nurse. They were married on January 10, 1914, in Uppsala, Sweden².

Several months later, Hoffmann and his new wife began a Christian mission in Kashmir. There, he served as a physician and performed numerous operations during their six-month stay. His wife fell ill, perhaps related to a pregnancy, which caused them to return to Geneva just before the start of World War I⁴. Their first child, Lennart, was born on February 22, 1915, in Geneva.

Although Switzerland was a neutral noncombatant in World Wars I and II, military service was, and remains, mandatory. Hoffmann, an avid outdoorsman, enlisted in the mountain infantry of the Swiss Army. Somewhat surprisingly, he chose not to join the medical corps. Instead, he served in the infantry, as a first lieutenant, in order be a more effective leader of the younger, more impressionable draftees⁴.

In 1915, Hoffmann brought his family to Tramelan, a small, rural town well known for watchmaking, located in the Bernois Jura, about 100 miles northeast of Geneva. There, he established a clinic in his home, where he treated a wide variety of patients. He also made house calls, often for emergency Caesarean sections, usually performed on the kitchen table!⁴ Hoffmann's goal was to build a small community hospital, but, in 1926, the town made plans to build a road through Hoffmann's house¹⁰. He left with his family for Geneva. During the twelve years he spent in Tramelan, Hoffmann and his wife had four more children, Bertil, Aline, Nils, and Karin, nicknamed Lily².

Hoffmann's interest in long-bone fractures may have begun in Tramelan, considering its location near the ski slopes. Being one of the few doctors in this rural area, Hoffmann probably treated the majority of skiing injuries, including both open and closed extremity fractures.

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Fig. 1:: Hoffmann as an intern at the Cantonal Hospital of Geneva, 1911-1912. (Printed with permission of Anne-Christine Hoffmann, MD.)

On returning to Geneva in 1928, Hoffmann established a surgical practice at 4 Rue Emile-Yung, adjacent to the Cantonal Hospital of Geneva. By then, Hoffmann had developed a solid reputation, and his practice grew quickly. At the same time, he began publishing articles and texts on assorted topics, including a biography of his mother, Aline Hoffmann¹¹, in 1926, and a handbook for a successful marriage, "Une Fois Mariés..." Réflexions d'un Médecin¹², in 1928. He also made a presentation to the Congress of the Swiss Society of Surgeons, in 1929, on the effect of arthritis on the knee, "Ménisques du Genou et Arthrite Déformante."¹³

Hoffmann's practice, in his Geneva surgical clinic, became increasingly focused on fracture management and care. This interest resulted from his concerns regarding what he considered to be unnecessary amputations, seemingly routine by military surgeons, for the treatment of complicated fractures⁴. Hoffmann began tinkering with the external fixators of his era, whose shortcomings included the need for open reduction before fixator application. He developed his own technique for fracture fixation, which he termed "ostéotaxis," derived from the Greek, meaning, "to put the bones in place."¹⁰ In 1938, Hoffmann published his new technique and presented it to the French Congress of Surgery. Near the end of his life, in 1969, he was presented with the Nessim Habif World Prize by the University of Geneva for this important contribution to the field of trauma surgery⁴.

Hoffmann's work on his external fixator would continue throughout his life, but this was far from his sole interest. He was a fervent temperance advocate and joined the Blue Cross, a Swiss, Christian organization founded to promote abstinence from alcohol¹⁴. Hoffmann wrote a series of articles on alcoholism in 1966 for the journal La Suisse and later published a pamphlet, entitled C₂H₅OH cet Inconnu or, "What is Unknown about Alcohol," detailing the damaging effects of its abuse¹⁵.

A dedicated and passionate alpinist and mountaineer, Hoffmann loved the outdoors. Among other activities, he cross-country skied near Lake Geneva, climbed Le Cervin (the Matterhorn) multiple times, and climbed both Mont Blanc and La Pointe Dufour at the age of seventy-nine. He regularly took walks throughout the Champel district of Geneva, in which he lived, and often made patient rounds by bicycle^4,16.

Hoffmann died on March 19, 1972, at the age of ninety-one, at his home, 28 Avenue de Champel. He was buried in the Petit-Saconnex Cemetery next to his wife, Elsa, who died in 1958^5,17. He was survived by five children and nine grandchildren.

Brief Historical Review of External Fixation

Brief Historical Review of External Fixation | Hoffmann's Technique: "Ostéotaxis" | The External Fixator in Combat Casualty Care | References

Long before Raoul Hoffmann was even born, others were making progress in the development of external fixation. Some credit Hippocrates (circa 460 to 380 BC) as the first to describe a primitive, but brilliant, external technique for achieving fracture reduction. He designed a system with levers bound to the patient's extremity. The levers then folded to maintain stability¹⁸.

Taking four rods, made of the cornel tree, of equal length, and of the thickness of a finger, and of such length that when bent they will admit of being adjusted to the appendages... There should be three sets of rods, or more, one set a little longer than another, and another a little shorter and smaller, so that they may produce greater or less distention, if required. If these things be properly contrived, they should occasion a proper and equable extension in a straight line, without giving any pain to the wound; for the pressure, if there is any, should be thrown at the foot and the thigh [as described for use on a tibial fracture]... And, if thought proper, there is nothing to prevent the two upper rods from being fastened to one another¹⁹.

After Hippocrates, however, the concept of external fixation lay fallow for over 2000 years.

The earliest modern concepts began in 1840, when Jean-François Malgaigne invented the pointe métallique, or "metallic point." Simply a metallic nail, it was placed through a semicircular metallic band and was percutaneously nailed into the fracture fragment. A belt, attached to the metallic band, was tightened around the limb until the nail had pushed the fragment to the desired reduction, and it could be left in place to prevent fracture displacement^20,21.

In 1843, Malgaigne developed the griffe métallique, literally and figuratively the "metallic claw." This device consisted of opposing pairs of curved points, each attached to sliding metal plates, which achieved compression by means of a turnbuckle-type screw. It was a simple closed reduction technique designed for patellar fractures^20,21.

Other investigators, including Carl Wilhelm Wutzer¹⁸, Von Langenbeck¹⁸, James Bolton²², R. Rigaud²³, and L.J.B. Berenger-Feraud²³, were instrumental in developing early external fixator prototypes. In 1852, Chassin modified Malgaigne's metallic point and claw for application to the clavicle to permit correction of anteroposterior displacements. In 1893, Keetley became the first to use bicortical percutaneous pins²⁰.

But it was Clayton Parkhill of Denver, Colorado, who, in 1897, invented the modern concept of unilateral external fixation. His bone clamp consisted of four fracture-spanning winged plates secured by a rigid external plate. Each plate was bolted to one of two half-pins proximal, or another two distal, to the fracture site²⁴. Parkhill reported good results and few complications²⁰.

Like Parkhill, Albin Lambotte of Antwerp, Belgium, also utilized two half-pins proximal and two distal to the fracture. His pins, however, were, at least initially, fixed between two heavy metal plates, making the apparatus rigid and inflexible, more suitable for early limb mobilization. However, his device, first described in 1902, necessitated initial, open fracture reduction and then pin insertion and fixator placement^20,21.

After Lambotte, many others made significant contributions to the development of the external fixator. Notable advancements were made by Codvilla in 1904²⁵, Crile in 1919²⁵, and Conn in 1931²⁵. In 1931, Pitkin and Blackfield developed the first bilateral frame²⁵.

In 1934, Roger Anderson of Seattle designed a device using transfixation pins that permitted multiplanar adjustment of fracture fragments²³. He was the first to advocate early weight-bearing and joint mobilization^20,26. In 1937, Otto Stader, a Pennsylvania veterinarian, designed a canine external fixator, dubbed the Stader splint, that facilitated fracture reduction in two spatial planes^24,26.

World War II provided a vast number of fractures caused by various explosive devices and high-velocity missiles, in which external fixation might have played an important role, especially in facilitating the transport of the patients who sustained these injuries. However, infection and fixator stability became a concern for military surgeons who were generally inexperienced in its use. External fixation was banned by the United States military because of these concerns^27,28.

In the meantime, Raoul Hoffmann was developing his unique external fixator and the innovative techniques for its application.

Hoffmann's Technique: "Ostéotaxis"

Brief Historical Review of External Fixation | Hoffmann's Technique: "Ostéotaxis" | The External Fixator in Combat Casualty Care | References

Building on the work of others, Hoffmann realized that major improvements were essential to make the external fixator more clinically relevant. He studied Lambotte's fixator, which required open reduction of the fracture²⁹. This added to the tissue damage already sustained and greatly increased the chance of infection. Hoffmann was eager to avoid these complications. He developed a technique based on closed reduction with guided percutaneous pin placement. Hoffmann's technique exemplified the first application of minimally invasive orthopaedic surgery.

Hoffmann's technique was simple, yet ingenious. He located long-bone fracture fragments by "tangentially probing" and "cross probing" (Fig. 2, A), using percutaneous needles—techniques that also localized drill "guide" placement (Fig. 2, B). The surgeon made at least three drill-holes through the far cortex and partially threaded half-pins were inserted. The surgeon could insert a maximum of five pins for more frame stiffness. The pins were available in different lengths for variations in bone depth. Hoffmann used blunt pins in order to avoid soft-tissue trauma²⁹. He experimented with these percutaneous pins in rabbits at the Institut Pathologique de Genève and found neither pin tract infection nor osteomyelitis¹⁰.

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Fig. 2:: A: A cross section demonstrating cross-probing and tangential probing. B: A drill guide with cross-probed percutaneous needles and three pins inserted into a fracture fragment (tangential needles not shown). (Reprinted, with permission of John Wiley and Sons on behalf of the BJSS Ltd., from: Hoffmann R. "Closed osteosynthesis", with special reference to war surgery. Acta Chir Scand. 1942;86:235-66. Copyright 1942, British Journal of Surgery Society Ltd.)

Hoffmann also designed strong clamps, which he called "grips," made of two rectangular steel plates held together with bolts. These bolts compressed the plates around the larger half-pins fixated in bone. Attached to each clamp was a "ball-and-socket" joint. At this point, with one clamp secured on either side of the fracture site, the fracture was reduced by "direct external manipulation." A rigid steel bar, 8 mm in diameter, was then placed through the ball-and-socket joint on either clamp and was fastened by wing screws, thereby uniting the clamps²⁹.

Most important, however, was Hoffmann's observation that, "This bar can just as well be put into position before the reduction process. Its presence in no way hinders the action of reduction" [italics added]²⁹. The ball-and-socket joints could swivel, thus permitting the rigid bar and, in fact, the entire frame to move in continuity (Fig. 3). This, in essence, was Hoffmann's unique contribution to external fixation. It allowed the surgeon to complete fracture reduction in three spatial planes independently. Additionally, secondary correction was possible until optimal reduction was achieved, since only the ball-and-socket joint had to be slightly loosened, the frame adjusted, and the joint retightened²⁹. Essentially, the fracture fragments, whether angulated, displaced, or rotated, could be accurately realigned. Hoffmann coined the term "ostéotaxis" to describe this process. Later modifications permitted both interfragmentary compression and distraction^30,31.

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Fig. 3:: External bar connecting two ball-and-socket joints. (Reprinted, with permission, from: Hoffmann R. Ostéosynthèse "a minima" par tuteur externe transcutané. Rev Med Suisse Romande. 1941; 60:216-34.)

The clamps described were used for diaphyseal fractures. For metaphyseal fractures, Hoffmann designed an analogous mechanism, intended particularly for use at the greater trochanter, lateral femoral condyle, anteromedial surface of the proximal part of the tibia, calcaneus, and superolateral aspect of the humeral head. This clamp was star-shaped and was anchored to the cancellous bone by means of a central pin (Fig. 4)²⁹.

Hoffmann's clamps, both straight and star-shaped, were remarkably versatile. Together, they permitted fracture stabilization virtually anywhere in the body. To manage extreme clamp placement angles, Hoffmann designed what he called "bayonet" connecting bars that were so shaped. This was particularly important, for example, in avoiding the radial nerve in its course around the humerus (Fig. 5)²⁹.

The external bars were customized to meet the patient's build, and they were available in differing lengths and widths. Likewise, Hoffmann designed pins of smaller caliber for the radius and ulna, or for pediatric long-bone fractures²⁹.

Keenly aware of the potential complications of external fixation, Hoffmann included various precautions in his technique. He recognized the importance of preventing pin tract infection and made skin tension-relieving incisions, if necessary. He placed Xeroform gauze at the pin sites, and also prescribed sulfanilamide—a precursor to the sulfonamides. To minimize soft-tissue injury, he used blunted pins and drills that were designed to prevent excessive bone penetration²⁹.

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Fig. 4:: Star-shaped clamp. (Reprinted, with permission of John Wiley and Sons on behalf of the BJSS Ltd., from: Hoffmann R. "Closed osteosynthesis", with special reference to war surgery. Acta Chir Scand. 1942;86:235-66. Copyright 1942, British Journal of Surgery Society Ltd.)

Other advantages of the Hoffmann fixator included the ability to loosen one or more pins in case of infection, without substantially sacrificing fixator stability. Also, the fixator could be applied for the minimal amount of time necessary, since the surgeon only needed to loosen the ball-and-socket joints to check bone consolidation. Additionally, unaffected neighboring joints could remain mobile throughout treatment. But perhaps most importantly, Hoffmann's technique avoided open reduction²⁹.

In 1938, Hoffmann first described his technique in an article entitled, "`Rotules à Os' pour la `Réduction Dirigée', Non Sanglante, des Fractures (`Ostéotaxis'),"³² which he presented at the French Congress of Surgery the same year. He patented his device in Switzerland on June 16, 1939³³, and in France on January 2, 1940³⁴, and later, in 1944, he described use of his fixator for fractures of the mandible³⁵. In 1951, he published a book about the fixator and its orthopaedic applications entitled, L'Ostéotaxis, Ostéosynthèse Transcutanée par Fiches et Rotules³⁰. In the intervening years, Hoffmann would author many more articles describing his technique, in a variety of languages, including Danish, Italian, English, French, and German. Many others have since modified the Hoffmann external fixator, but the core concepts of his technique have continued in use, even to this day.

The External Fixator in Combat Casualty Care

Brief Historical Review of External Fixation | Hoffmann's Technique: "Ostéotaxis" | The External Fixator in Combat Casualty Care | References

Hoffmann's experience as a first lieutenant in the mountain infantry convinced him that his external fixator was applicable to the care of combat casualties. It was especially suitable for complicated closed fractures, open fractures, comminuted fractures, and fractures caused by high-velocity missiles. Additionally, external fixation provided rigid immobilization, particularly suited for military transportation²⁹. Unfortunately, although Hoffmann described his fixator before World War II, it was never used to treat soldiers in that war, since it was not produced commercially until Hoffmann's collaboration with the Jaquet Frères Company (later renamed Jaquet Orthopédie) in 1947.

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Fig. 5:: Bayonet connecting bar as applied to the humerus. (Reprinted, with permission, from: Hoffmann R. L'ostéotaxis, ostéosynthèse transcutanée par fiches et rotules. Paris: Éditions GEAD; 1951.)

For military use of his external fixator, Hoffmann slightly modified the components, in part, because of cost considerations. Instead of external bars, Hoffmann devised metal "straps," in which basically any piece of metal of the requisite length could substitute. For extra stability and utility, the clamps, in this case, without the ball-and-socket joint, were also connected by "Bridges of Wire Reinforced Plaster."²⁹ This consisted of a "bridge," made of malleable iron wire, covered in plaster until approximately 4 to 6 cm thick²⁹.

During World War II, United States Navy surgeons used Otto Stader's fixator, while the United States Army utilized Roger Anderson's fixator^24,27,36. Both were used guardedly, however, as a method of fracture fixation in the United States, especially within its armed forces, because of a relatively high rate of complications, including poor pin fixation, pin tract infection, and localized osteomyelitis^26,27,37. Indeed, the copious purulent drainage from the pin sites of Anderson's device became so infamous that it was dubbed "Seattle serum," after the city in which he worked. These complications likely resulted from surgical inexperience with fixator application, rather than inherent fixator design flaws²⁸.

Despite a growing body of literature in support of external fixation, especially from Europe, and especially by Dr. Hoffmann, enthusiasm for external fixation remained modest after World War II. A survey by the Committee on Fracture and Trauma Surgery of the American Academy of Orthopaedic Surgeons reported, in 1950, that only 28% of the responders believed external fixation had a definite role in fracture management. The report admonished that only those surgeons with advanced training, i.e., those who performed such procedures under the supervision of a surgeon who himself had completed no less than 200 procedures with external fixation, should utilize the modality^26,37.

From the end of World War II through the early 1970s, a functional casting technique, described in the 1960s by Dehne, was the accepted technique for long-bone fracture management³⁷. External fixation was all but forgotten. Even war wounds, such as those with massive soft-tissue destruction encountered during the Korean (1950-1953) and the Vietnam (1961-1973) wars, were treated without external fixation³⁷. Neither internal nor external fixation of long-bone fractures caused by high-velocity missiles was permitted in the combat zone.

The 1970s, however, witnessed increasing studies in the literature, particularly from Europe, demonstrating excellent results with external fixation. Techniques improved, and variety increased. The most notable works included those of Judet in France, Charnley in England, DeBastiani in Italy, Vidal in France, Burny in Belgium, and Ilizarov in Russia. As a result, the United States began to see an upsurge in the use of external fixation³⁷, especially in the armed forces³⁸. The Department of Defense eventually solicited frame designs suited for military application. During the Persian Gulf war in 1991, the Howmedica Ultra-X model was purchased and deployed³⁸. Until that time, external fixation had not been recommended for military use since World War II—a span of approximately forty-six years!

The United States Armed Forces currently use the Hoffmann-II external fixator (Stryker, Mahwah, New Jersey), a modified version of its predecessor. One cannot help but imagine the pride of Raoul Hoffmann had he been able to witness history's most powerful army using his device for the care of its troops. The Department of Defense has chosen this model, in particular, because of its versatility. It is a modular system, in which components can be interchanged as a wounded soldier is transported through the evacuation chain³⁸. Likewise, combat casualties with external fixators are significantly easier to transport³⁹. There are fewer components to the Hoffmann-II Sterile Field Kit, facilitating the ease and speed of application, especially since radiography is not necessary³⁸.

Reports from the frontlines in Operation Iraqi Freedom indicate that the Hoffmann external fixator has played a major role in initial fracture stabilization. Explosive ordnances have caused massive and complex extremity injuries, often requiring multiple irrigations and débridements, neurovascular repair, and soft-tissue coverage in order to salvage a limb. The Hoffmann-II Sterile Field Kit, designed for far-forward application, has been used extensively in the combat setting to provide rigid, temporary fracture stabilization. Its benefits are numerous—including the ability to apply the fixator easily and rapidly in the field⁴⁰. Patients with severe injuries requiring extensive surgical management are transported to either Walter Reed Army Medical Center in Washington, DC; the National Naval Medical Center in Bethesda, Maryland; or the Brooke Army Medical Center in San Antonio, Texas. Patients often arrive with fractures stabilized by the same external fixator applied in the field⁴¹.

In conclusion, in the history of external fixation, there is no doubt that Raoul Hoffmann's device was one of the most influential. His is perhaps the first application of minimally invasive surgery, a modality that drives today's innovative surgical concepts. The unique beauty of Hoffmann's device was its outstanding versatility and modularity, making it a favorite of many trauma surgeons. The Armed Forces of the United States currently include the device as standard inventory.

Although the most modern unilateral external fixator may incorporate some advanced modifications, the basic principles, technique, and indications for its use were first described by one of the great surgeons of our time, Dr. Raoul Hoffmann.

References

Brief Historical Review of External Fixation | Hoffmann's Technique: "Ostéotaxis" | The External Fixator in Combat Casualty Care | References

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Hoffmann R. Ostéotaxis, guide technique et clinique. Geneva: Jaquet Frères; 1961. 1961

Hoffmann R. "Rotules à os" pour la "réduction dirigée", non sanglante, des fractures ("ostéotaxis"). Helv Med Acta. 1938;5: 844-50.5844 1938

Hoffmann R, inventor. Fixateur pour le traitement des fractures des os. Swiss Confederation patent number 203544. 1939Jun16. 1939

Hoffmann R, inventor. Fixateur pour le traitement des fractures des os. French Republic patent number 851028. 1940Jan2. 1940

Hoffmann R. Fixateur externe transcutané pour fractures mandibulaires. Helv Med Acta. 1944;3: 521-4.3521 1944

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Topics

fracture ; external fixation devices

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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Evan M. Schwechter, Kenneth G. Swan; Raoul Hoffmann and His External Fixator*. The Journal of Bone & Joint Surgery. 2007 Mar;89(3):672-678.

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