Friday, August 27, 2010

Don’t throw away the cane

In Chapter 1 of the 4th edition of Intermediate Physics for Medicine and Biology, Russ Hobbie and I quote the article “Don’t throw away the cane” by Walter Blount (J. Bone Joint Surg. 38: 695–708, 1956).
“The patient with a wise orthopedic surgeon walks with crutches for six months after a fracture of the neck of the femur. He uses a stick for a longer time—the wiser the doctor, the longer the time. If his medical adviser, his physical therapist, his friends, and his pride finally drive him to abandon the cane while he still needs one, he limps. He limps in a subconscious effort to reduce the strain on the weakened hip. If there is restricted motion, he cannot shift his body weight, but he hurries to remove the weight from the painful hip joint when his pride makes him reduce the limp to a minimum. The excessive force pressing on the aging hip takes its toll in producing degenerative changes. He should not have thrown away the stick.”
I recently looked up the full article, which is delightful. It was listed as a JBJS classic in 2003 (85: 380). Here are a few more quotes. I suggest you read the entire paper.
“As the causes of premature death are conquered one by one, man is given a longer life in which to grow old gracefully. In the twilight years that his forefathers rarely knew, he needs help in seeing, hearing, chewing, and walking. Gradually we are coming to look upon eye glasses, hearing devices, and dentures as welcome aids to gracious living rather than as the stigmata of senility. They should be accepted eagerly as components of a richer life. The cane, too, should be restored to favor as a means of preventing fatigue and a halting gait, rather than maligned as a sign of deterioration.

The use of the cane in order to prevent strain upon an ailing hip or knee is not generally accepted. In the patient's mind there is a nice distinction between the permissible use of a stick postoperatively and the adoption of this humble support for no other reason than the relief of a slight physical infirmity. A fat lady may waddle like a duck when she laboriously walks a few steps, but she resents the suggestion that she carry a cane. She would look much better with a stick than with the limp; and with support she could walk enough to get some exercise. More walking would help with weight reduction. But no! she is not ready for a cane yet! The patient with residual disability after poliomyelitis and with a fatiguing, unsightly lurch needs a cane. Early degenerative hip disease may require no treatment other than weight reduction and a stick in the opposite hand; however it takes an impressive orthopaedic surgeon to sell the idea. […]

As Pauwels has shown so well (Fig. 8), the use of a cane in the left hand reduces the pressure on the right femoral head without the need for limping. The support afforded by the stick greatly lessens the pull required of the abductor muscles in helping to support the body weight. The cane works through a long lever, so that a moderate push on the stick greatly relieves the strain on the hip [my boldface]. The relative forces are shown in Table I. Pauwels estimated that during the stance phase of walking, without the support of a cane, an average person exerts a static force of 385 pounds on the stationary hip. This weight can be reduced to 220 pounds by pushing down on a stick with the opposite hand the equivalent of 20 pounds. The cane is really an efficient mechanical device. […]

I should rather be remembered as a thoughtful surgeon than as a bold one. I submit that a well planned sequence of lesser operations with long intervals between, and the use of a cane as needed, may prove better for the patient and productive of a more desirable end result than some more heroic surgical procedure. There is a tendency among orthopaedic surgeons to exchange simple methods for dramatic treatment that will not require the use of the cane. The surgeon looks for a single, definitive, bridge-burning operation that will cure the patient completely for the rest of his life. Too often, this goal is not reached. The patient still needs the stick (or even crutches) after this heroic operation. If a satisfactory arthroplasty or reconstruction operation is performed, how much better it would be for most patients to urge the continued use of a cane in order to preserve the function of the reshaped bone by taking the strain off the hip for years, not for months only.”
Blount was a leading physician and surgeon in orthopedics. His grandfather was a civil war surgeon, his mother was a physician and surgeon, and his sister was a pediatrician. He attended the University of Illinois and Rush Medical College. He helped develop the Milwaukee brace for spinal malalignment, was an expert on fractures in children, and introduced tibial stapling for epiphyses. In 1954 he became president of the American Academy of Orthopedic Surgeons.

1 comment:

  1. Medicare used to (two years ago) pay for special shoes for diabetic patients. They no longer cover this cost and as such, many patients make do without this 'luxury.' Can you comment on what the consequences of this loss might mean in terms of the health of the patient?