18-01-30 wrench and spokesGavriil Ilizarov, a Pole, attended medical school in Crimea and Kazahkstan during World War II and then, without any practical training, was posted to Kurgan, Siberia. This war-torn region was 1200 miles east of Moscow–far away from any established center of advanced understanding. The area was rife with wounded soldiers suffering from nonhealing, infected fractures.

With vast need, limited resources, and no preconceptions to restrain him, Ilizarov developed an external fixation frame, which would immobilize the fracture during healing but without the need for any fixation hardware at the fracture site, which was commonly infected.

18-01-30 frame and x-rayAbove and below the fracture site at several levels, Ilizarov drilled multiple fine wires through the skin, through the bone, and out the other side of the limb. He quickly ran out of wire and resorted to bicycle spokes. He attached the ends of the spokes to metal rings that surrounded the limb, and then he connected the rings to one another with threaded steel rods. Voila, an external fixator–only the skinny pins were in the body. The stabilizing support was all outside.

Ilizarov compared his novel external fixator to a bicycle wheel, where the bone was the fully-stabilized “hub”, and the rings encompassing the limb at several levels above and below the injury site were the “rims”.

The aim of the external fixation was to hold the fractured bone ends firmly against each other; and by eliminating motion between them, the bone-producing cells could go to town and mend the fracture. This was problematic, however, when a bone gap existed, because bone-forming cells can “jump” only so far–maybe across a stream but not across a chasm. Ilizarov used a wrench to make daily, tiny adjustments of the rings on the threaded rods and could thereby slowly draw the bone ends together. He showed the nurses how to perform this in order to close the fracture gap in almost imperceptible increments over weeks.

One confused nurse, however, kept turning the wrench the wrong way, repeatedly enlarging the fracture gap rather than closing it. To Ilizarov’s surprise when he saw an X-ray of the patient weeks later, the slowly expanding gap was filling in with new bone. The bone-forming cells had been toiling happily, unaware that their task was ever-expanding.

Other surgeons had lengthened limbs through external distraction before. They had performed the distraction more quickly, however, which always necessitated a second operation to fill the gap in the lengthened bone with bone graft taken from elsewhere in the body, often from the rim of the pelvis. Pain, disfigurement, and disability at the donor site could ensue. Sometimes the gap in the broken bone was too big for even the largest possible bone graft to span it.

18-01-30 IlizarovIn an ah-ha moment Ilizarov realized that by moving the bone ends apart ever so slowly (less than a sixteenth of an inch a day in six evenly spaced intervals), new bone would fill in the gap on its own. (Yank on taffy and it snaps in half. Pull on it gently and it stretches.) This slow movement between bone ends could allow lengthening of bones that had healed too short. The “bone stretching” could also correct angular and rotational deformities of fractures that had healed with misalignment. (Twist taffy slowly, it twists.)

Ilizarov applied the technique widely, and his patients called him the Magician from Kurgan. Nonetheless, the medical establishment in Moscow considered him a quack and discounted his growing achievements and reputation. Nobody in the West had even heard of him.

Next week: Bike Spokes Allow Crippled High Jumper to Leap 6’9″

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4 thoughts on “Bike Spokes and a Wrong Turn Advance Fracture Treatment

  1. Dr. Meals,
    Thank you for a very clear and concise explanation of the Iilizarov device and of how a wrong turn can lead you in the right direction if you are paying attention. Julie Belkin

  2. Wow!! What interesting and valuable information. Makes me want to know more about the Magician from Kurgan and what the balance of his life was like after his period of isolation came to a close and he began to circulate into the general population. What events occurred that brought his insights into general acceptance and what his life was like until that event occurred. How many times leaps and bounds of growth and change occur when the current established standards are not longer a pressure to follow.

    Another great insight in a series of many.

    Thank you.

    1. Hi Michael,
      You have anticipated my plan. The posts the next three weeks will be follow-ons for Ilizarov and his technique.
      Best wishes, Roy

  3. When I visited Dr Ilizarov in his hospital in Kurgan in 1988 he told me that he asked to be assigned to that city to do
    general practice in preference to serving with the Soviet forces because as a Jew he would be killed by the Nazis if captured.
    Avrum Froimson
    Cleveland Clinic

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