CHAPTER XXXIV
.
FRACTURES.
The term _fracture_ is, in surgery, applied to such injury of bone and cartilage as effects break in continuity. This injury is effected instantly, and it is rarely that fracture is produced by any slowly
## acting cause, although this latter may so affect or disintegrate
bone as to permit fracture upon the application of a mild degree of force. Fractures are variously classified and grouped for convenience of description; thus we speak of _traumatic_ and _pathological fractures_, implying by the former those which occur by violence in normal conditions of health, and by the latter those which are produced only because of some previous disease in the bone. The difference is that in the former case there is no preëxisting disease, whereas in the latter it is an essential feature of the case. Fractures are also classified as _complete_ or _incomplete_, the former term implying injury to the whole thickness of the bone, while the latter are separately classified: (_a_) _Fissure_, in which there is a line of fracture by which there is no complete separation of fragment, it being essentially a crack; (_b_) the _green-stick fracture_, such as occurs in the young, where the bone is not thoroughly calcified, but is capable of bending to some extent, while a portion of it breaks; (_c_) _depressed fracture_, which is generally produced by direct violence, and occurs in a flat bone, _i. e._, the skull, the scapula, etc.; (_d_) _detachment_ of a fragment or separation of an epiphysis; (_e_) _partial fractures_, corresponding much to the green-stick, but without deformity or change in shape or position.
[Illustration: FIG. 276
Impacted fracture of the shaft of the femur produced by a fall upon the knee in a man aged eighty-three years. Illustrating impaction. (Bryant.)]
Fractures are also described by means of the following adjectives, which practically explain themselves, for instance:
_A._ _Complete_, _transverse_, _oblique_, _longitudinal_, _dentated_, etc. _Spiral_ fracture is also described and occasionally seen. It involves only the long bones, and not only implies a considerable degree of violence, but is itself regarded as exceedingly serious.
_B._ In number they are _single_, _multiple_, or _comminuted_, as when there are a number of fragments.
_C._ They are often _impacted_, which means that one fragment is driven into and more or less embedded in the other. This impaction or interlocking of fragments occurs usually in the neck of the femur and the lower end of the radius. In the former locality it is advisable not to interfere with it; in the latter it should always be dislodged in order to restore the fragment to its proper position (Fig. 276).
_D._ As to their nature and location, fractures are referred to as _pathological_, _gunshot_, _intra-articular_, or _extra-articular_, etc., the latter terms referring to involvement of a joint. If blood can escape from the site of the fracture into a joint cavity, or if synovial fluid can escape from the latter into the former, then the fracture is called _intra-articular_.
_Pathological fractures_ imply preëxisting disease. This may be constitutional, as in the case of the fragilitas ossium, already described in the chapter on the Bones, or it may be due to some secondary deposit of cancer or a primary sarcoma. In adults, especially those with a cancerous history, any spontaneous fracture, or even one occurring with trifling violence, should lead to suspicion of a metastatic focus in the bone at the site of its yielding. The atrophic changes which notably occur in various bones as old age comes on lead also to a condition which is pathological, _i. e._, it permits of fracture from what would appear to be a trifling injury.
_Gunshot fractures are practically always comminuted_, save perhaps some of those inflicted with the modern military weapons. A Mauser bullet will frequently make an almost clean perforation, but the gunshot fractures met with in civil practice are almost invariably comminuted, especially those of the skull (Fig. 277).
_E._ The term _compound_ is applied to any fracture in which there is wound of the soft tissues and so located as to permit access of air to the injured bone. There is a distinction between a compound and a complicated fracture. A fracture of the femur accompanied by a gash or extensive wound, so long as air cannot come in contact with the broken bone, would be described as a fracture of the femur complicated by a lacerated wound. On the other hand, if through the slightest puncture of the skin, even at a distance from the fracture, air can even theoretically enter and come in contact with bone surfaces at the site of the fracture, such an injury constitutes a compound fracture. This distinction is not a trifling one, for upon the exclusion of air, which to a certain extent means the exclusion of germs, depends very much the rapidity and perfection of recovery. _Compound fractures are all dangerous in proportion as they permit of infection_, and while air infection is not necessarily the most serious of any, it nevertheless is often sufficiently so to set up sepsis and interfere with consolidation, even if it does not prevent it. Fractures are made compound by _direct violence_ from the outside or by _indirect violence_, as where a bone end perforates soft parts and the skin. Even if a sharp point of bone thus protruded from within is quickly drawn back again it is enough, since both the skin and the air in contact with it are sources of germ activity. Thus it may happen that a slight and apparently trivial injury of this kind is more serious than one which is extensive.
[Illustration: FIG. 277
Skiagram of compound comminuted (gunshot) fracture of elbow, inflicted with a Dumdum bullet. Illustrating the extreme of comminution. (Lexer.)]
_F._ _Epiphyseal separations_ constitute a somewhat distinct form of injury, having at the same time the importance and dignity of fractures in the truer sense of the term. In the chapter on Diseases of the Joints will be found a table of the ages at which epiphyses unite. In childhood and youth a fracture near the joint is most likely to partake of this character, and it is of importance that it should be recognized as such when it occurs. Injuries occurring beyond the ages mentioned in the table are not likely to be of this character unless ossification is delayed by some morbid process.
By virtue of their occupations and habits men suffer fractures more frequently than women. Fractures are, moreover, ten times as frequent as are dislocations. The aged, by virtue of their atrophic changes, are more subject to fractures than others. Fracture in the vicinity of certain joints predisposes as well to dislocation of these joints, and it often happens that the treatment for the dislocation is reduction and treatment of the fracture. So far as the external causes of fracture are concerned they are frequently referred to as (_a_) fracture by external violence, and (_b_) fracture by muscle activity. The former are easily explained; the latter occur from excessive muscle
## action, as in violently throwing a ball, or, as in one case with which
the writer was conversant, where a colored preacher in the vehemence of his gesticulations fractured his own humerus. Obviously the long or large bones are more liable to fracture than those which are short and irregular. Certain bones, especially the clavicle, are peculiarly exposed.
_Intra-uterine fractures_ have not as yet been mentioned. These occur during the intra-uterine life of the fetus; this term does not include such fractures as may be inflicted during delivery with or without instruments. In a fetus already affected with congenital rickets it may not require any severe contusion upon the abdomen of the mother to inflict a fracture. Starvation (_i. e._, scurvy, syphilis, and struma) in the mother may so disturb nutrition as to weaken the osseous system of her offspring.
Such previous conditions as ensue from osteomyelitis (_i. e._, caries and necrosis) may often weaken the bone. Nevertheless with distinct necrosis there is usually so much new bone formation as to strengthen rather than weaken the part. Bones may also become fragile as the result of syphilis, especially when gummas develop within them.
Fractures frequently produce certain _deformities_ which are more or less conspicuous and easily recognized. They are designated as _angular_, _lateral_, or _axial_ (_i. e._, when the axes of bone are considerably displaced, even though they may be more or less parallel), _longitudinal_ (when ends overlap), _rotary_, etc.; while by the interposition of muscles and other soft tissues more or less wide _separation_ may be produced, the same result occurring when the olecranon or the upper half of the patella is widely separated from the main bone or portion by muscle pull.
DIAGNOSIS OF FRACTURES.
Fractures give rise to subjective symptoms and objective signs. In diagnosis the history is also of value, especially in those cases where it is a question of some constitutional affection and a minimum or absolute absence of violence. The apparent immunity which the intoxicated enjoy is in large measure due to the fact that by virtue of their condition one of the predisposing causes of fracture is avoided. There can be no doubt but what _muscle tension_, due to voluntary or instinctive efforts to avoid harm, is a contributing factor in the separation of many bones or their processes. A patient stupidly drunk will not make these efforts, and will fall in a relaxed condition, in which violence will probably be much less extensive, and the consequences less disastrous than if he made an effort to save himself from falling.
_Pain and tenderness_ are evidences of injury, and will often serve for its location; even the reference of pain is somewhat suggestive. It is stated as a universal rule that when pressure is applied laterally or in the long axis of a bone and evokes pain, referred to a distance from the point where pressure is made, it will indicate fracture at the point to which it is referred. There is always _impairment_, usually _loss of function_, while effort to move a thus injured limb will give rise again to localized pain and tenderness. The pain of contusion is usually diffuse, and that of fracture is referred to a limited area. The tenderness produced by handling or examination will vary with the stolidity, the age, and the character of the patient, as well as the nature of the injury.
Objective signs are _crepitus_, _mobility_, _deformity_, _ecchymosis_, _redisplacement_. _Crepitus_ means the sensation of grating or rubbing produced when fractured bone surfaces are moved upon each other. It is recognized by the sense of touch, sometimes by that of hearing. Its presence is pathognomonic, but its absence is a negative sign, and an effort should be made to obtain it. To repeat the demonstration, especially to demonstrate it to others, means superfluous manipulation, which is not to the best interest of the patient. Crepitus, then, should be carefully sought for; once detected it should be sufficient.
_Abnormal mobility_ is explained only by fracture. It is easy to detect it in the shaft of a long bone, but when near the joint it is confusing. Its determination by manipulation is not seen in green-stick or impacted fracture unless these are further broken up by manipulation. When evident it should serve as a caution against unnecessary or rough handling, for if it be easily recognizable crepitus need not be sought.
_Deformity_ is a striking and pathognomonic feature of fracture. It may be imitated by hematoma or sudden swelling of the soft parts or of joints. It may consist of shortening or of angular, lateral, or rotary displacement, or perhaps of depression or indentation. Careful inspection, then, and palpation should precede other methods of examination, as they are often sufficient to indicate the location, the nature, and sometimes even the character of the active causes.
_Inspection of the injured part alone is not always sufficient._ Careful comparison between the two sides of the body should be made in order that actual measurement or comparative examination may reveal what mere inspection would not. In connection with inspection it should be ascertained whether the individual has ever received previous injuries. The writer recalls a case where a physician claimed a recovery after fracture of the femur, treated by incompetent method, yet with ideal result, inasmuch as he said there was absolutely no shortening. A personal question, however, to the patient revealed the fact that he had had the other thigh broken some years previously, and that an apparently similar amount of shortening followed in each case.
The ordinary indications of fracture are frequently followed by _ecchymosis_. This will appear at a date corresponding with the depth of the injury beneath the skin (it may occur within an hour or three or four days). The blood will follow the fascial planes and work its way to the surface along them. The sign is of the greatest value in the diagnosis of basal fractures of the skull and certain fractures of the hip and pelvis. When it occurs after an interval it is a confirmatory rather than a promptly available sign.
_Redisplacement_ implies that the parts when properly put into apposition quickly fall out of it unless mechanically supported--that is, they _do not stay reduced_. This sign is not universally applicable. It applies especially to the fractures of the long bones of the extremities, and particularly to the humerus, the femur, or double fractures of the radius and ulna in the forearm or both bones of the leg.
=Diagnostic Aid Afforded by the Fluoroscope and the Skiagram.=--Since Röntgen’s memorable discovery the _cathode or x-rays_ have been of greater and greater use in the diagnosis and portrayal of injuries and morbid conditions in the osseous system. To such an extent is this now true that well-equipped hospitals have ample conveniences for fluoroscopic and photographic work, while many medical men are doing it in their private practice. There can be no question but that diagnosis and methods of treatment have been made more perfect since this new method of investigation has been made available. On one hand, however, it has led perhaps to something of neglect of the methods previously in vogue, which necessitated anatomical knowledge and logical reasoning. On the other hand, the knowledge thus obtained has been sometimes a two-edged sword, since the display of skiagrams, or _x_-ray pictures, in court has too often worked harm or discredit to the surgeon or the institution with which he was connected. Moreover, even this method of diagnosis, with its apparent certainties, is not always reliable, and disappointments have sometimes followed.
=Intra-articular Fractures= are subject to peculiar complications which enhance the difficulty of treatment and jeopardized the result. Among the more common of these are the following:
1. Too wide separation of fragments by hemorrhage or distention, with failure in resorption of fluid before fixation in bad position has resulted.
2. Complete or partial rotary displacement, preventing proper apposition of bone surfaces.
3. Interposition of soft or fibrous tissues between fragments by which bony union is prevented. This is conspicuously common in fractures of the olecranon and patella, and is of itself sufficient reason to justify operation in otherwise suitable cases.
4. Separation of a fragment within a joint capsule, by which its blood supply is cut off, making it essentially a foreign body. This occurs especially at the anatomical necks of both the humerus and femur.
5. Exuberance of callus with consequent limitation of motion.
6. Insufficient amount or absence of callus, which, when bone ends are bathed in joint fluids, is not often thrown out.
All of these are _immediate consequences_. The following are among the more undesirable _remote consequences_ of the same injuries:
1. Exuberant callus, which may be the result of too early attempt to move the parts, or may result from other causes; it offers more or less mechanical obstruction to joint movements.
2. Separation of fragments to an extent precluding the possibility of repair, and interfering with function.
3. Pseudo-ankylosis, as a result of condensation and organization of blood clot between joint surfaces.
4. Adhesion of tendons to surrounding callus or within their own sheaths.
5. Displacement and distortion of bone ends with vicious union, for which the medical attendant is _sometimes_ responsible. Unfortunate consequences of this kind are generally seen at the elbow after fractures of the condyles; at the wrist, after incomplete reduction of Colles’ fracture; at the hip, when insufficient traction has been made; at the ankle, after the complete form of Pott’s fracture.
6. Exostoses and osteophytic outgrowths, which often complicate fractures.
7. Absorption of bone, which is usually seen after fractures of the neck of the femur.
8. Involvement of nerves by pressure of callus, most often seen about the elbow.
9. Thrombosis leading to obliteration of the deeper and enlargement of the more superficial veins.
10. Edema, also the result of venous obstruction by pressure of callus.
11. Chronic hydrarthrosis.
12. Arthritis deformans traumatica. This is usually a remote result of fractures, and manifests itself by slow changes in shape and position, with deformity and disability. It occurs most often in the aged.
13. Necrosis, which may be the result of failure in the process of repair and will probably necessitate operation.
14. Malignant changes. These have to do with the occurrence of sarcoma in bone callus, a complication which is known to occasionally arise. (See Sarcoma.) It also refers to primary sarcoma, by which bone is weakened, or secondary carcinoma, which produces the same result.
15. Syphilis. Chronic syphilitic disease is well known to weaken bones by atrophic processes as well as by the deposition of gumma. It is known also to delay, or sometimes almost prevent, the process of callus formation, ossification, and later absorption. Syphilitic patients with fractures need to be kept under antispecific medicines.
REPAIR OF FRACTURES.
The immediate consequence of a fracture is outpour of blood both from the broken-bone surfaces and from whatever other tissues may have been lacerated. This produces, first, a hematoma, which is followed by a certain degree of local edema, perhaps even of general edema of the distal parts. The latter will subside with a rapidity proportionate to the promptness of suitable treatment and the nature of the injury. The blood begins to coagulate within a short time, while with the disappearance of the more fluid portion granulations begin to form from the periosteum, as well as bone surfaces, externally and internally, and even from the marrow. The clot loses its original characteristics and is permeated more or less rapidly by granulations. With the site of the injury wrapped in a mass of granulation tissue we speak of the so-called _provisional callus_, whose amount will depend upon the severity of the injury and the accuracy of the replacement of the parts. If laceration has been but trifling and the bones are accurately apposed the amount of callus will be small, otherwise it may be large; so large, in fact, as to be easily palpated and even to cause edema and pain by pressure. Repair of the fracture is effected by the gradual conversion of this callus into cartilaginous tissue and then into bone. So much of it, at least, as lies on the outer side of the bone and is known as _external callus_ goes through this change. The _internal callus_, _i. e._, that within the marrow cavity, undergoes a more direct transformation, which amounts to immediate ossification. The internal callus usually ossifies completely, and then forms a _medullary plug_ that serves as an internal splint and affords support and strength. In time it completely disappears, this time varying in different cases.
The external callus is converted into bone by passing through the intermediary condition of cartilage. Between the broken-bone ends granulation occurs more slowly, and repair at this point is delayed,
## partly because of poor circulation and nutrition; but the internal
callus acting as a bobbin within, and the external callus acting as a solder on the outside, give sufficient support and strength to effect a final and absolute ossification of all the interfragmentary granulation tissue. When the time comes when callus is no longer necessary it begins to disappear by absorption. When everything proceeds normally callus is absorbed in a proportion commensurate with its loss of utility. When bone ends have badly united considerable callus remains permanently. When apposition has been ideal it almost completely disappears, even the medullary cavity being restored.
Fragments which are completely detached may be reunited by practically the same primary process, but fragments of considerable size usually become surrounded by granulation tissue, by which they are nourished and may be finally reunited, with more or less departure from their original shape and location. It is in this way that a comminuted fracture may heal. Fragments that are separated sometimes necrose and have to be removed.
[Illustration: FIG. 278
FIG. 279
Compound fractures resulting from arm being caught in belting and wound around shafting. End of radius united to ulna and lower end of ulna to the radial fragment. Pseudarthrosis of humerus, thrice operated, the third time in the Buffalo Clinic. (Skiagram by Dr. Plummer.) (Arch. Phys. Therap., May, 1905.)]
The repair of the flat bones is effected by a similar process, which is referred to as callus formation. In the skull it is brought about chiefly through the agency of the diploë, whose powers in this direction are somewhat limited. Cancellous bone tissue usually throws out but little callus. Its repair occurs from within. _Cartilage_ heals by a very similar process, though it is not now ossific tissue but _fibrous_ which reunites the fractured surfaces. Instances of both kinds can be seen when a fracture has crossed a joint surface.
In a compound fracture much will depend upon the existence or absence of septic complications. In a clean wound, whence blood and fluid may have escaped, there will be little but granulation tissue. Should this wound suppurate the exposed bone surfaces will undergo at least a superficial necrosis, necrotic particles being removed by the same granulation tissue which will later bind the bone ends together. Here, too, the internal callus plays the largest role in the process of repair. The bone tissue first formed is always coarse and soft. Complete calcification and restoration of original density and vascularity occur slowly. Neither cartilage nor bloodvessels alone appear capable of forming bone; the latter is produced only under the influence of the _osteoblasts, which penetrate from the periosteum and the bone itself_ along the course of the bloodvessels.
The process is one of conversion of blood clot into provisional callus, which then changes into granulation tissue or into cartilage, both of these materials undergoing subsequent conversion into bone through the medium of the osteoblasts and osteoclasts (or giant bone cells), the neighboring bone itself undergoing a rarefying ostitis, to change back into its original condition with the final changes of the callus.
Repair of intra-articular fractures has already been described as influenced by the presence of synovial fluid and cartilage. The latter does not proliferate, and the line of fracture usually appears as a groove on its surface. At epiphyseal junctions union is usually rapid and satisfactory, for the changes taking place at this point are in the direct line of what is needed for repair.
DELAYED UNION; NON-UNION.
The above description refers to the process which is supposed to take place in normal bone repair. When, however, this is disturbed, as it may be from a variety of causes, there may be _delayed union_; when it completely fails we have _non-union_. General conditions have bearing on these local failures. Whatever makes a strain upon the system may interrupt the process, _e. g._, pregnancy, lactation, exhausting hemorrhages, acute diseases, starvation. Again, failure may result from purely local conditions, such as marked displacement, and particularly the intervention of some of the soft tissues, or any foreign body. _Suppuration_ will also frequently cause great disappointment. The humerus is the bone most often troublesome in this direction; next the bones of the leg, the femur, and the bones of the forearm. It is necessary to distinguish between delayed union and absolute non-union. In the former normal processes may be simply retarded. _When thus delayed they may be stimulated_ by rough handling, rubbing the bones together, or by perforating the callus with the point of a drill, from several directions. This method of drilling was introduced by Brainard, of Chicago. The existence of syphilis has much to do with delay, and should be combated by free use of antispecifics. Many patients will be found to have _phosphaturia_, _i. e._, to be eliminating phosphates which should go to repairing the bone. Such patients should be given phosphoric acid, with some of the phosphates, preferably of calcium, in order to make up for loss in this direction. Much can be done also by massage, and by everything which stimulates nutrition and general health (Fig. 280).
[Illustration: FIG. 280
Vicious union with great deformity after fracture, requiring extensive operation. (Buffalo Clinic.)]
In _non-union_ efforts at repair are at a standstill; the bone ends become rounded off, the marrow cavity is plugged on either side, while in time the surrounding granulation or connective tissue undergoes condensation, as well as organization, and a _capsule_ is formed in which a certain amount of fluid resembling true synovia collects, and thus is formed sometimes an almost perfect _pseudarthrosis or false joint_, whose perfection as a joint must be admired, although its presence is so deplored. The causes of non-union are now better understood than formerly, and consist largely in the interposition of fibrous and muscular tissues, that act as a barrier and keep the granulation tissue or the callus on one side from coalescing with that on the other.
_Treatment_ of these cases will vary with their causes. In _delayed union_ patients should be encouraged to use the parts, thereby causing greater activity, but in the presence of an actual _false joint_ no method is of avail except that of actual exposure, by incision, with removal of all intervening fibrous tissue, and freshening of the bone surfaces by saw or chisel, the endeavor being to so shape them that they may lie in contact, and then be so maintained, by some mechanical expedient, such as a wire nail or suture, an ivory peg, a chromicized tendon, a bone ring, a small metal brace fastened with screws, or by any other expedient which may suggest itself to the ingenuity and the means of the operator. There are, however, occasions when one deliberately endeavors to secure a pseudarthrosis, as after ankylosis of the shoulder-joint, if in making powerful effort to break up adhesions the neck of the humerus should snap it would be better to prevent union rather than favor it, as in this way something resembling the original joint, so far as function is concerned, would be obtained. At the hip, also, after such an accident, the same principles may be adhered to or more deliberately secured by a subcutaneous osteotomy, as is sometimes done for relief of deformity.
_Fibrous union_ implies such organization of granulation tissue as converts it into simple fibrous or ligamentous tissue, the change stopping here and not going on to formation of cartilage or bone. There are three localities especially where fibrous union is sometimes the best that can be obtained and often proves sufficient of itself; these are the olecranon, the patella, and the neck of the femur. Even though the halves of the patella be separated by two inches of ligamentous tissue the patient may still have reasonable use of the limb. A separation of half an inch to one inch at the olecranon does not materially disable the arm, while at the hip-joint two or three inches of ligamentous tissue between the main end of the bone and the fragment will not totally interfere with locomotion, except so far as it permits an equivalent amount of shortening of the leg. There are, then, occasions especially when the hip is involved in elderly and decrepit people, when ligamentous union is the best that can be hoped for or attained.
TREATMENT OF FRACTURES.
In principle the treatment of fractures is very simple. It consists in _putting the parts in apposition and maintaining them there_ for sufficient time to permit of complete repair. That which is so simple in theory is often very difficult and sometimes even impossible in practice, made so by the nature of the injury or the disposition of the patient. In the aged, who cannot lie long in one position for fear of pulmonary stasis; also in the insane, in the epileptic, and in those suffering from delirium tremens, will be met difficulties which are insuperable. In such instances the first indication is to preserve the life of the patient, the second is to get a good result, the third is to do the best we can. Good management is not the least important feature of such treatment. This will include suitable nutrition, provision for elimination, prevention of bed-sores or pressure-sores, and many other less important features.
Diagnosis having been made, the surgeon should study how he may best carry out the fundamental principle of putting the parts in apposition and so maintaining them.
The greatest obstacle to reduction and maintenance in position is _muscle pull_. After an injury of this kind there will be more or less muscle spasm, the more powerful groups displacing bones in the natural direction of their pull. In the humerus and femur especially all arm or thigh muscles will coöperate to produce shortening. As indicated in the chapter on Joint Affections, nothing so thoroughly overcomes chronic muscle spasm as _traction_. The principle underlying treatment by traction is exceedingly simple, but there are numerous ways and mechanical expedients for effecting it. In the lower limb, whether this shall be done by anterior suspension, by weight and pulley, by elastic contraction, or by some of the more complicated splints, matters little so long as it be efficiently made. Of all these methods it may be said in general the simplest is the best. In the upper extremity traction may be made by similar methods with the patient in bed, or the patient may be allowed to rise and be about with a weight hanging from the elbow or some simple expedient of this kind.
The method of traction is one to be combined usually with further protection, by which not only longitudinal but lateral displacement maybe overcome. This suggests the use of _splints_ in addition to mere traction methods.
It is not always possible to put in operation at first that method which we may prefer a little later, as _swelling_ is usually so pronounced as to make it advisable only to put the parts at rest and hasten absorption. The same is true of hemorrhage. In rarer instances it may be a question as to whether the distal parts may undergo gangrene from the disturbance of circulation. These are matters to be duly regarded before the later and more complete dressing. _Mechanical aids_, usually in the shape of splints, are therefore necessary. The physiological rest which it is so necessary to ensure will lead to a certain wasting of muscles and stiffening of joints, which are only temporary, but which by no means lessen disability when splints are removed. _That splint is best for a given case which best fits it and permits the surgeon to carry out its peculiar indications._ The writer is opposed to manufactured splints, as they seldom fit the part. This can be obviated by packing cotton or other compressible material into the splint. For temporary purposes they will frequently suffice. For fixed dressing, however, it is preferable to make a splint which shall fit the limb to which it is affixed. Immobilization is difficult of accomplishment and at many points impossible. Thus in fracture of the ribs or clavicle it is impossible to avoid a certain amount of motion with each respiratory effort, even though an uncomfortably tight dressing be applied.
Splints are made of various materials, metal, wood, various compositions hardened in molds, plaster of Paris, or some of its substitutes, _i. e._, glue, soluble glass, or a composition like one made of equal parts of powdered starch and fine isinglass, added to a solution of potassium silicate, this being allowed to stand for several days, after which a little fine boric acid powder is added; when this is painted over gauze dressings it solidifies and forms a light and rigid splint. There is one objection to all methods which comprise a solution that hardens slowly--that is, that during the time required for the purpose redisplacement may occur. It is not advisable to dress a recent fracture in a wet pasteboard splint or in such a composition as that mentioned above. Later, when a certain amount of consolidation has already occurred they may serve a useful purpose.[38]
[38] Jenkins’ packing, such as is used on some engines, has been recommended by Spotswood as a substitute for plaster-of-Paris bandages, its advantages being that it is not affected by any antiseptic washes as a plaster dressing would be, that it is lighter, and that by placing it in hot water it can be molded to assume the shape of the limb.
There are two methods of using plaster of Paris: one is gauze bandages sprinkled with it, rolled, and kept ready for use, to be placed in water at the time of their employment. A limb may be enveloped in these, after being covered with a layer of wadding or some other protective material, by which the plaster shall not come in actual contact with the skin. It is also a good plan to place a strip of tin or pasteboard along the exposed surface of the limb, over which the surgeon cuts to remove the splint. Thus one may avoid any danger of injuring the skin with the point of the knife. It is also a good plan to make at least a part of this cut before the plaster has sufficiently hardened, _i. e._, to do most of the work, leaving perhaps a layer or two of gauze to be cut through some time later. It is necessary to impress the fact that when a quickly hardening fixed dressing is used approximation should be ensured by the greatest attention, maintaining it until the splint is so hardened that redislocation is impossible. Another method of using plaster of Paris is by sopping strips of surgeons’ lint, ordinary canton flannel, or almost any other similar material, in plaster-of-Paris cream, then molding these to the injured limb, maintaining the same rigid precaution as to the proper position of the same while the splint hardens. In this way a splint can be adapted to the part, and, at the same time, made removable, permitting as frequent access to it as may be desired.
COMPOUND FRACTURES AND THEIR TREATMENT.
As already stated, it is the communication of fractured bone surfaces with the external air which makes a fracture compound in the strictly surgical sense. This may occur through a minute and tortuous opening or through a large and extensive wound. Although the communication is with the atmosphere the danger comes not so much from germs floating in the air as from those on the surface of the body and within the pores of the skin, or else from foreign material admitted through the external wound. Obviously the great danger is of septic infection. Whether the tissues may prove more or less susceptible, and thus resist or break down, cannot at the outset be foretold. This leaves but one imperative ride to follow, _to act in every instance as though serious injection had occurred and to take precautions accordingly_. Even a small puncture made by a spicule of bone may permit germs to be withdrawn into the tissues as the bone is replaced. If, then, the surgeon seals such a puncture he necessarily takes the chances and must abide the result. Whether he shall do this or not will depend upon the patient and the injury. At all events, the site of puncture should be carefully cleansed and disinfected and the case so dressed that it may be carefully watched. Complete sterilization of every particle of exposed tissue is absolutely necessary, and for this purpose hydrogen dioxide or some of its later substitutes will prove effective. A protruding splinter of bone should be removed with cutting forceps, unless the wound must be enlarged as a part of the treatment of the fracture. In most instances it will be safer to pursue this course, _i. e._, to extend the wound which makes the fracture compound, to a degree permitting thorough exploration and cleansing. Not infrequently fragments of bone will be found, which when nearly or completely detached should be removed. Such a free opening permits also of wiring, or other means of fastening together bone ends, by which apposition may be more perfectly secured. _A compound fracture which has been long unattended may be safely assumed to be septic._ Here free incision, with cleansing and ample drainage, will be a far safer course than non-compliance with the general rule.
_Compound fractures of the skull_ are nearly always depressed fractures, and practically always call for operation. Their proper treatment will be dealt with when considering Injuries to the Head. A fracture of the ribs may be made compound by penetration of a sharp bone end, and such injury to the lung as may permit air to escape into the pleural cavity. Such a pneumothorax may be followed by a hemothorax and hydrothorax, and these perhaps by empyema. Compound fractures of the pelvis are not infrequently complicated by perforation of the bladder or bowel, or rupture of the urethra, or some other serious visceral injury which may determine their fate. Compound fractures are difficult of treatment because they entail frequent changes of dressing and prevent the use of desirable splints. These fractures are also sometimes so serious as to necessitate amputation, which may be necessitated either by such comminution of bone as to make repair impossible, or such injury to vessels as may determine gangrene. If the circulation can be shown to be sufficient, either at the time or perhaps by delay of a few hours or a day, a limb may be saved by the resection of one or both bones, which in pre-antiseptic days would have required amputation.
The surgeon does not always see these cases in their recent or fresh state. He may be called to a case complicated by suppuration, cellulitis, and sepsis. Here though amputation may be required he may still delay it, hoping to improve local conditions, and thus to make it more promising, or he may have to resort to various expedients, such as suspension with constant irrigation, or temporary packing with yeast, in order to justify any further attack upon the parts already involved.
In the treatment of compound as of simple fractures we should never lose sight of the _dangers of too tight bandaging and of pressure sores_. I have seen both these lead to gangrene, with its necessary mutilation, in cases where the attendant has forgotten the proneness of injured parts to swell, and has either not allowed for this within the dressings or has not atoned for it in time when it has already occurred.
In the treatment of all these cases the operator should never forget the medicolegal aspects of such a case nor the necessity for constant attention and caution on his part. He should remember that his minutest precautions will often be disobeyed. He may, however, be cheered by the fact that only in cases of carelessness will he incur legal responsibility.
SPECIAL FRACTURES.
Fractures of the skull and of the vertebræ will be considered under the respective headings of Injuries to the Head and to the Spine.
FRACTURES OF THE NOSE.
The nose is the most frequently broken of all the bony parts about the face. One nasal bone or both may be broken, and each may be separated from its bony supports as well as from the other. The fracture may be compound in either direction, most frequently so into the nasal cavity, as a result of which infection may as easily take place from within as from without. The cartilages may also participate in the injury.
The injury would be easy of recognition were it not for the amount of swelling that often accompanies it. The signs are mobility and crepitus, with more or less deformity. So long as the nose can be grasped between the fingers recognition of fracture is easy. If swelling prevents this an instrument or the finger can be passed into one nostril and combined manipulation practised. There is generally more or less bleeding from the nose, and sometimes considerable emphysema. Swelling and ecchymosis are also often pronounced. This will all subside under cool and soothing applications. The most important indication is to replace the nose and hold it where it should remain. The difficulty is increased by the efforts which the patient instinctively makes to dislodge clot or secretion. The importance of accurate reposition is in some cases sufficient to justify an anesthetic and instrumental help. This will permit of the application of such force as may be necessary to elevate or to shift fragments, while a gutta-percha splint may be molded upon the outside, or a sterilized pin or needle made to transfix the nose from one side to the other (Mason), passing behind the fragments and through the septum in such a way as to keep it from dropping backward. A good plan is to introduce a tube into each nostril, perhaps a piece of silk catheter, around which a certain amount of gauze can be packed, and which can thus be used as an internal splint, while on either side and externally a little roll of gauze is held in place by adhesive plaster crossing the cheeks. The operator should take as much pains to see that the septum is in its original position as in attending to outside and cosmetic effects. The septum can be controlled by a pair of forceps.
A nose properly held in place will heal within a few days, to a point requiring little if any support. A transfixion pin should not be needed, if used, for more than four or five days. An internal splint should be removed each day, so that the nose may be sprayed with cleansing solution (Dobell’s) and retained secretions removed.
The disfigurement resulting after this injury is dropping in at the root of the nose, constituting the so-called _saddle-nose_ defect. Such disfigurement as results can be later atoned for by subcutaneous injection of paraffin. (See chapter on Surgery of the Face.)
FRACTURES OF THE SUPERIOR MAXILLA, WITH OR WITHOUT OTHER BONES OF THE FACE.
The more protected portions of the upper jaw are rarely fractured, save by extreme violence. The _alveolar process_, with one or several teeth, may be partially or completely detached. Such fractures are compound, and after replacement need antiseptic mouth-washes as well as other attention. Usually the teeth in the fragment can be utilized for the purpose of fastening it back into place by means of the uninjured teeth, retention being secured by wire or waxed silk. Extensive detachment may necessitate sutures through drill holes. The lower jaw can usually be utilized as a splint for the upper by binding the jaws firmly together and feeding the patient on fluid food. When one or two teeth are loosened or displaced it will often be possible, if they can be promptly secured, to successfully _reimplant_ them in their sockets. Both the sockets and the teeth should be thoroughly cleansed. After replacement it will be necessary only to ensure absolute rest and retention in position.
In regard to other _facial bones_ there is no injury which may not occur, as the result of direct violence. The _zygoma_ and the _malar bone_ may be broken away, or the entire collection of facial bones may be loosened from their connection with the bones of the skull proper. The margins of the _orbit_, or its walls, may also be injured, and the sinuses opened, with perhaps more or less entrance of foreign material. These fractures are generally compound and are accompanied sometimes by injuries to the soft tissues. It becomes then a question not merely of cosmetic result, but of avoiding infection and saving life. The latter is the more important, and measures should first be directed to that object. Satisfactory results can be attained by drilling and holding bone fragments together with tendon or other sutures, and by neatly trimming and cleaning wounded surfaces and bringing them together. Subcutaneous sutures should be used for this purpose.
FRACTURES OF THE INFERIOR MAXILLA.
This bone is broken nearly as often as the nose, and almost invariably by direct violence. Here, as in the upper jaw, there may be trifling or serious fractures of the _alveolar process_, which should be treated on the same principle as above set forth. Fractures of the rami occur more often in those parts which are occupied by teeth, or from which teeth have dropped out by senile changes, the jaw being weakened at these locations. The most frequent seat of fracture is near the middle line. Fractures of the _ascending ramus_ and of the upper processes are rare. Double fractures are not infrequent, the lines of separation being rarely symmetrical. The gum and the skin are often torn and the majority of these fractures are compound. The bone is considered to be weakened at the dental foramen; at all events it often yields in this vicinity. By fracture with much displacement posterior to this opening the inferior dental nerve may be injured or torn. The condyle, after extreme violence, has been known to have been driven up into the cranial cavity through the base of the skull. _Gunshot fractures_ are nearly always comminuted (Figs. 281, 282 and 283).
[Illustration: FIG. 281
Use of silver wire in fixation of fragments by utilizing the teeth.]
[Illustration: FIG. 282
FIG. 283
Bandage and splint for fracture of lower jaw. (Bryant.)]
The _signs_ of fracture of the lower jaw are unnatural mobility, crepitus, displacement, pain, and loss of function. No bone in the body is more easily investigated by sight and touch, and recognition of these fractures is usually easy. Pain is provoked by attempting to move the jaw, even in talking, and depends on the extent to which the inferior dental nerve is injured. Irregularity in the line of the teeth will sometimes permit recognition. These fractures furnish excellent illustrations of the effect of muscles in producing displacement. Those of the tongue and the floor of the mouth, as well as the anterior muscles of the neck, will pull the fragments in various directions, according to the direction of the line of fracture and its location. This displacement may be trifling or serious. These fractures are often compound, internally or externally, such injuries constituting an unpleasant complication, but affording occasionally an opportunity for fastening fragments by drill or wire suture, which would otherwise require an opening to be made. In every instance antiseptic mouth-washes should be frequently used.
=Treatment.=--The treatment is simplified when the dentition is good and regular so that the fragments may be fastened together with wire or waxed silk ligature around the adjoining teeth, and then fixation accomplished with a simple molded gutta-percha or plaster-of-Paris splint, by which the lower jaw is held firmly against the upper. Such a dressing is held in position by a four-tailed bandage (Fig. 283). A silk or wire loop, used for the purpose just mentioned, should include two teeth on either side of the fracture, for by constant tension the nearest tooth will soon loosen, and if this were next to the break the effect of such displacement would be injurious (Fig. 281). When the line of fracture is oblique there is often greater difficulty in adjustment.
While the simplest means by which the fragments may be kept in position are the best, there should be no hesitation in serious cases to resort to operative measures having for their purpose the insertion of wire sutures or their equivalent. These are inserted after drilling the bone at suitable points, and are introduced with a view to their subsequent removal, the ends being left projecting in order to facilitate this. In clean cases, where the incision is made in unbroken skin, the ends may be twisted short and turned in, previously to closing the wound. Such operative treatment is required when there has been a double fracture, the central fragment being badly displaced by groups of muscles which tend to pull it downward and backward.
A dentist should be consulted, as he may be able to make a mold and then construct a plate or _interdental_ splint, by which a more perfect reposition may be effected.
Swelling, emphysema, ecchymosis, etc., may be treated in the usual way. Irritation is likely to provoke free secretion of saliva; this may be combated by small doses of belladonna. Patients should be fed by fluid or thin semifluid food, and mouth-washes should be frequently used.
FRACTURES OF THE HYOID BONE.
The hyoid may be broken by direct violence, either locally applied or by forcing the head backward. Fracture of the bone itself is not so serious as the lesions which accompany or follow it, either hemorrhage or inflammation, with _edema of the larynx_, which may impede respiration or cause strangulation. Fracture produces difficulty in breathing, swelling, and pain on talking. It is doubtful if bony union is attained, but fibrous union answers equally well. The treatment consists essentially of physiological rest. Edema may necessitate tracheotomy, and dysphagia feeding by an esophageal tube or by the rectum. Should the fracture be compound, or should a fragment be displaced so as to be detected, it may be removed through suitable incision.
FRACTURES OF THE LARYNX.
This may be fractured by injuries of the same character as those which fracture the hyoid, except that it is more exposed to the direct violence of a blow, as from a baseball. In elderly people in whom calcification of the laryngeal cartilages has occurred fracture is more dangerous than in the young. Injuries which produce these lesions are of a serious nature, as prompt swelling, either from hemorrhage or edema, occurs and threatens respiration. For illustration a death occurred on the baseball field within a few minutes after reception of a blow upon the front of the neck with laryngeal fracture; the cause of death was suffocation due to swelling, which might have been averted if tracheotomy could have been performed. In the milder injuries of this kind much can be done with sprays of cocaine and adrenalin, to quiet laryngeal irritation and reduce vascularity.
FRACTURES OF THE STERNUM AND RIBS.
Fracture of the _sternum_ in childhood is exceedingly rare. In adults it may occur in connection with other injuries or as a solitary lesion. Such a fracture, of itself, would indicate in most cases excessive violence. It is usually more or less transverse, the periosteum being rarely so torn as to permit of much escape of blood. Cases are recorded in which it has been broken in straining during the act of parturition. It is most commonly injured by compressing and crushing injuries.
Sternal fractures are followed by much pain, aggravated by deep respiration and made worse by pressure. Sometimes displacement can be made out, while crepitus may be detected with the stethoscope. Occasionally there is sufficient deformity to make the injury apparent at a glance.
Displacement should be reduced and apposition then maintained by a plaster-of-Paris jacket or other suitable apparatus. It is advisable in some cases to anesthetize the patient and to make a sufficient opening that instruments may be used by which fragments may be lifted or pried into place. This should be done under aseptic precautions.
_Diastases or separations of ribs or cartilages_ from the sternum or from each other have essentially the dignity of fractures, are recognized by the same general signs, and are treated in the same general way. A cartilage may snap in the young, and in the old, when calcified, may break as would a bone or even a pipe-stem.
_The ribs_ are usually broken in their lateral aspects, but rarely between the head and angle. They may be fractured by muscle action or by external violence, examples of the former being violent efforts at lifting or sneezing. Violence may be applied in so many ways that it is not necessary to specify them. Fractures may pertain to one or to several ribs in proportion to the extent and violence of the exciting injury. In some crushing injuries an entire section of the chest wall may be broken loose and depressed, this corresponding to a depressed fracture of the skull. Rib fractures are usually of themselves innocent, but may be made serious by _complications_, as when the pleura is torn, or an intercostal artery bleeds profusely, or when a jagged fragment of bone first scratches and then perforates a lung. This will lead first to the outpour of blood and then of pleuritic fluid, by which in a short time the lung will be separated from the chest wall. Should infection occur through the injured lung, _i. e._, entrance of germ-ladened air, then empyema may seriously complicate matters and later necessitate operation. Even the heart has been injured, in several reported cases, by projecting fragments of bone. Gunshot fractures of the thoracic wall imply those features pertaining to every compound fracture, plus the injury possibly done to the lungs, heart, or mediastinal contents, such as hemothorax or pneumothorax.
The first and second ribs are so protected and the eleventh and twelfth so movable that by far the greater proportion of rib fractures pertain to the eight intervening ribs.
=Symptoms.=--These are often vague, when but a single rib has been cracked through and not displaced, and comprise pain on pressure, as well as that provoked by deep breathing, coughing, and certain other movements. Should this pain be limited, or constant and made worse by pressure, fracture of the rib may be suspected. If auscultation crepitus can be heard, diagnosis is at once made. When abnormal mobility is unmistakable, or when by any means crepitus is elicited, the signs are positive. Sometimes the patient himself will recognize crepitus. This may be learned either by auscultation or by pressure with the flat hand over the affected area. _Emphysema_ is an unmistakable evidence of fracture with perforation, while the signs of the presence of fluid in the chest cavity will also indicate fracture.
=Treatment.=--Fracture of one or two ribs with displacement is ordinarily a matter of trivial import, the adjoining ribs acting as splints. It necessitates practically nothing but physiological rest, which may be best afforded by keeping the patient in bed, with _firm compression_ around the chest, made either with a binder of strong cloth or a broad piece of adhesive plaster carried nearly around the body, or in more aggravated cases by a plaster-of-Paris jacket. In thin individuals the formation of callus can be recognized by the sense of touch. So soon as this is fairly formed displacement is less likely to occur and uncomfortable compression may be relaxed. Should there be external angular displacement this may be corrected by pressure. A projecting fragment which threatens to perforate should be cut away with bone forceps through a small incision, taking pains to permit as little air as possible to enter. If there be a _traumatic pneumothorax_ the air should be removed with an aspirating needle. When it is evident that there is serious injury to the chest wall and that air has already separated the lung from it (traumatic atelectasis) the parts should be freely exposed, to permit the rounding off of bone ends, the seizure of intercostal vessels, the cleansing out of the pleural cavity, with perhaps later wiring of fragments or else their complete removal and closure of the external wound with or without drainage, as may be required. If blood or air has already escaped into the pleural cavity the blood should be speedily removed. The same plan is advisable in fractures of the cartilages. Sedatives to check cough, _e. g._, heroine, are also indicated.
FRACTURES OF THE CLAVICLE.
The clavicle and the radius are the two bones most frequently broken, the former more often in the young, the latter in the elderly; the clavicle yields both to direct violence, as by blows on the shoulder, and that which is transmitted through the arm from the elbow or hand. For convenience of description the bone is divided into thirds, the most common location for fracture being near the junction of the middle and outer third. Save for epiphyseal separations the extremities of the bone are seldom broken. In spite of its subcutaneous position and its proximity to large vessels, compound injuries or other complications are quite uncommon.
The clavicle is the brace which keeps the shoulder proper from falling upon and around the thorax. _Consequently when it is broken the shoulder tends to drop downward, forward, and inward_, except in a green-stick fracture, while even then there may be some displacement in these directions. Deformity is usually easily recognized, one or other fragment projecting beneath the skin in such a way as to be easily palpated. There is enough spasm of cervical muscles to draw the head over toward the affected side, while there is loss of function in the affected arm. Pain is made worse by pressing the shoulder inward as well as by moving it in any direction.
In young children the bone is often broken with a minimum of displacement. Fracture of both clavicles is not so very rare. Trouble may occur later in the course of the case from pressure of exuberant callus upon nerves and even vessels. This is to be prevented by foresight and by careful attention to maintenance of parts in proper position.
=Treatment.=--The multiplicity of dressings which have been suggested for fractures of the clavicle attest the fact that so long as primary indications are observed the treatment can be made very simple. These indications are to _keep the shoulder upward, outward, and backward_, as it tends to drop in the opposite way. The action of three muscles is of great importance in considering the proper treatment of these cases, _i. e._, the sternomastoid and the trapezius, because they tend to pull fragments upward, and the pectoralis major because advantage can be taken of its arrangement to overcome upward displacement. It was Moore, of Rochester, who taught many years in Buffalo, who showed how this could be done. The fibers of the great pectoral which arise highest, _i. e._, from the clavicle, are those which are inserted lowest along the bicipital groove of the humerus, because of the semi-revolution made by the tendon of this muscle as it passes to its insertion. By putting the arm in such a position that these fibers are pulled upon the operator may counteract the upward pull of the other muscles just mentioned. This is the underlying feature of Moore’s suggestion; to force the elbow far backward, into a position which is for the time being uncomfortable, in order thus to pull down fragments which jut up beneath the skin. Any dressing which permits this position to be maintained will be equally serviceable. Moore suggests for this purpose what he calls a double figure-of-eight, which is shown in Figs. 284 and 285. It is put on as follows: A strip of cloth, sheeting, or anything of the kind, about two yards in length and folded sufficiently to make a strong strip eight inches wide, is held near its middle over the surgeon’s hand. This hand is placed beneath the elbow of the injured side, so that the strip crosses the under surface of the flexed forearm at the elbow. One end, which should be the longer, lying to the inner side, is passed upward and in front of the arm, carried over the shoulder across the back and under the opposite axilla, then over in front of the sound shoulder, meeting on the back the other end, which is carried up first over the outside of the forearm, then behind the shoulder and across the spine. This bandage should be pulled tightly, while an assistant holds the elbow as far backward and upward as the patient can tolerate it, as the more the position is exaggerated the more are the clavicular fibers of the muscle pulled upon and the better are the fragments held in place. This dressing not only meets the three primary indications laid down, but gives the added advantage just described. By it the shoulders are drawn backward and fixed to each other. The _elbow should be lifted_ as the dressing is applied, so as to lift the shoulder. Most of the cloth materials used for such a dressing are more or less elastic, and it may need to be tightened once or twice a day during the time that it is worn. After a few days, when consolidation should have occurred, it may be changed for some other less irksome form of dressing. The hand should be supported in a sling. This dressing is useful in dislocations of the clavicle, especially of its outer end, and in every kind of injury in which the indication is to hold the shoulder upward and backward. In simple cases without much displacement the primary indications may be more simply met by a dressing of adhesive plaster, known in the East as Sayre’s and in the West as Freer’s. It consists of two strips of plaster of about the width of the arm itself. One of them is wound around the upper end of the arm, close to the shoulder, in such a way that, as it is passed around the back and brought over the chest, the arm and shoulder are pulled backward. The other strip passes from beneath the elbow of the injured side obliquely up and over the opposite shoulder. When it is applied the elbow should be _firmly lifted_. After the completion of either of these dressings the injured shoulder should appear at least one inch higher than the well one. Should the patient’s arm and chest be hairy they should be shaved before the application of the plaster strips. Like other material, plaster will stretch and slip, and these, like other dressings, should be readjusted every day or two, _for the shoulder should be kept elevated for at least a week_.
[Illustration: FIG. 284
Moore’s apparatus (back view).]
[Illustration: FIG. 285
Moore’s apparatus (front view).]
When the case is complicated by other injuries necessitating confinement in bed it is sufficient to keep the patient flat upon the back and without a pillow. In this position the shoulder falls naturally in the direction desired, and perhaps no other attention will be required. Many other methods are combined with a figure-of-eight bandage, crossing the back and forming a loop over each shoulder, so as to keep it from dropping forward.
While the results of treatment are nearly always good, if one is insistent upon a minimum of deformity, confinement upon the back on a hard bed is the surest way to obtain satisfactory results. Cases in which there is little or no tendency to deformity need only the simplest support by which rest may be ensured.
Epiphyseal separations are to be treated as fractures.
FRACTURES OF THE SCAPULA.
The most frequent fracture of the scapula is that of the _acromion_; this is usually the result of direct violence, such as a fall upon the tip of the shoulder. Detachment of this fragment permits a peculiar flattening of the shoulder, but without dislocation. The fragment can be easily felt, while the deltoid is displaced and its rounded contour lost. Treatment consists solely in _forcing the arm upward_, by dressings applied beneath the elbow, thus lifting the fragment into its place; fibrous union occurring here much more often than osseous, the latter is possible only in case a good apposition be maintained. Any form of dressing, then, by which the elbow is crowded upward and rest maintained will be appropriate.
The _surgical neck_ is occasionally detached, sometimes with and sometimes without the coracoid process. As the humerus is attached to it by the capsular ligament the arm drops with the fragment when the patient is in the upright position, and the elbow will be found lower than that of the injured side. The arm is unduly mobile, and the fragment can usually be seized and crepitus obtained within the axilla. Here it is necessary to hold the arm up, as it controls the position of the fragment. It is usually sufficient to lift the elbow up and bind the arm firmly to the side, the scapula being immobilized by broad straps of adhesive plaster.
The _coracoid process_ is occasionally detached, usually by muscular violence, _i. e._, it is pulled off by the coracobrachialis and the coracoid head of the biceps which arise from it. The injury is recognized by failure to detect the process in its proper place, and usually by discovery of the fragment at a point below its normal position, to which it has been drawn out by the muscles arising from it. Ligamentous union can be secured by relaxing these muscles, which is done by placing the hand over the opposite shoulder and dressing the arm firmly against the chest. I have seen paralysis of the arm result from excessive callus after fracture of the coracoid.
The _spine_, _body_, and the _angles_ of the scapula are occasionally broken by severe violence. In the aged comminution may occur. Crepitus can be nearly always obtained. It may be necessary to distinguish the scapular fracture from one of the ribs beneath it. The treatment consists in simply fixing the shoulder-blade upon the chest, to which it is naturally adapted, by firm bandages, which shall immobilize not only it but the arm as well.
FRACTURES OF THE HUMERUS.
At the _upper end_ of the humerus we deal with fracture of the processes, _i. e._, the _tuberosities_, which may be torn off by violent action of the muscles therein inserted; of the _anatomical neck_, which is rare and occurs most often in the aged; of the _surgical neck_, which is the most common; or, in the young, _epiphyseal separation_, which is the equivalent of the last named. Separation of the tuberosities is diagnosticated mainly by exclusion, possibly by _x_-rays. The _anatomical neck_ lies within the capsule, and should the head be thus detached it might remain as a foreign body in the joint, having no means of securing nutrition. Fractures of the _head of the bone_ are not classical and are usually the result of gunshot injuries or extreme violence. In all of these injuries there will be swelling, loss of function, while crepitus is sometimes obtained, but is very difficult to locate, even under an anesthetic. The diagnosis is to be made mostly by exclusion.
The _surgical neck_ is the most frequently broken; the line of fracture passing below the tuberosities and above the muscles inserted along the bicipital groove. Therefore the pectoralis and the latissimus muscles will both conspire to pull the upper end of the shaft toward the thorax to such an extent that it can be felt in the axilla. This gives its axis a different direction, while all the muscles extending from the shoulder to the forearm will tend to produce shortening. Deformity is usually distinct, crepitus is easily obtained, and undue mobility is well marked. The head of the bone can be detected in its proper place beneath the deltoid, but does not rotate with the shaft. In rare instances a certain amount of impaction may make this evidence of fracture obscure. _Epiphyseal separation_ will give the same signs and symptoms.
=Treatment.=--The primary indication here is to overcome muscle pull by traction in a direction toward the crest of the pelvis of the same side. At the same time, with a certain degree of coaxing of the upper end of the shaft outward and a little forward, it may be possible to so re-apply broken surfaces to each other, and so affix the arm to the thorax, as to be effective. When serious difficulty, however, is encountered the writer advises traction, applied to the arm alone, if the patient be able to be upright, or to the arm and forearm, if he be confined in bed. It will take considerable stretching to overcome the combined action of all the muscles which tend to produce displacement. Along with such treatment a coaptation splint should be applied, the best being that which can be carefully molded to the parts and adapted to their needs. For this purpose a molded plaster-of-Paris splint is preferable to one of metal made to some standard size. In the dressing it is necessary to include not only the shoulder and arm but also the forearm, otherwise the principle of physiological rest would not be enforced. Fig. 286 illustrates the common tendency to displacement in these injuries.
_Fracture_ of the surgical neck is occasionally combined with _dislocation_ of the head of the humerus, by which such an injury is seriously complicated. Reduction may be attempted by manipulation. Until recently it was generally advised to wait for a week or ten days, and until consolidation had occurred, and then to make the attempt at reduction; but Porter and McBurney have shown that it is advisable to cut down upon the dislocated upper fragment, and, fixing it with forceps or with an instrument shaped like a corkscrew or hook, to force it back into place again. If this be done under the strictest precautions it lends no serious features to the case, while, in most respects, such a procedure would greatly simplify it, the wound being closed with or without drainage, and the usual fracture dressing being applied.
In cases of _old fracture and dislocation_ the head of the bone should be exsected, the functional result thus obtained being excellent.
_Epiphyseal separation has been too often mistaken for dislocation._ Fig. 287, from Moore, shows how the periosteum is not necessarily entirely detached, but is stripped up to form a hinge, the fragment displaced forward, and its outer aspect often turned upward. This makes traction in an outward direction an essential feature of the replacement of the fractured surfaces, the manipulation being combined with fixation of the fragment so far as it can be seized through the axilla. If the epiphysis is properly slipped over upon the end of the humerus the case assumes ordinary features, and is to be dressed as usual.
[Illustration: FIG. 286
Fracture of the surgical neck of humerus. (Hoffa.)]
[Illustration: FIG. 287
Separation of the upper epiphysis of the humerus; displacement forward of the lower fragment. (Moore.)]
The shaft of the bone is frequently broken, lines of fracture running in all directions and occurring at all levels. A variety of displacement may take place. The evidences of fracture are usually recognizable and diagnosis is not difficult. The brachial artery and the musculospiral nerve are occasionally involved, either in callus or by primary injury from a spicule of bone. These fractures are more liable to delay in union or even to non-union than almost any others. These occur often without evident cause, while more or less absorption of bone has been known, by which complications are produced.
In the _treatment of fractures of the shaft_ posture is necessary to observe, the fragments not only being held in position, but the axis of the bone being maintained. An external splint, extending up to and rounded over the shoulder, and an internal splint molded to the inner side of the arm, taking in the elbow and forearm, and placed at a right angle, and then the immobilization of the entire arm by its fixation to the body will give the best result. The writer prefers to make these of plaster of Paris, by molding strips of surgeons’ lint sopped in plaster cream, and maintaining the limb in the desired position while they harden. Should comminution be extreme, or shortening difficult to overcome, a few days’ confinement in bed, with traction upon the forearm, either extended or included in the above dressing, by the usual method, with weight and pulley, will give the best result. So soon as callus has bound the ends of the bone together the patient may be released from bed and the arm left in the right-angle position, in plaster, as above. Or over such a splint as has been described, made of molded plaster, may be hung by a bandage at the elbow sufficient weight (a bag containing shot) to maintain constant traction upon the lower fragment, while the patient is in the upright position, and to influence for good any overlapping or displacement of any kind during the critical period when the bone ends are being united by callus.
The _epicondyles_ are occasionally chipped off from the condyles, the internal being the more frequently injured. These detachments are extra-articular and are relatively unimportant, the fragments being kept from displacement by their fibrous investments. If such an injury should be compound any fragment completely loosened should be removed. It is sufficient to dress such an injured elbow with cold wet compresses in the flexed position. _Supracondyloid_ fracture, or its equivalent in the young (an _epiphyseal separation_) are somewhat similar, the latter occurring nearer to the articulation than the former. In each of these injuries the arm is flexed and shortened, the fragment lying usually in front of the shaft and the olecranon protruding posteriorly. The more the arm is extended the more prominent the deformity, while by flexion it is much diminished. Hence the advantage of dressing it in the position of overflexion sometimes called Jones’ position.[39] Injury to the vessels at the bend of the elbow may occur in these fractures. If not dressed in this position the elbow should be put at a right angle, while a weight is slung over the elbow, as already mentioned above. Joint function will be greatly hampered if complete extension and reduction be not effected (Fig. 288).
[39] In supracondyloid fractures there is almost always posterior and upper displacement of the lower fragment. When the parts are found in this position, and especially when the skiagram shows the line of fracture in the usual location (from above downward and forward), the fracture should be treated by flexion of the arm in the so-called Jones’ position. By this the fragment is best restored to its proper position, being pried there by the muscular cushions of the forearm and arm. (Ashhurst.)
[Illustration: FIG. 288
Supracondyloid fracture or epiphyseal separation. (Lejars.)]
In considering fractures about the elbow no greater aid can be obtained than by a study of the relations of the three prominent or salient anatomical points to each other. These are the internal and external condyles and the tip of the olecranon. They afford a key to nearly all the displacements which may be produced after fracture or even dislocation, and the only conditions under which they cannot be made available are those where there has been tremendous swelling before the case is seen by the surgeon. A fourth prominent feature, the head of the radius, is also of much assistance, but is less often available, especially in muscular or swollen forearms. When a normal arm is flexed to a right angle and viewed from behind the three points above mentioned constitute the angles of a nearly equilateral triangle. When seen from the side the point of the olecranon is just below the external condyle and in the same plane; when the arm is completely extended and viewed from behind these three points are practically in the same line. By a careful study of the variations from the above relations which are produced by injury diagnosis can be greatly facilitated.
[Illustration: FIG. 289
T-fracture of humerus. (Helferich.)]
[Illustration: FIG. 290
T-shaped fracture of lower epiphysis of humerus.]
[Illustration: FIG. 291
Intracondyloid fracture of humerus. Almost perfect functional result. (Parmenter.)]
[Illustration: FIG. 292
Gunstock deformity after fracture of internal condyle, illustrating neglect of precautions mentioned in text. (Beatson.)]
The _condyles_ may each be broken loose by itself, or they may be _both broken_ at the same time. Fig. 291 illustrates what is known sometimes as a T-fracture, where the lower extremity is not only separated from the shaft but is broken into halves; such fractures imply great violence, and are particularly difficult to treat. Should the condyles be detached in such a way as to leave the lower end of the humerus in pointed wedge shape it may perforate or do much harm to the soft parts (Fig. 290). In these _intercondyloid_ fractures the writer would advise dressing in the extended position, with a molded plaster-of-Paris anterior splint and a gentle degree of traction, the patient being confined to bed for a few days. In applying such a splint the surgeon should give extreme care to holding the fragments in proper position while the splint hardens, and in preserving the “carrying function” (Fig. 291). (See below.)
[Illustration: PLATE XXXIX
Supracondyloid Fracture. (Child, nine years old.) Union with deformity, fragment so joined to lower end of shaft of humerus at an angle that when forearm is completely flexed upon this fragment it yet is only at right angle with the arm. Operation indicated. (X-ray picture.)]
The _external condyle_ when fractured is displaced by muscle pull; when the _internal condyle_ is broken the tendency is to backward displacement of the fragment and widening of the joint.
_Fracture of the internal condyle_ is often an exceedingly serious matter, because it is so often associated with more or less dislocation and with permanent deformity, as a result of inattention to the anatomical relations of the bones. The ulna sustains peculiar relations to the inner condyle; at its upper end it is wrapped around the process, holding it much as a monkey-wrench can be made to seize an ordinary object, and being held to it by the internal lateral ligament. Herein lies the secret of success or failure in treatment, for the fragment, being so fixed to the ulna, should be controlled by it, _i. e._, the position of the ulna is the most essential feature of the treatment of the fracture. The forearm makes an angle with the arm proper, by which a considerable degree of divergence is maintained. This has been alluded to by Allis and others as the “carrying function.” It can _only be estimated in the extended position, and be accurately judged by comparison with the other arm._ If the arm be flexed all possibility of estimating it is lost; therefore to _dress such a fracture in the right-angle position is bad practice_ (Fig. 292). The only position in which the carrying function can be preserved is the extended, or one a little short of it for the purpose of comfort. If the ulna is put in the proper position the fragment will be held equally so or as nearly as possible (Fig. 294).
[Illustration: FIG. 293
Fracture of external condyle. (Lejars.)]
In the _treatment of fractures of the inner condyle_ the patient, if a child, should be anesthetized, the upper part of the body exposed, both arms extended, and the injured arm made to correspond exactly with the other so far as concerns the angle of divergence. Upon the arm so placed an anterior plaster-of-Paris molded splint should be carefully applied, extending from axilla to wrist, and then lightly secured with bandages, the surgeon holding the arm in the proper position _until the plaster is sufficiently hardened to permit no displacement._ The arm should be kept in this position for at least ten days, after which the splint may be removed and gentle motion practised. It may then be reapplied for two or three days, after which we may begin to flex the arm, applying either a new plaster splint or any other that seems suitable, and in such a way that at the expiration of another week the forearm is brought to a comfortable position of right angle, where it may be maintained with a light splint or simply with a sling, according to the age and tractability of the patient. Fig. 294 illustrates the splint and the position, which is the only one in which the surgeon maintains his own security and can properly estimate the carrying function. The mistake has been in dressing this fracture, like most others at the elbow, in the right-angle position.
In _fractures of the outer condyle_ these anatomical conditions do not prevail, and these may be dressed in whatever position best meets the indications of comfort and accurate reduction. _Intercondyloid fractures_ are subject to the same conditions as those of the _internal condyle_, plus others which are added, and should therefore be dressed in the _same position_.
[Illustration: FIG. 294
Molded plaster splint for entire arm, and especially for fractures of the internal condyle, showing proper position for dressing same.]
_Epiphyseal separations_, as well as supracondyloid fractures, should be dressed either with traction in a somewhat extended position, or in that of extreme flexion, called also Jones’ position, according as the fragments may best fall into place in one or the other.
[Illustration: FIG. 295
Molded plaster splint for arm.]
[Illustration: FIG. 296
Molded plaster splint for forearm.]
The writer has for his own purposes discarded almost all other splint material for the upper extremity in favor of the plaster-of-Paris splints already mentioned. Figs. 294, 295 and 296, may illustrate the method and purpose of their use; many other modifications can be devised as may be demanded. It is customary, after such a splint is hard and firm, to remove it for a few moments, trim it, smooth the edges, line it with a fresh piece of soft lint or its equivalent, and then reapply it to the arm with a roller or starch bandage, the arm meantime not having been disturbed, but maintained in its proper position, and being restored to the splint and made to take its previous position. Such a splint fits accurately the individual for whom it is made. It is worthless for anyone else; nor should it ever be used again, the _intent being to mold a splint for each case which shall serve its individual purpose and none other_.
Too early passive motion with the intent to regain mobility is inadvisable and often dangerous. A fractured joint should be kept at rest until the bone is consolidated. If callus be thus reduced to the minimum, and consolidation be undisturbed, the patient will, in due time, recover motion, often to the extreme limit. In fractures of the humerus five or six weeks are required for the attainment of perfect union. In spite of precaution callus formation will sometimes be excessive and interfere with motion. Absorption of exuberant material then is most desirable. This can be encouraged by constant but gentle pressure. Thus when callus in front of the lower articular surface of the humerus obstructs the coronoid process of the ulna and prevents complete flexion the patient should wear for several hours at a time an elastic sling, made with a piece of Martin rubber bandage sufficiently long to make a loop around the neck, into which the hand is passed. It should be made so tight as to exert gentle but constant pressure; the result of this will be to cause rapid disappearance of the callus upon which it is made. Conditions may be reversed when necessary, and the patient may have some weight affixed to the hand by which, when the arm hangs down, reversed pressure shall be made, or when desirable these measures may be alternated. One should not, however, be tempted into resorting to them too early, since much is done, even in unfavorable cases, by purely natural processes, this being especially true of children who are growing rapidly.
FRACTURES OF THE FOREARM; THE ULNA.
At the upper end of the _ulna_ the most frequent fracture is that of the _olecranon_, whose separation by direct or indirect violence corresponds to fracture of the patella. The fragment is pulled upward along the back of the arm by the triceps muscle, and the power of extension is almost lost. There is rarely any difficulty in diagnosis, except in conditions of extreme swelling, which of itself would be suspicious, as under hardly any other circumstances could a joint be so distended (Figs. 297 and 298).
[Illustration: FIG. 297
Fracture of olecranon. (Erichsen.)]
[Illustration: FIG. 298
Fracture of ulna, upper end. (Lejars.)]
[Illustration: FIG. 299
Fracture of olecranon with fibrous union. (Park.)]
=Treatment.=--The difficulty here, in _treatment_, consists in the necessity for counteracting the pull of the triceps. The arm first of all should be dressed in the _extended position_. Sometimes it is possible, by partly encircling the posterior surface of the arm just above the fragment with a strong piece of adhesive plaster, to which is attached some rubber tubing, to make a constant elastic pull upon the fragment, the tubes being brought down and attached to the sides of the anterior splint below the elbow. In the absence of swelling this can often be made quite effective. So long as much fluid is present no means will be efficient. It may, therefore, be well to wait two or three days until the fluid has disappeared, aspirating the joint if necessary. In young and otherwise healthy subjects there is strong reason for advising _operation_, as only by absolutely approximating the fragment to the main bone and maintaining it in position can bony union be secured. In properly selected cases, and when performed with every precaution, this measure frequently gives ideal results. A short ligamentous union is represented in Fig. 299. At other times the fibrous band will stretch out to an inch or more, not completely disabling the arm but weakening it. The extended position may be relaxed within a week after operation, but not for at least two weeks after other treatment. Passive motion should not be begun too early in the latter cases.
Fracture of the _coracoid process_ is often combined with _backward dislocation of the forearm_, which is no doubt an incident of the injury or may occur later by mere muscle pull. The brachialis anticus, which is inserted into it, will pull the fragment up against the anterior surface of the humerus. This fracture should be dressed in the right-angle position, in order to relax the muscle, taking care to prevent backward displacement, while ligamentous union is ordinarily all that can be hoped for.
The _ulnar shaft_ may be broken at almost any point, usually as a result of direct violence. As it is weaker in its lower half the greater number of fractures occur here. Fracture of the shaft is easily recognized, crepitus being always obtained, unless muscle tissue has intervened, this being a condition which will occasionally prevent bony union. If it can be established by _x_-rays that bony surfaces are not in contact and cannot be so placed, it is advisable to cut down upon the site of the fracture, remove the obstacle, and fasten the fragments together. So long as one bone is broken in the forearm the other may be relied on to act as a more or less efficient splint. There is but one position in which any of these fractures can be dressed with safety, that is _midway between pronation and supination_, _i. e._, with the thumb pointing toward the patient’s face. Splints used for this purpose should always be wider than the forearm itself, lest by pressure the ends be forced toward the other bone. Some hold that by gentle pressure along the line between the bones, as by a narrow pad or splint, the muscles may be made to press the injured bone away from the other; nevertheless only moderate pressure can be tolerated for this uncertain purpose. It has been generally customary to use two light wooden splints, one along the palmar, the other along the dorsal surface of the forearm, padding them properly and securing them in position by strips of adhesive plaster and suitable bandages. The same plaster-molded splints mentioned above can, however, be made just as effective for this purpose, if properly applied.
When either bone is broken near the wrist, and especially when both are broken, we have to combat the tendency of the pronator quadratus, which tends to pull the lower fragments together.
The _styloid_ process is occasionally detached, as in violent sprains, or broken off in connection with other injuries. Inasmuch as it carries the upper end of the internal lateral ligament its detachment can be quickly recognized by the abnormal freedom of motion which such an injury would permit.
[Illustration: FIG. 300
Obliteration of the interosseous space in a fracture of the forearm.]
FRACTURES OF THE RADIUS.
The radius vies in frequency of fracture with the clavicle. The _head_ is seldom broken, its fracture being most likely when the shaft is driven against the humerus by falls upon the open hand. The _neck_ is more frequently broken in children than in adults. These fractures have sometimes to be determined by a process of exclusion or by the use of the _x_-rays. In muscular forearms they lie so deeply that it is not always possible to recognize them. Ordinarily, however, if the head of the bone can be found to remain stationary while the rest of the bone is being rotated, and if, at the same time, crepitus be felt, the matter may be regarded as settled. So far as the _shaft_ of the radius is concerned the remarks made above regarding the ulna mostly hold true for its fellow-bone. When the neck of the bone is broken the shaft will be pulled upward by the biceps tendon, while when the shaft is broken below its insertion the upper fragment is displaced by it. In either of these cases, then, the forearm should be dressed at a right angle with the arm in order to relax the muscle. The supinator brevis and the pronator radii teres should also not be neglected, for the former will tend to rotate and the latter to more or less displace the upper portion of a shaft broken high up. With a fracture near the upper end, in a powerfully muscular arm, diagnosis is not always easy. Fractures in the lower portion of the shaft are to be treated like those of the ulna. But those high up should be dressed with the elbow at a right angle and the forearm supinated. A plaster-of-Paris molded splint here can be adapted to the needs of every individual case if the surgeon will give minute care _at the time of its hardening_ to placing the parts just as he desires them to remain.
FRACTURES OF BOTH BONES OF THE FOREARM.
These are not uncommon, though much less frequent than injuries to either bone alone. They may occur at the same level or be quite widely separated. The loss of function is complete in these instances, while deformity will depend largely upon whether the fractures lie near together or not. It is of the greatest importance to remember, in these cases, that the mass of muscles around the upper fragments tends to crowd them together, while the lower fragments are brought together especially by the pronator quadratus. Everything then conspires to convergence of the four fragments, a tendency which it is sometimes difficult to combat. Every large museum contains specimens showing a common callus, in which all four bone ends are involved, and illustrating the permanent loss of rotation that ensues. This is to be combated, not alone by rest, which tends to limit callus formation, but by _position with the arm midway between pronation and supination_, in which the bones are naturally farthest separated, and by _splints_ applied with such gentle pressure as may hold the bones apart. This pressure should be applied between the dorsal and palmar surfaces, while the lateral aspects of the forearm should be kept absolutely free from it (Figs. 300 and 301).
[Illustration: FIG. 301
Fracture of both bones near lower extremity. (Lejars.)]
It is a serious matter to dress any of these injuries with moistened pasteboard, or other material which does not take its desired shape and strength promptly, for no matter how carefully the desired position may be enforced at first the very nature of a material which remains too long plastic will permit the loss of all that should be maintained. The writer has seen malpractice suits instituted and men forced out of the State by inattention to this precaution.
FRACTURE OF THE LOWER END OF THE RADIUS; COLLES’ FRACTURE.
This is perhaps one of the commonest fractures in the body, occurring at all ages; when seen in growing children it is to be regarded as an epiphyseal separation rather than as a distinct fracture. It derives its name from the fact that until Colles, a Dublin surgeon, over one hundred years ago, described this injury as a fracture it had been always regarded as a peculiar dislocation at the wrist. It is produced by falls upon the hand in the hyperextended position, the force being usually transmitted through the carpus to the radial end. The name is usually limited to those fractures which occur within one and a quarter inches of the articular surface (Fig. 303). Here the structure of the bone is cancellous and impaction may easily occur, this being a decided feature in many of these accidents, and making replacement more difficult. The deformity which results from the fracture is characteristic and more or less uniform. This is called the “silver-fork appearance,” the lower fragment being so displaced, and usually more or less tilted, as to raise the tendons and the structures on the back of the wrist; at the same time it is usually drawn toward the radial side. The more the fragment is impacted or driven into the shaft of the bone the less easily is crepitus elicited.
The fracture is more common than is supposed, and there is no doubt but that many alleged sprains of the wrist illustrate cracks in the bone without displacement, which, nevertheless, are slow to heal and are sometimes followed by thickening and impairment of function. (See Plate XL.)
Along with the radial fracture separation of the _styloid process_ of the ulna may also occur, or, as Moore has shown, the process itself may perforate the internal lateral ligament so as to protrude through the skin; and the surgeon has occasionally to withdraw the styloid from the ligament which has been impaled upon it. The radio-ulnar ligament is also frequently injured, and this permits the ulna to become more prominent than normal. If the styloid has perforated the skin it lends a compound feature to the case. The interarticular fibrocartilage may also be displaced.
=Treatment.=--The secret of obtaining a good result and the explanation for failures lie in the completeness or incompleteness of the reduction of the fragment. If the latter be _absolutely and accurately replaced_ it makes but little difference what dressing is applied. On the other hand any fragment not completely restored will lead to subsequent deformity and impairment of function. _Successful reduction, then, is the keynote to success_, and should be accomplished at any reasonable cost. Sometimes it is not difficult, and then no anesthetic is required; sometimes it is extremely difficult, and the operator has to exert all the strength he has in his arms, aided by profound anesthesia. Moderate cases can usually be dealt with successfully under nitrous oxide gas. The surgeon grasps the hand as if to shake hands, _i. e._, with his corresponding hand, the elbow being firmly held by an assistant. Traction is then made upon the hand to which the fragment is affixed, while with his other hand the operator makes such pressure, rotation, or coaxing manipulation with his thumb and fingers as may assist in restoring the fragment to its place. With whatever other effort may be made traction should be combined. Forcible swaying movements, combined with hyperextension, may be necessary to dislodge an impacted fragment. Any degree of force is preferable to failure in this respect. Perfect reduction is the key of success; without it, no dressing is efficient; with it, almost anything will suffice.
[Illustration: FIG. 302
Comminuted but not compound fracture of wrist. (Beatson.)]
Reduction once accomplished it is usually an easy matter to hold the arm in position. The writer prefers above all other means a molded plaster-of-Paris splint, which should extend from the line of the knuckles upon the palmar surface well up toward the elbow. It should be fitted neatly to the hand and forearm, bandaged comfortably upon it, while as it solidifies the surgeon should hold the hand slightly flexed to the ulnar side as well as anteriorly. When the splint is hardened and bandaged a simple sling will suffice. The hand should be dressed with the thumb pointing toward the face, while upon the back of the wrist an ice-bag can be applied. Ecchymosis is sometimes extreme; I have seen it extend even to the shoulder after an apparently simple break (Figs. 304 and 305).
[Illustration: PLATE XL
Skiagram of a Fracture of the Lower End of the Radius. (Wharton.)]
I have not described other splints for dressings, at this point, for two reasons: the dressing given above is ample and sufficient for all cases, and, aside from it, the number of splints and methods devised is so large as to be confusing. It is much better to know one method well than to have a slight working acquaintance with several.
[Illustration: FIG. 303
Colles’ fracture. (Anger.)]
[Illustration: FIG. 304
FIG. 305
Deformity from faulty union following fracture of wrist. Buffalo Clinic. (Skiagrams by Dr. Plummer.)]
While Colles’ fracture is far more frequent than all other fractures about the wrist, it is possible to have less-known forms with different displacements; thus a fracture the reverse of Colles’ has been described by Barton and by R. W. Smith, being occasionally produced by falls upon the back of the hand instead of upon the palmar surface. Figs. 306 and 307, from photographs given me by Dr. Beatson, of Glasgow, illustrate both the clinical picture and the actual condition of the bones. Of all these fractures it may be said that accurate reposition, as in the case of Colles’ fracture, is the key to success. Once the fragments are reduced the same plaster-of-Paris molded splints will answer for these as for the others.
[Illustration: FIG. 306
A Barton or Smith fracture at wrist. (Beatson.)]
[Illustration: FIG. 307
Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case represented in Fig. 306.)]
BENNETT’S FRACTURE.
When considerable force is applied to the distal end of the first metacarpal, as in striking with the clenched fist, or, as in a fall upon the outstretched thumb, the first metacarpal is often fractured transversely at its neck or longitudinally, its interior basal projection being broken off, both injuries being often associated. This is a condition lately proved by Russ, of San Francisco, to be more common than has been generally supposed. It was first described by Bennett, of Dublin, in 1885, and is known as Bennett’s fracture of the thumb. Its peculiar features can be best seen in a radiograph. It produces much pain and swelling of the hand, with tenderness, especially at the base of the bone involved, _i. e._, at the root of the thumb. There may be more or less displacement of fragments. The injured thumb should be treated by traction and with such coaptation splints as may be extemporized or prepared for the purpose, in the position of abduction. If accurate coaptation and sufficient traction be made to overcome both deformity and muscle spasm the result obtained will be satisfactory. Otherwise more or less loss of function and local tenderness may long persist.
[Illustration: PLATE XLI
Skiagram of Fracture of the Proximal Phalanx of the Ring Finger. (Wharton.)]
FRACTURES OF THE WRIST AND HAND.
Fractures of the carpal bones seldom occur, except when the parts have been crushed. The _scaphoid_ is, however, broken much more often, and doubtless many cases of so-called severe sprain include this injury. The use of the _x_-rays has done more to teach the relative frequency of carpal fractures than was ever previously appreciated. The scaphoid ossifies by two centres, which do not appear until the eighth year. When the bone has been thus cracked the usual signs of sprain are present, which subside and leave a tender wrist and hand whose fingers can be normally moved, but whose wrist movements are reduced one-half, while attempts at motion beyond these limits produce great muscle spasm and pain. Codman and Chase[40] have shown that the sheaths of the radial extensor tendons are in close relation to the periosteum of the bone at this point, as well as to that of the radius, so that by injury here blood may escape into the sheath without appearing at other parts; the result being a tense, fluctuating, triangular swelling over the radial half of the wrist, the blood being effused so deeply as not to discolor, or at least not at first. They regard the presence of such an engorged bursa as diagnostic of fracture either of the radius or the scaphoid.
[40] Annals of Surgery, March, 1905.
While carpal fractures call ordinarily for treatment by absolute rest, Codman and Chase have advised removal of any loose fragment, especially of the scaphoid, by incision along the back of the wrist just to the inner side of the long radial extensor. The annular ligament is to be divided between it and the long extensors of the fingers, and without opening tendon sheaths; inasmuch as this ligament does not retract when divided its borders must be held apart. In this way the joint may be completely exposed over the proximal half of the scaphoid. The line of fracture being made out, a blunt hook is introduced into the fissure and the fragment elevated, loosened by a tenotome, and removed, its removal seeming nowise to interfere with the function of the whole bone or the usefulness of the wrist.
The _metacarpal bones_ are frequently broken, usually as the result of violence, the distal portions suffering more than the proximal. The diagnosis is best made with the fingers closed, when any lack of symmetry in the row of knuckles may be seen or any protrusion of a fragment noted. Here the _x_-rays are useful. Such injury should be treated by placing the hand upon a palmar splint extending well up the forearm and maintaining rest by suitable pressure, with or without traction upon the finger of the bone involved. For this purpose adhesive plaster may be passed up and down the finger and attached to an elastic band which is fixed to the end of the splint.
The same is true of fractures of the _phalanges_, which are often made compound by the injury. Here the danger is not so much to the bone as to the tendon sheaths or thecæ, along which infection may easily spread. Widespread and prolonged suppuration might disable a hand thus injured unless properly and promptly dressed. Ordinarily adjoining fingers can be utilized for splints, and if the outstretched hand be fastened upon a palmar splint and the injured finger kept in position by its neighbors a good result can generally be obtained. Occasionally distinct splints for one or more fingers are required, and occasionally also the suggestion made above with regard to traction may need to be enforced.
FRACTURES OF THE PELVIS.
Fracture of the pelvis may be serious not only in and of itself but because of frequently accompanying injuries to the various pelvic viscera. Save in the possible separations that may occur during parturition it is always the result of direct violence. Such injuries are usually divided into fractures of the _pelvic girdle_ and those of the more exposed prominences, such as the _iliac crest_, the _ischiac tuberosity_, the _coccyx_, etc. Lines of fracture may run at any point, although it is at the synchondrosis that the pelvis is usually broken loose from the sacrum. As in the skull and the lower jaw double fractures or even comminutions may occur. The same considerations concerning the transmission of serious violence may account for some of the vagaries seen in these cases. The _sacrum_ is usually broken as the result of great violence. The pelvic girdle is perhaps weakest opposite the joints and in the neighborhood of the pubis. Here there may be a separation of the symphysis, but the break usually occurs a little to one side of the middle line. In rare instances the head of the femur has been forced through the acetabulum (Fig. 308).
In a general way fractures of the pelvic girdle can be recognized not merely by local evidences of injury and shock, but by the resulting more or less complete loss of function; patients will be disabled in proportion to the violence and extent of the injury. The more unilateral the symptoms the easier it is to localize the site of the injury. Mobility can often be detected upon examination, sometimes crepitus. This is essentially true of fractures of the pubis. Occasionally combined manipulation, with a finger in the rectum or vagina, will permit more accurate localization of the injury. When the crest of the pelvis is fractured, or any of the parts to which the abdominal muscles are inserted, then the patient will be still further disabled in movements of the lower part of the body, while by palpation the fracture is sometimes easily determined.
Not the least serious features of these injuries are those which pertain to the viscera. These include not only the ordinary results of abdominal contusions which may produce all sorts of harm, for example, ruptures of the kidneys, spleen, or liver, but also more localized lesions, such as ruptures of the rectum, bladder, or urethra, or even the pelvic connective tissue. If the urinary passages be torn there is always opportunity for urinary infiltration and infection. The same is true of the rectum so far as possibility of infection is concerned. Therefore one of the earliest maneuvers in dealing with such a case should be the passage of a catheter, to determine if the urine be bloody or the urethra obstructed. In such a case, in the male at least, it will usually be wise to make a perineal section and to open widely and then drain the bladder. In not a few of these instances the laceration takes place internally, and a pelvic crushing injury, which is followed by collapse and abdominal rigidity, without satisfactory explanation as above, should be _promptly explored_ by abdominal section, the danger of doing it being considerably less than the risk of leaving it undone.
[Illustration: FIG. 308
Fracture of pelvis. (Mudd.)]
[Illustration: FIG. 309
Great deformity after multiple fracture of femur, with synostosis. (From the Buffalo Museum.)]
Some of these fractures are conspicuously _compound_, and the treatment for the external wound will permit of more careful exploration of the bone injury, as well perhaps as the insertion of wire sutures or other means of fixation.
Fig. 309 illustrates a serious complication that ensued in one case after multiple fractures of the pelvis and hip, with synostosis at the hip, as well as extensive deformity following fracture of the shaft of the femur.
=Treatment.=--Treatment of pelvic fractures should comprise, first, absolute rest. This means not merely confinement in bed, with traction applied to one or both limbs, but probably fixation of the pelvis and perhaps the thighs, either in a compressing bandage or in a plaster-of-Paris double spica, the pelvic jacket running as high as may be necessary upon the trunk of the body. Cases which seem to permit of operation and suturing are entitled to it, but they will constitute but a small proportion of the total. While patients are so rigidly confined provision should be made for free elimination, and possibly conveniences provided for receiving the evacuations without possibility of infection. Recovery is in many instances complete; occasionally it occurs with considerable displacement. If the viscera escape injury much may be expected in the way of repair of the bones under suitable treatment.
The _margin of the acetabulum_ is occasionally chipped off, sometimes by itself, sometimes as a complication of dislocation of the hip. The posterior margin of the brim is the part which usually suffers. Diagnosis should be made by the ease with which such a dislocation recurs after manual reduction. Sufficient traction to keep the limb from displacing the fragment, and snug bandaging with pressure, especially around the injured hip and above the trochanter, is indicated in such cases.
The _coccyx_ and even the lower portion of the _sacrum_ are occasionally broken loose, either by external violence or during parturition. Here the fragment is drawn forward by the levator ani, displacement is marked, and pain and soreness are great. Should there be doubt as to the nature of the injury, combined manipulation, with a finger in the rectum, will make diagnosis positive. Fibrous union is about all that can be expected in either of these cases. The fragment may be justifiably removed at any time.
FRACTURES OF THE THIGH.
Fractures at the upper end of the thigh are more common than those at the lower. At the upper end there may be fractures of the _head_, of the _neck_, those which pass _between the trochanters_, and _epiphyseal separations_. All of these are rare except those of the neck.
Fractures of the _neck of the femur_ occur most commonly in those who have passed the fiftieth year of life. They occur, however, during the middle period and even in children, and, as Whitman has shown, are by no means so rare in the young as was until recently supposed.
The shape and structure of this portion of the bone, and the peculiar changes which occur with advancing years, constitute the explanation for the frequency of this injury in late life. As the jaw begins to change in shape, and the teeth to drop out, there occur also unseen changes within the cancellous structure of the head and neck of the femur by which the strength of the latter is materially reduced. It is still further weakened by the change in shape which the bone also undergoes as it loses its obtuse angle and becomes set more at a right angle with the shaft. The reduced ability to resist strain produced by these changes is remarkable, and accounts for the ease with which fractures occur, even from so apparently trivial an accident as tripping on the floor. With all the violence directly transmitted there is usually present an element of twist or torsion by which fracture is still further favored.
As between so-called _intracapsular_ and _extracapsular_ fractures surgeons have made distinctions to which unnecessary importance has been attached. Anteriorly the capsule is attached to the intertrochanteric line, while posteriorly it does not extend nearly so far outward; it can thus be seen that many fractures are partly intracapsular and partly extracapsular. These lines vary in different individuals, especially that of the posterior insertion; it is not usually possible to make minute distinctions of this kind. The principal importance which attaches to them is in the direction of prognosis, for if the fragment be absolutely intracapsular it can derive its blood supply only through the ligamentum teres, which is, to say the least, a precarious method of existence and usually disappointing. In general it may be assumed that a fracture close to the head is intracapsular, but that when it occurs well out toward the shaft it may partake of both characters. In this connection the _x_-rays will afford, usually, more satisfactory information than can be obtained by even extensive or rude manipulation.
_Impaction_ occurs with considerable frequency in these cases, and, unless accompanied by too much deformity or displacement, is rather a fortunate occurrence, since by it is afforded an automatic splint which it should be the surgeon’s endeavor to not break apart. There can be no doubt, moreover, but that trifling degrees of impaction with incomplete fracture occur, especially in the aged, in many injuries to the hip. It would be the greatest misfortune to the patient in one of these cases to complete the separation, and when assured of the existence of such a lesion it is best to treat the case as though it were a fracture. I am sure that many cases which have gone into court have been due to incomplete fractures with impaction, where there has been later absorption of bone, by which the femoral neck has been much shortened, so that recognizable deformity as well as more or less disability have resulted. Other changes comprised among those already described in the chapter on Joints, under the section on Arthritis Deformans, may also occur. Callus which has been at one time abundant may also undergo too great absorption.
[Illustration: FIG. 310
Sections of impacted extracapsular fractures of neck of femur, showing the degree of impaction and of splintering in different cases. (Erichsen.)]
[Illustration: FIG. 311
Extracapsular fracture of thigh.]
Fig. 311 illustrates extracapsular fracture and comminution. Figs. 312 and 313, also from specimens in the author’s collection, show some of the changes described above, including impaction, displacement, and some osteophytic outgrowth.
[Illustration: FIG. 312
FIG. 313
Impacted fractures of necks of femurs.]
_Signs of fracture of the neck of the femur_ of special import are _history of injury_, _pain_, _loss of function_, _shortening_, _rotary displacement_, usually eversion, _crepitus_, _relaxation of the fascia lata_, and _disarrangement of the lines of triangulation_ between the bony prominences of the pelvis and the trochanter. Diagnosis should be attempted with as little manipulation as possible lest impaction be dislodged. The patient should be placed upon a comfortably hard surface. Anesthesia will sometimes afford important aid. It should be ascertained, first, that there had been no previous injury which could produce shortening. If, then, _shortening_ be apparent it is of itself almost a diagnostic sign. Such a limb is practically helpless, and unless the neck be so driven in upon itself as to produce impaction the foot will be usually everted, while the tension of the fascia lata will be relaxed and there will be fulness in Scarpa’s triangle. Absolute inability to use the limb implies fracture without impaction. Should the patient have been able to help himself or work after the injury, impaction may be safely assumed. The parts are exceedingly tender and pain is easily produced. Shortening is to be assumed only after placing the limbs and body in a _perfectly symmetrical position_ (the pelvis being at right angle with the spine), after which the measurement most usually made is from the anterior superior spine to the internal malleolus. _Nélaton’s line_ is the shortest line which can be made to pass around the hip, in one plane, from the anterior superior spine to the tuberosity of the ischium. While the line is curved it should lie in the same plane. Normally this passes just over the great trochanter. If there be real shortening the trochanter should rise above this line to an extent corresponding with the shortening made out by other measurements. Still another method of measurement is to hold a straight edge opposite to the superior spine and perpendicular to the surface upon which the patient is lying; the distance between this edge and the great trochanter should be as much less than the distance found by similar measurement on the other side as the amount of shortening measured by the other methods. This is the easiest way to measure the lines included in Bryant’s iliofemoral triangle. Both are illustrated in Fig. 314. Impaction can sometimes be determined by comparing triangles drawn between three points on either side, these points being, respectively, the great trochanters, the anterior spine, and the centre of the pubis, which is common to both. The lower line of the triangle on the injured side should be shorter than on the other, in proportion as the head and the end of the shaft have been driven toward each other.
[Illustration: FIG. 314
Nélaton’s line, dark. Bryant’s iliofemoral triangle, dotted. (Erichsen.)]
_Crepitus_ is a sign to be elicited with care and gentleness. Up-and-down movements of the thigh upon the side of the pelvis or gentle rotary movements, combined with circumduction of the knee, will yield it if it is to be easily detected. Every effort of this kind disturbs the injured bone and should be minimized as much as possible. One other sign of considerable value is the fact that if the patient be turned upon his face a fractured femoral neck will permit the leg to be _hyperextended_ to a degree not permitted by the normal condition. In making this test the pelvis should be held firmly; it should be made but once, the intent being to disturb the parts as little as possible.
=Diagnosis.=--The diagnosis of fracture is often easy, but in some cases it is accompanied by many difficulties. It would be better to give the patient the benefit of a doubt and treat him for a fracture with rest than to subject him to excessive manipulation. Such an injury is not likely to be mistaken for anything else save a dislocation of the hip, although occasionally separation of the margin of the acetabulum might cause confusion.
=Prognosis.=--The prognosis depends upon the age and vitality of the patient, the location and extent of the fracture, the method of treatment, and upon causes which seem at first foreign to the subject. Patients with pulmonary or cardiac trouble, who need frequent change in position, or perhaps absolute rest, are likely to develop something hurriedly which will disarrange ordinary calculations. Sometimes they die suddenly or they may develop pulmonary edema or hypostatic pneumonia. The circulation may be so poor as to lead to early development of bed-sores, while ordinary complications in prostatics, or habitual constipation in the aged, may make care and treatment exceedingly difficult. It should be emphasized, then, that treatment of the fracture alone is by no means all that these patients require, and prognosis means something more than what may merely happen to the bone. In this last respect, however, the better nourished the fragment the more likely is bony union to take place _if_ good position can be maintained. When osseous union has failed patients get fairly useful limbs with _fibrous or ligamentous union_, even with one or two inches of shortening, and such patients may hobble about for years, with a cane or a crutch, with limbs that are semiserviceable.
=Treatment.=--Of these cases it may be said that interests of life are paramount to those of limb, and the treatment should be directed to that which the patient can tolerate. Reasonably healthy, muscular people can bear the application of adhesive strips and traction such as the thin and delicate cannot tolerate. The ideal method is that by which sufficient traction is made to overcome all muscle pull which shall produce shortening, the measure of weight to be used in these cases being the effect thereby produced. Thus if twenty pounds be sufficient, well and good; if not, it should be increased to thirty or forty pounds, providing that the patient can tolerate it. At the same time a broad binder around the pelvis may afford sufficient support with a tractable patient, while many will require a _long side splint_, extending from the axilla to beneath the foot, to which both body and the injured limb should be fastened, in order to more perfectly maintain that physiological rest which is so necessary. This last is the so-called “Physick” splint, which has been variously modified, while the method of traction has been usually spoken of as Buck’s extension. It seems well thus to commemorate the names of the American surgeons who showed the value of these methods. When a long side splint cannot be borne, sandbags 15 in. or 20 in. in length and 3 in. in diameter may be used to give support. Any decided tendency to eversion of the limb should be corrected as well as the shortening. When the long side splint is used the foot can be held in place with it and thus the position of the shaft of the femur controlled. At other times this may be done by flexing the knee and thus preventing upward rotation. In all methods of traction it is advisable to _keep the heel free from the bed_, in order that the effect of the method may not be lost by the obstruction of the mattress.
[Illustration: FIG. 315
Fracture of upper third of femur. Vicious union.]
[Illustration: FIG. 316
Shortening resulting from overlapping.]
[Illustration: FIG. 317
Overlapping fracture of femur.]
Other methods of treatment of these fractures are common as well to those of the shaft, and will be considered later. These include the single and double inclined plane and the method by anterior suspension. In general the _first indication is efficient traction_. This should be made as efficiently as possible. When the patient cannot tolerate any of the usual methods, then the double-inclined plane may be used, the knee being hung over its apex, or anterior suspension may be practised. In severe cases patients should be simply made comfortable, with such local treatment as they can bear. It may be even necessary to place them in the semi-upright position in bed, in order to free the lungs, or to frequently change their position to avoid the formation of pressure sores.
[Illustration: FIG. 318
Fracture of lower end of femur, with great displacement of condyles.]
=Fractures of the Shaft of the Femur.=--Fractures of the shaft of the femur are usually oblique and accompanied by considerable displacement, because of the powerful thigh muscles which tend to shorten the limb. These fractures are often _compound_, and occasionally the femoral fragment causes serious damage to important vessels or nerve trunks. When the fracture is just below the insertion of the psoas into the lesser trochanter this muscle tends to not only pull up but to externally rotate the upper fragment. Inasmuch as there is no way of controlling this muscle or the fragment, the fractured limb should be dressed upon an inclined plane, or in anterior suspension, in such a way as to make the axis of the shaft fall into line with that of the fragment. When the fracture is in the middle of the thigh, or lower, there is sufficient length of the upper portion so that pressure can be made upon it, or that psoas activity can be overcome. Fig. 315 illustrates the tremendous deformity that may result from neglect of these precautions. Fig. 316 illustrates a certain degree of overlapping without conspicuous other deformity. Fig. 317 shows the shortening which is often inevitable.
_Muscle spasm_ should be overcome as an essential part of successful treatment, the most important feature in making traction being to use force sufficient to tire out and overcome the irritated muscles.
=Fractures of the Lower End of the Femur.=--Fractures of the lower end of the femur are usually the result of extreme violence, and may be classified as were those of the lower end of the humerus. When there is a _supracondyloid_ fracture the two heads of the gastrocnemius will help to displace backward the upper end of the lower fragment to an extent permitting injury to the bloodvessels, while there is always marked shortening. Here the patella will be made unduly prominent, and there will be depression above it. _Either condyle_ may be broken loose alone, or there may be _intercondyloid_ or T-fractures which are serious because the amount of force required to produce them may have played serious havoc with the soft tissues. The joint capsule will probably be filled with blood, the ligaments rent, and perhaps the blood supply of the limb compromised. In such a case as this the joint may be opened, the contents turned out, and the fragments readjusted and wired or fastened in place (Fig. 318). _Epiphyseal separations_, which may occur up to the twentieth year, are not essentially different, although lateral displacement is perhaps more common, while they are often compound.
=Treatment.=--Oblique fractures of the femoral shaft can be more easily adjusted under the influence of powerful and continuous traction than the transverse, where lateral displacement and overlapping tend to occur. A more general application can be made of the method described above when dealing with fractures at the upper end of the shaft, _i. e._, when the upper fragment cannot be controlled the balance of the limb must be adjusted to it in whatever position it may be required to maintain. By the use of sufficient traction, combined with molded or other splints, a fair result may usually be obtained. In stout individuals it is by no means easy to determine just how the fragments lie, save by the use of the _x_-rays. If traction be so adjusted as to maintain the limb at equal length with the other the surgeon may feel that, with certain coaptation splints, he is doing the best he can. Application of the same rule given above would lead him to place the limb on a double inclined plane, in case of fracture near the knee-joint, in order that in this position the sural muscles (the calf) may be relaxed and backward displacement of the lower fragment be adjusted. If the apex of this plane be arranged sufficiently high, so that the patient’s knee is practically hung over it, and that the weight of the body makes sufficient _countertraction_, then the use of weight and pulley may not be necessary. Here, however, pressure which will be efficient may produce numbness, as will any long-continued pressure in the popliteal space, and after a few days it may be necessary to assume some other position. Fractures which loosen the condyles will need lateral pressure, while the position of each condyle may be controlled by the position of the leg, through the medium of the corresponding lateral ligament.
[Illustration: FIG. 319
Extension band and foot-piece.]
[Illustration: FIG. 320
Same, folded and ready for use.]
The standard “Buck’s extension” (for which latter word I prefer to substitute the term “traction”), by weight and pulley, with the limb in the extended position, is still the resort of the majority of surgeons, but combined with other support by long side splints or coaptation splints as may be needed. Fig. 321 illustrates the method of its use, except that the ends of the adhesive strips should be extended upward to a point nearly opposite the site of the fracture. The amount of weight to be used should be graduated to the effect produced. From ten to forty pounds, or even more, may be needed. After the muscles are thoroughly tired the amount of weight may be somewhat reduced[41] (Figs. 319, 320 and 321).
[41] Before applying the strips of adhesive, the best for the purpose being that made of moleskin spread with material with which zinc oxide is incorporated, the limb should be carefully washed and shaved and then completely dried. A little cotton should be placed over each malleolus, in order to avoid pressure-sores, while the strip of wood beneath the foot should be sufficiently wide to prevent or minimize this pressure. The heel should be kept off the mattress.
[Illustration: FIG. 321
Mode of applying adhesive plaster. (When the dressings are completed the limb should not be allowed to rest on the bed.)]
Continuous and anterior traction was devised by Nathan R. Smith, in the use of a so-called _anterior splint_, which was later modified and improved in device by Hodgen. The method of its use is shown in Fig. 322. Adhesive strips are used in this method as well, permitting the leg and foot to be attached to the lower bar of the wire frame. The position of the frame which contains the limb, swung within it upon turns or strips of bandage, is then controlled by a suspension apparatus, as shown, which tends to constantly pull the frame and its attached lower part of the limb _away_ from the patient, the effect being to make a constant but gentle traction. If the point of suspension were placed directly above the limb there would be no traction whatever. The essential feature of the method, then, consists in arranging it as shown, so that the pull shall be oblique, and that, according to the obliquity of the suspension cords, the amount of traction shall be regulated.
[Illustration: FIG. 322
The Hodgen suspension splint.]
In this method of treatment there is no violent attempt made at reduction or overcoming displacement, but dependence is placed, at least for two or three days, on the effect of the constant pull and its overcoming muscular activity. After this such added splints or expedients may be adopted as the case may require. The knee is usually flexed at a comfortable angle, the intent being not to lift the foot too high, so as to avoid being compelled to overcome this added weight, but to regulate the tension by the obliquity of the suspending cord.
[Illustration: FIG. 323
Fracture of the femur in a child treated by vertical extension. (Bryant.)]
This method has found favor in the West under the enduring influence of Hodgen’s teaching. In the East it is not so generally practised. It has, however, several advantages, as follows: (1) Equably perfect and comfortable extension; (2) easy adjustment; (3) easy exposure for inspection; (4) when a fracture is compound it permits of easy application of dressings; (5) adaptability to nearly all fractures of the femur. It is peculiarly serviceable for feeble and aged patients who chafe at restraint. If it be desirable to flex the knee to a considerable degree this can be done, _e. g._, in fractures near the lesser trochanter.
In fractures of the thigh, patients are frequently disturbed by muscle spasms occurring during sleep. This can usually be obviated or minimized by suitable doses of sulphonal, given early in the evening.
Fractures of the femur _in children_ are not uncommon. In those who still wear diapers, and perhaps in those a little older, these injuries may be best treated by vertical suspension, with sufficient weight to overcome all shortening. Here the adhesive strips and the suspending cords should be attached to both limbs alike, in order to have sufficient access to the perineum, and in order to judge of the effect which we are obtaining. Figs. 323 and 324 illustrate this method.
Plaster-of-Paris dressings for fractures of the thigh appeal especially to those who are most familiar with the use of the material. Some patients with fracture of the neck of the femur may be early put in the erect posture, upon an elevated surface, allowing the injured limb to hang down while the patient rests upon crutches. In this upright position, with the down-hanging leg, to which traction can be made by an assistant, a plaster-of-Paris spica may be applied, extending from the waist-line down to or below the knee. As a limb is thus dressed so it will heal, and it is of importance that complete reduction be effected as a part of the procedure.
[Illustration: FIG. 324
Fracture of the thigh; vertical suspension. The fracture is compound in the patient on the right. (Stimson).]
FRACTURES OF THE PATELLA.
During the active period of middle life the patella is the bone most frequently broken by muscular violence. In many cases it is practically cracked over the condyles, as one would crack a piece of wood over the knee. If direct force be applied, as by a fall, in connection with the above, the effect is even more marked. In such cases the fracture is sometimes comminuted (Fig. 325), or the line of fracture may run more or less perpendicularly rather than horizontally. Ordinarily, however, these fractures are transverse, while the upper fragment is pulled upward, sometimes to a considerable distance, by the powerful extensors of the leg. When the fracture runs vertically the displacement is very slight. Occasionally these fractures are compound, a most undesirable complication, since the knee-joint is thus exposed to infection, from which it suffers unless first attention be prompt and scientific. There is usually sufficient hemorrhage to distend the joint cavity, and it may at first be quite impossible to bring the fragments near enough to each other to get crepitus, but the loss of the power of extension and the evident gap between the fragments will serve to make diagnosis positive, at least in all transverse fractures. A _vertical_ fracture without much separation is a milder form of injury which may be regarded in a much more favorable light (Figs. 326, 327 and 328).
In these transverse fractures it is rare that bony union can be secured by non-operative methods. This is not only because of the difficulty in maintaining parts in apposition, but because it is notably the case that fragments of periosteum or other tissue drop in between bony surfaces and tend to prevent their actual contact, no matter how firmly they may be pressed toward each other. Osseous union then _may_ occur without operation, but is rare. The best that can be expected is fibrous union, the intervening fibrous band being short or long, according to the success met with in treatment and to the amount of strain later put upon it by too early use of the limb. Even with two inches of fibrous tissue intervening patients are not completely disabled. The usefulness of a limb under these conditions, however, is seriously impaired. Something will depend, also, on the extent to which the joint capsule and the aponeurosis terminating the vasti muscles may have suffered.
=Treatment.=--The non-operative treatment consists in placing such a limb upon a single inclined plane, for the purpose of relaxing the quadriceps extensor group. In this position the limb should be maintained for at least from ten to fourteen days. Some expedient should be added, so soon as swelling has subsided, by which the upper fragment can be coaxed downward toward its fellow. A neatly molded splint, formed out of gutta-percha or of plaster of Paris, may be fitted to the thigh above the fragment, held in position, and then drawn downward by elastic traction on either side of the leg, the principle of traction being thus given a special application. Something of this kind should be done if the fragments are to be approximated to each other.
[Illustration: FIG. 325
Comminuted fracture.]
[Illustration: FIG. 326
Stellate fracture of the patella. (Erichsen.)]
[Illustration: FIG. 327
Fracture of patella, united by ligamentous tissue. (Erichsen.)]
[Illustration: FIG. 328
Side view of same.]
The more completely mechanical method, partaking of the operative, is afforded by the use of certain _hooks_, whose points are permitted to pass through the skin above and below the fragments and to engage in the bone. By a screw mechanism these points are drawn toward each other, and thus approximation is effected. This method was first devised by Malgaigne and is usually known under his name, although his device has been much improved. This is far from ideal, and yet has given good results in some cases. The surgeon should constantly guard against infection through the punctures.
By far the most ideal method, when it can be suitably carried out, is the _open operation_, a transverse incision being made across the front of the joint, which is completely opened; this affords an opportunity to empty out clots and to thoroughly cleanse it, which of itself is a great advantage, since these clots often produce subsequent adhesions. The exposed surfaces may now be freed from clot and all soft tissue, or they may be neatly sawed as near to the fractured surfaces as possible, the intent being to permit them to come into absolute and complete contact, and to hold them there by wire or other sutures, for a length of time sufficient for absolute bony union. When properly performed this operation gives ideal results; it, of course, exposes to great danger if improperly done.
Treatment by non-operative method rarely affords a useful member under an average period of from thirteen to fourteen weeks, while the operative method permits a reduction of this time to less than half. It, therefore, has obvious advantages for those (_e. g._, laboring men) to whom time is of great importance. The operation, however, is not to be practised as a rude emergency affair, but only when we may be absolutely certain of everything pertaining to aseptic technique. After operation it is rarely necessary to use a drain, and such a limb can usually be dressed in a plaster-of-Paris splint. Compound fractures, however, will probably need drainage at least for a day or two, and because of this need may as well be operated at once. In _comminuted fractures_ the method is desirable, since by a loop or by some other expedient fragments can be held together as in no other way (Figs. 329 and 330).
[Illustration: FIG. 329
FIG. 330
Wiring patella. (Lejars.)]
Injuries to the patellar region, equivalent to fractures, are _separations_, either of the _tendon_ from the bone, or of the bone from the _ligament_ which holds it to the tibia. Such injuries can be recognized by the fact that the contour of the bone itself is preserved; in the former case it is not drawn up, although the extensor muscles have lost their power while in the latter it is drawn up, leaving a well-marked gap below it.
Remarks concerning the treatment of fractures apply equally here. Choice can be made between the operative and the non-operative treatment. In well-selected cases the former seems much the more desirable, the fibrous end of the tendon or ligament being held to the bone by strong sutures of silk or wire.
THE LEG; FRACTURES OF THE TIBIA.
The _head of the tibia_ is occasionally broken as the result of extreme violence, the fragment being usually held reasonably in place by one or other of the lateral ligaments. Hemorrhage into the joint will be profuse, with swelling extreme, while disability will be complete. Not a few of these cases justify operation, directed toward opening the joint, removing all clot, and fastening the fragment in place with suitable sutures (Figs. 331 and 332).
_Transverse fracture below the tubercle_ is less rare. The insertion of the terminal ligament of the quadriceps extensor group will, in all of these injuries to the upper portion of the tibia, tend to pull up the upper fragment and make it project beneath, even protrude through the skin. Fractures of the _lower part_ of the tibia are freer from such distorting influences. Fig. 333 illustrates the distortion produced as above, while Fig. 335 shows one of the tendencies in fracture of the lower end of the tibial shaft, which has to be overcome by correct emplacement of the foot within the dressing. Fig. 334 illustrates synostosis as the result of fracture of both bones at about the same level. Torsion is a factor of no small importance in the production of most of the fractures of the leg, to such an extent as sometimes to make a completely spiral fracture, a condition generally held to be more serious than fracture of the ordinary type. The line of fracture often extends in such a direction as to leave a sharp spicule of bone close beneath the skin; here rough handling, or carelessly made pressure in the dressing, may cause a perforation within a few hours or days after the injury, by which a simple is converted into a compound fracture. Such a complication should always be avoided.
[Illustration: FIG. 331
FIG. 332
Wiring tibia. (Lejars.)]
FRACTURES OF THE FIBULA.
The lower end of this bone is much more often fractured than the upper, although it may be broken at any point. Into its upper termination is inserted the external lateral ligament, and this insertion may be torn off from the bone in cases of violent sprain of the knee, damage occurring which is similar to that which happens in injuries about the ankle. The upper portion of the bone lies well buried beneath muscles, and fractures here are not so easily recognized. A good maneuver for their recognition is to seize the bones at the lower portion of the leg and press them together; if such pressure gives severe pain above, or if it be shown that the fibula is more movable than natural, fracture may be practically diagnosticated, even though crepitus be not detected. A skiagram would, of course, clear up such a diagnosis.
Fractures of _both bones of the leg_ occur almost as frequently as of either alone, usually as the result of direct violence, with or without more or less torsion; as, for instance, when the foot is more or less entangled, and, at the same time, twisted at the time of injury. These double fractures are by no means necessarily placed upon the same level; thus the tibia may be broken low down and the fibula high up, so high indeed that the latter fracture may escape observation. With fracture of both bones disability becomes complete, while shortening is very likely to occur, all the muscles passing from the leg to the foot conspiring to this effect. These fractures, moreover, are often _comminuted_ and _compound_, sometimes to an extent necessitating exsection of fragments or of an inch or more from the shaft of each bone. In exsection of the tibia an equivalent amount should for obvious reasons be taken from the fibula. Displacements are extremely likely to occur, and in every compound fracture the presence of the opening may be utilized for the emplacement of sutures or suitable means for enforcing approximation. Indeed, other means failing, resort may be had to this measure in order to secure an ultimately good result.
[Illustration: FIG. 333
Fracture of upper end of tibia.]
[Illustration: FIG. 334
Transverse fracture, with anterior displacement. (From the Buffalo Museum.)]
[Illustration: FIG. 335
Line of fracture at junction of lower and middle thirds of tibia.]
While wire sutures may be used as freely as may be indicated it will be well, at least in the majority of cases, to leave the ends protruding in such a way that they can later be untwisted and removed. The presence of wire after a certain length of time rather interferes with the process of ossification than helps it.
Fractures of the _lower end of the leg_ nearly always involve the joint, to some extent at least, in respect of being accompanied by sprain if nothing else. They are accompanied by displacement of the foot, and are produced by violence, which first involves the foot. The term “_Pott’s fracture_” is meant to include the injury originally described by Pott himself. In the typical Pott’s fracture, as shown in Figs. 336 and 337, there are a chipping off of the internal malleolus, of the outer portion of the articular end of the tibia, and fracture of the fibula a little above the joint. In spite of the classical description which Pott gave fractures of the fibula alone, those accompanied by tearing of the internal lateral ligament, or chipping off of the malleolus, are frequently referred to under the same term. The more complete the injury the greater the possibility for displacement. Eversion and outward displacement, of course, are conspicuous. Lesser degrees of injury are accompanied by less displacement, but all of these injuries will be followed by extreme swelling of the ankle-joint, which may at first make diagnosis somewhat difficult, because of the extreme tenderness which prevents the handling necessary for careful determination. It is not always easy to so completely replace the bones, when we have the combination of three fractures as above, as to get an ideal result. Nevertheless with suitable treatment usually very useful limbs are secured. When the injury has been made _compound_ the difficulties are increased. Such a result will not be obtained, however, unless the tendency to backward and lateral displacement be overcome, when the limb is placed in its permanent plaster-of-Paris splint, as it should be after a few days. Great care should be given to this point in the management.
[Illustration: FIG. 336
Pott’s fracture. (Hoffa.)]
[Illustration: FIG. 337
Exaggerated deformity in Pott’s fracture.]
=Treatment of Fractures of the Leg.=--Nearly all these fractures are likely to be followed by swelling, even to a degree which makes it impracticable to put them up in permanent dressing until the swelling has subsided. This means a period of two to several days, during which the limb should be kept absolutely at rest, and the bones maintained in apposition by side splints, while the limb is restrained within a folded pillow or other comfortable cushion. More frequently here than in any other part of the body there will form blebs or large blisters, which are most liable to occur in alcoholic subjects. The leg should be scrubbed and shaved before putting on dressings, in order that the skin may be reasonably clean before its surface epithelium is raised. Ecchymosis, infiltration, and sometimes general edema may become somewhat pronounced, and the splint which would be required to fit a limb under these circumstances would soon be too large when this disturbance has subsided. The limb should not, therefore, be placed in a fixed or permanent dressing until it is in every respect ready.
While these disturbances are subsiding, or perhaps being encouraged to subside by the use of an ice-bag or of cold wet applications, extreme care should be taken that proper position and apposition are maintained. This will at times need considerable ingenuity. A delirious or maniacal patient would need restraint far beyond that required for one who is rational and docile. Moreover in all of these fracture cases which entail confinement to bed there is a tendency to deficiency of elimination which will require judicious use of laxatives and other eliminatives.
The writer prefers a well-molded set of side splints, properly padded, to any other first dressing for fractures of the leg. A limb thus dressed may be supported on a pillow and even made adaptable for transportation should it be necessary to remove the patient from one place to another. The fracture box can be well superseded by this method.
So soon as swelling has subsided, plaster of Paris should be used for a fixed dressing. The limb should be enveloped in a layer of cotton, by which the skin is protected, within which swelling may occur without much strangulation. Over this and down the front of the leg a strip of thick pasteboard should be placed, which can be moistened and made to adapt itself, or a strip of sheet tin, an inch wide, which can be made to fit the part, and upon which one may cut down later in removing the splint. This refers especially to the use of the roller bandage saturated with plaster of Paris. Molded splints can be made, as recommended for the upper extremity, out of surgeons’ lint, canton flannel, or old blanketing, while at the lower end of these splints may be incorporated, with the plaster, a strip of bandage or other material, by which a loop is formed beneath the foot, which may be utilized for the purpose of traction.
The foot should _always be placed at a right angle to the leg_. If there be too much muscle spasm to permit this, or make it too uncomfortable, the tendo Achillis may be divided. This position should be maintained during the period of repair, in order that so soon as one resumes the use of the limb the foot may be planted naturally upon the ground. In addition to this precaution it must be noted that backward displacement is completely overcome, and that eversion is perhaps a trifle overcorrected.
In all fractures of the lower end of the leg the foot and entire leg should be enclosed in a bandage. In fractures near or above the middle not only the leg but the lower part of the thigh should be immobilized if the promptest and most satisfactory results are to be obtained.
The limb being immobilized it soon becomes a question as to how quickly the patient can leave the bed and begin to move about on crutches. This will depend to some extent on the patient’s temperament. Timid women are less desirous of getting out of bed than are active men and children. Some patients acquire facility with crutches very slowly. Others are so tenderly built that crutches give pain and even produce crutch paralysis. It is advisable to get patients at least into the sitting posture so soon as the immobilization has been secured, while those inclined may be encouraged to use the uninjured limb and move about with crutches. A foot and leg too long kept off the ground will swell when again lowered. The later this dependent position is attained the greater the liability to edema. Patients should be cautioned about this.
The so-called _ambulatory method of treatment_ has found favor with some surgeons. This implies something more than merely permitting motion with crutches; it means really such dressing as to permit use of the injured limb in locomotion. The various forms of splints used for immobilizing the limb in hip-joint disease may be used in this way. A useful splint is made with body and perineal bands, or an inside steel bar with ischiatic crutch and a cross-bar below the sole of the foot, on which the weight of the body may be supported. This is to be combined with a plaster-of-Paris support.
The ambulatory treatment is occasionally of value, but the advantages claimed for it have not been generally sustained.
FRACTURES OF THE FOOT.
The astragalus and the calcis suffer more often than the other tarsal bones, partly because of their size and partly because they are in the line of transmission of force as usually directed after accident. When the posterior end of the calcis is broken off there remains a fragment which is easily palpated, and which would be displaced backward and upward by the tendo Achillis were it not for the plantar fascial fibers which are inserted into it. The bone may also be comminuted, in which case that part of the foot will lose much of its shape and distinctive peculiarities. The sole will be flattened, but swelling and hemorrhage will at first be so great that there will be much difficulty in recognizing the exact nature of the injury.
The _astragalus_ is usually broken by being caught between the calcis and the lower end of the leg. It is generally broken through the line of its so-called neck. Not infrequently one or more of the fragments is forced out of place, usually beneath the anterior tendons. When such extensive displacement occurs the fragments should be removed if the fracture is compound. In both of these bones results are generally satisfactory when displacement is not marked, also after removal of the entire astragalus. The foot and leg should be immobilized in the best possible position, and this can be best accomplished within a plaster-of-Paris dressing.
In regard to the _tarsal bones_, diagnosis can now be made accurately by the use of the _x_-rays. These bones, according to Eisendrath, may be fractured in any one of the following ways: (1) Compression, as when the weight of the body is violently thrown upon the feet; (2) sudden dorsal flexion, often with fracture of the inner malleolus; (3) forced supination or pronation, the interosseous ligaments being stronger, the bones forcibly pulling the latter apart; (4) violent traction upon the heel through the calf muscles, by which the tuberosity of the calcis may be torn from the rest of the bone; (5) extensive crushing injuries, in which several tarsal bones may be involved; (6) gunshot fractures. Some assistance in diagnosis may be obtained by computing the distance from the malleoli to the bottom of the heel, which will be shortened when the bones are compressed; or shortening of the length of the foot, or by fixed abnormal positions.
The _metatarsal bones_ are broken by direct violence, the first and fifth being most exposed. As in other fractures of the foot contusion will be a serious feature, and swelling and laceration will frequently seriously complicate, while the fractures themselves may be compound. The same is true, also, of fractures of the _phalanges_, crushing and comminution being common. The matter of treatment often includes an estimation of the blood supply and of the vitality of the distal portion. The operator may sometimes temporize with an antiseptic dressing until this matter is settled. Simple fractures require only immobilization in good position.
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