The principles and practice of modern surgery

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.

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.

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.

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).

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]

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).