Columbia Unibertfttp mtfjeCttp of Jleto |?orfe College of $J)P£trian«s anb burgeon* Reference library \. ^ ^ N . rr iM. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/clinicaltreatiseOOhopk A CLINICAL TREATISE ON FRACTURES BY WILLIAM BARTON HOPKINS, M. D. Surgeon to the Pennsylvania Hospital, and to the Orthopedic Hospital and Infirmary for Nervous Diseases PHILADELPHIA J. B. LIPPINCOTT COMPANY i goo Copyright, 1900, By J. B. LIPPINCOTT COMPANY. PREFACE. As the title indicates, the intention of this work is to treat the subject of Fractures in its clinical aspect. The matter presented is, in fact, a report of unpublished clini- cal lectures delivered by the author at the Pennsylvania Hospital, so revised and elaborated as to eliminate the elements of incompleteness of clinical delivery and lack of method necessarily incident to utilizing clinical material. The many details, too, of individual cases which may prof- itably be referred to in a clinical lecture have been gener- ally omitted. It has also been thought desirable to avoid the restating of traditions which have become obsolete, the recording of statistics, and the formulating of methods of treatment long since abandoned; for, while such historical matter seems inseparable from a work of reference, it is not essential in a treatise intended for practical use. In the matter of the management of fractures it may be stated that while at times a choice between several methods is given, the author usually advises that form of treatment which in his own experience has proved most simple and effective. The skiagraphs reproduced have been selected from a great number taken at the Pennsylvania Hospital by 4 PREFACE. Drs. Starbuck and Stewart. The illustrations of fractured bones are from specimens in the Mutter Museum of the College of Physicians, and the Museum of the Pennsyl- vania Hospital. To the pathologist of the latter, Dr. H. W. Cattell, the author owes his thanks for many pho- tographs. CONTENTS. CHAPTER I. PAGE INTRODUCTION 9 CHAPTER II. FRACTURES OF THE UPPER EXTREMITY 25 Fractures of the Hand 25 Phalanges 25 Metacarpal Bones 28 Carpal Bones 33 Fractures of the Forearm ■ 33 Fractures of the Radius 33 Fractures of the Ulna 51 Fractures of the Shafts of the Radius and Ulna 61 Fractures of the Humerus 67 Fractures of the Lower End of the Humerus 68 Fractures of the Shaft of the Humerus 77 Fractures of the Upper Extremity of the Humerus 83 Fractures of the Scapula 94 Fracture of the Body of the Scapula 94 Fracture of the Coracoid Process of the Scapula 95 Fracture of the Acromion Process of the Scapula 96 Fractures of the Clavicle 98 CHAPTER III. FRACTURES OF THE LO^YER EXTREMITY 106 Fractures of the Foot 106 Fractures of the Phalanges 106 Fractures of the Metatarsal Bones 107 Fractures of the Tarsus 109 5 6 CONTENTS. PAGE Fractures of the Leg 114 Fractures of the Tibia 114 Fractures of the Fibula 118 Fractures of both Bones 122 Fractures of the Patella 131 Fractures of the Femur . .- 147 Fractures of the Shaft 148 Fractures of the Upper Extremity of the Femur 152 Fractures of the Lower Extremity of the Femur 156 CHAPTER IV. FRACTURES OF THE PELVIS 169 Fractures of the Ilium 169 Fractures of the Pubis. .' 170 Fractures of the Ischium 171 Fractures of the Acetabulum 171 CHAPTER V. FRACTURES OF THE STERNUM AND RIBS 174 Fractures of the Sternum 174 Fractures of the Ribs 17 6 CHAPTER VI. FRACTURES OF THE SPINE 182 Fractures of the Spinous Processes 188 Fractures of the Laminae 189 Fractures of the Bodies of the Vertebra 191 CHAPTER VII. FRACTURES OF THE SKULL 201 CHAPTER VIII. FRACTURES OF BONES OF THE FACE 228 Fractures of the Nose 228 Fractures of the Upper Jaw 230 CONTENTS. 7 PAGE Fractures of the Malar Bone 231 Fracture of the Zygoma 232 Fractures of the Lower Jaw 232 Fractures of the Hyoid Bone 237 CHAPTER IX. COMPOUND FRACTURES 238 CLINICAL TREATISE ON FRACTURES. CHAPTER I. INTRODUCTION. In reviewing the clinical history of fractures, their causes, predisposing and direct, may first be considered. Of the predisposing causes, age, sex, occupation, and constitu- tional conditions (including diseases and peculiarities of the osseous system) are the principal. Age influences the occurrence of fractures in many ways. The friability of the bones in young persons and their brittle- ness in the aged more than offset the comparatively pro- tected conditions in which they live. The many statistics which have been collected show that between the ages of sixty and eighty there is a larger proportion of fract- ures than at any other equal period of life. During adult life fractures occur with greater frequency in the male sex than in the female, because of the more exposed life led by the former. In infancy and early childhood there is little difference in the relative frequency. Occupation largely affects the occurrence of fractures. Persons who lead lives of activity and hard work are, for IO A CLINICAL TREATISE OX FRACTURES. very obvious reasons, more likely to suffer them than those engaged in sedentary occupations. Certain diathetic diseases predispose their subjects to fracture, because of the increased brittleness of the skele- ton incident upon them. Height is also a predisposing cause, as long bones are relatively more liable to fracture than short ones. The direct cause may be briefly and pertinently described as force. The long bones yield to force applied in three distinct ways : (i) direct force, (2) indirect force, and (3) muscular force. (1) Direct force, often called direct impact, causes fract- ure by the transverse strain to which the bone is subjected, as a plank supported at its ends breaks when stood upon. Direct force may also crush the bone if resistance is met with beneath, as when a car-wheel passes over a limb; or direct force may puncture or shatter the bone, as in gun- shot fracture. (2) Indirect force causes fracture by the end-on-end strain applied to the bone, whether this strain be produced by press- ure exerted at both of its ends, as when the femur is fract- ured by compressing forces acting between the hip and the knee, or by the impact resulting from a fall when the resistance of the ground is equivalent to one force and the weight of the body is the other. (3) Muscular Force. — The contraction of a muscle may fracture a bone by direct, indirect, or by tensile force, accord- ing to the point of insertion and mode of action of the mus- cle. If its contraction causes a transverse strain upon the INTR OD UCTION. 1 1 shaft of the bone, the force will be seen to be in all respects similar to that of direct impact, except that it operates by traction instead of impact, — the clavicle may be fractured in this way. Should the insertion of the muscle and its origin act on the extremities of the bone, the force is indirect, and the bone yields from a bending or crushing strain. Fracture of the humerus from muscular violence is thus produced. The tensile strain exercised by mus- cular contraction is most prominently illustrated by fract- ure of the patella; but it also operates in every instance in which a large or small fragment of a bone is torn off by the tendon attached to it, as from the os calcis or olec- ranon. The measure of force required to break a bone depends not only upon the advantage or disadvantage under which such force operates, but also upon the resistance offered by the bone. The former is influenced by mechanical condi- tions too varied to formulate. The latter in average skele- tons is determined by age and other conditions above referred to. The younger the bone, the more flexible it is ; the older the bone, the more brittle. Bone, during infancy and youth, though flexible, is friable; and it steadily increases in strength until about the age of thirty years, when the maximum is reached. While we have little data upon which to base any definite conclusion regarding it, the period of maximum strength lasts perhaps for ten years. Its gradual diminution in strength results from increased brittleness which finally in old age once again renders it friable. Young bone bends very much before it breaks; 12 A CLINICAL TREATISE ON FRACTURES. but it must be borne in mind that old bone also bends before it breaks, however brittle it may be. "The limit of stiffness is flexure, and the limit of strength or resist- ance is fracture." If a bone is bent within the limit of its elasticity, it springs back to its normal axis and leaves no trace of the strain to which it has been subjected. As this limit in the young bone is wide, it may frequently be demonstrated while performing osteoclasis, by relaxing the pressure of the instrument. A strain beyond the limit of elasticity produces in young bone a kink, a greenstick fracture, or an incomplete fracture ; but these conditions occur with diminishing frequency as the age of the bone increases. The actual force in pounds required to fracture adult bone is of sufficient interest to have suggested the perform- ance of a series of experiments with the well-known testing- machines of Messrs. Riehle Brothers. For this purpose, various bones recently removed from a strong male adult mulatto, twenty-seven years of age, who had died of an acute disease, were selected as best representing the average full-grown skeleton. The strains applied by the appropri- ate testing-machines were transverse, crushing, and tensile. Transverse force, which, as stated above, corresponds to direct impact, was applied to the femur, and the tibia and fibula; crushing force, corresponding to indirect force, was applied to the femur, tibia and fibula, and to the humerus ; and tensile strain was tested on the patella. The bones, having been properly protected with padding, were subjected to the various strains as follows : the left INTR OD UCTION. 13 femur yielded to a transverse strain of 11 55 pounds, causing, as shown in Fig. 1, a transverse fracture in its middle third; Fig. i. the right tibia and fibula FlG - 2 yielded to a transverse strain of 1 1 15 pounds, with a trans- verse fracture at the junction of the middle with the lower third of the former, and a transverse fracture at the junc- tion of the middle with the upper third of the latter, as shown in Fig. 2. A crushing strain of 3130 pounds applied to the right femur caused it to yield at its middle third, with a slightly oblique fracture, as shown in Fig. 3, but not before it had bent twenty degrees from its axis. A crushing strain ap- plied to the left tibia and fibula caused an oblique fracture in the upper middle third of the former, and a transverse fracture in the lower middle third of the lat- ter, at 2270 pounds (Fig. 4). A crushing strain produced a transverse fracture of the right humerus in its lower third at a pressure of 2530 pounds (Fig. 5). Tensile strain, that cor- responding to muscular action in causing fracture of the patella, was tested upon that bone, with the result that the Tibia and fibula fractured by a transverse strain of 1115 pounds. Femur fractured by a transverse strain of 1155 pounds. 14 A CLIXICAL TREATISE OX FRACTURES. Fig. 3. Fig. 4. ligament of the patella was ruptured about its middle, but no damage was done to the patella itself, at 1845 pounds. The results of these several tests, particu- larly the crushing ones, those applied end-on- end, appear remarkable, but as their accuracy is unquestioned, they must be accepted. That the bones yielded only to such enormous strains is to be ex- plained by the fact that the pressure was ap- plied gradually. A bone is almost invari- ably fractured by sud- denly applied force and rarely by one which moves almost imper- ceptibly, as did those applied by the testing-machines. The impact of a tack-hammer, light as the latter is, has its value in pounds, and that a sufficient weight superimposed upon a tack will drive it is obvious. Rapidity of impact, therefore, momentum, and leverage are all factors in causing fracture. But, as above stated, to formulate their modes of operating would Tibia and fibula fract- ured by a crushing strain of 2270 pounds. Femur (posterior view) fractured by a crush- ing strain of 3130 pounds. INTR OD UCTION. I 5 be too complex a problem to state. As the bones were fresh and had not dried out at all, they presumably had neither •lost nor gained strength by being dead. That r IG. 5- neither the femur nor the humerus is an erect 40fc«> cylinder, but each possesses a curve which mate- rially lessens its vertical strength, may also be noted. That the pressure of over half a ton applied transversely was required to break the femur, and of nearly half a ton to break the tibia and fibula, is also remarkable, while the tensile strain of 1845 pounds which failed to break the patella has an interesting bearing upon the fracture of this bone by muscular action. The actual power, however, exerted by muscles in /. \ performing the various movements of the body, jM~„, 1 r per* acting as they usually do upon levers of great ? w* ' Humerus fract- disadvantage, is far greater than has been attrib- ure dbyacrush- uted to them. This fact has been demonstrated in s strain of by the author in a series of studies based upon the relations between fulcrum, power, and weight in execut- ing certain movements of the arm. The processes of repair by which the fracture unites, belonging as they do to surgical pathology rather than to clinical study, need not be referred to. The varieties of fractures may be classified as : Simple fracture, which signifies the loss of continuity of a bone unaccompanied by other injury. The term is used especially in contrast with compound fracture. 1 6 A CLINICAL TREATISE ON FRACTURES. Compound fracture, one communicating with the exterior through a wound. Comminuted fracture, where a bone is broken into three or more fragments. Fissured fracture, where a line of fracture or crack FlG 6 extends through a bone in such a manner that it does not destroy the continuity of the latter. Multiple fracture indicates the presence of two or more separate seats of fracture, as shown in Fig. 6. Complicated fracture is a term with a wide range of significance, used to denote the coex- istence with the fracture of some other injury likely to interfere with the proper course of the latter. It is too indefinite a term to be of much use. Punctured Fracture. — The penetration into a bone of a substance which either causes a fract- ure along the course it travels, or, by the vio- lence of its impact, one which radiates in various directions, may be described as a punctured Multiple fract- fracture. The commonest form of such is gun- emur. ^^ fracture, presently to be referred to ; but not infrequently a horseshoe, cotton-hook, pick-axe, or knife is driven into a bone, causing a puncture of the latter. A fracture thus produced is always compound, and, owing to the liability of the introduction of material which causes infection and consequent necrosis, is one which requires particular attention, thorough cleansing, and perfect drain- INTR OD UCTION. I J age. Two remarkable instances of such fracture have come to my notice, one under the care of a colleague, the other under my own care. An ordinary penknife- blade was driven through the parietal bone of an adult into the brain. Breaking off flush with the surface of the skull, it not unnaturally escaped detection for some time. When its presence was discovered it was extracted by tre- phining. Later, serious cerebral symptoms suggested further exploration, and revealed an extensive brain abscess, which proved fatal. The other was the case of a man who had received multiple stab-wounds of the back. He had been under treatment several days before a well-defined promi- nence was observed beneath the integument of the right shoulder. An incision revealed the presence of a large knife- blade embedded for nearly its entire length in the head of the humerus. It was then ascertained that while the man was being stabbed he had clutched the back of his neck with his clasped hands. In the final thrust made in the shoulder the knife had entered the extremely rotated head of the humerus, and had broken off; the arm, in resuming its natural position, had carried the blade to a point far ante- rior to the small wound of the integument through which it had entered. It is interesting to mention that a perfect reproduction of the cancellous structure of the bone was etched on the bright steel surface. The punctured wound of the humerus in this case healed without suppuration. Punctured fractures occurring along the anterior surface of the tibia are those most likely to be followed by necro- sis. While it may often be limited and trivial, at times. 1 8 A CLINICAL TREATISE ON FRACTURES. through an infectious osteitis, it becomes extensive. The treatment of punctured fracture is similar to that of other forms of compound fracture. Gunshot Fi r actures. — Fractures produced by projectiles of either small or large arms are generally described as gunshot fractures. They include, therefore, fractures produced by the discharge of pistols, rifles, shotguns at short range, and the various machine-guns. The characteristic phenomena of the gunshot fractures commonly met with in civil practice, and often caused by pistols of small or large calibre but low power, differ widely from those in military surgery, especially since the very general adoption of army rifles of small calibre but high power. The extent of damage done to a bone by a ball is in direct proportion to the size of the latter and in inverse ratio to its velocity. The large ball at low velocity shatters the bone; while the small ball at high velocity, generally speaking, bores a round hole through it, and perhaps does nothing more. The physical effects upon the bone of gunshot fractures are various. The ball may merely graze it, may splinter a fragment from it, may bore a hole through it, may cause loss of continuity with more or less comminution, as shown in Fig. 7, or may completely shatter it, as shown in Fig. 8. The fracture thus produced, whatever its other characters may be, is inevitably a compound fracture. If the wound of entrance is near the seat of fracture, the conditions present closely resemble those of compound fracture otherwise produced. On the other hand, if it be remote, the compound wound is not only long, but, owing to the probable alteration incident INTR OD UCTION. 19 Gunshot fract- ure of the humerus. to changes in the position of the limb in the relation of skin to fascia, fascia to muscles, and muscles to bone, it is fig. 7. also tortuous, and communication fig. 8. between the wound of entrance and the seat of fracture is thereby cut off. The effect of such ob- literation of the compound wound is either the fortunate and imme- diate conversion of the fracture into a simple fracture, or, should any source of infection have reached it, suppuration of an ex- tremely insidious character. The diagnosis of gunshot fract- ure rests, first, upon the existence of a gun- shot wound ; and, secondly, upon whether the missile inflicting the latter has damaged the bone. The presence of the gunshot wound having been determined, a bone lesion Gunshot fracture of . the femur. may be perfectly patent or its detection may require careful investigation. If not directly beneath the wound of entrance, the fracture may be demonstrated by the ordinary signs of fracture, — mobility, crepitus, and deform- ity; or its presence may be revealed by a probe or in the course of dissection incident to exploration for the ball. The treatment of gunshot fractures, apart from the fract- ure, is based upon the general management of gunshot wounds, — to locate and if possible extract the ball. The presence and location of the ball, at a point remote from 20 A CLINICAL TREATISE ON FRACTURES. the wound of entrance, if superficial, are not infrequently shown by a small blue point of ecchymosis of the integu- ment. This spot pressed upon will be found tender, and the ball may at times be felt. The silver probe tipped with porcelain — Nelaton's probe — will occasionally reveal the pres- ence of the ball; but it and all similar methods have to a great extent been abandoned for the definite and graphic demonstration furnished by the Roentgen apparatus. With it the presence and position of bullets in either upper or lower extremities can in most cases be determined with sufficient accuracy to enable the surgeon to cut down directly upon them. If the ball is removed, the management of the fract- ure may be proceeded with as with a compound fracture otherwise produced. Delayed union and ununited fracture result from either local causes affecting the conditions at the seat of fracture, or from constitutional tendencies or diseases which act locally in retarding or preventing union. The chief local causes are imperfect fixation, unreduced deformity, the intrusion between the fragments of a tendon or band of fascia, necro- sis, and, rarely, the development of malignant disease, such as osteosarcoma. Imperfect fixation is, in my opinion, by far the most frequent cause, but it is by no means always preventable. Certain fractures cannot by the use of any device be kept at rest if muscular contractions, voluntary or involuntary, which disturb them are persisted in. Any con- stitutional disease which, by weakening the osseous system predisposes to fracture, is liable to retard or prevent union after fracture because of the deficiency in the processes of INTR OD UCTION. 2 1 repair associated with it. Ununited fracture, therefore, fre- quently occurs in rachitic and syphilitic subjects, and some- times in those with osteomalacia. Ununited fracture is, fortunately, far less common than formerly; particularly is this true of fractures of the leg, Improved results in fractures of the tibia and fibula are prob- ably largely attributable to the almost universal employment of plaster-of-Paris or other fixed dressings. The very general use, too, of the Roentgen apparatus to inspect with the fluoroscope, and, if necessary, to photograph the seat of fracture before and after its reduction has been attempted, has certainly been of benefit in securing more perfect coap- tation of fragments, and consequently their early union. The treatment of delayed union may be briefly stated as prolonged fixation. When the failure to unite continues and is evidently uninfluenced by prolonged fixation, the fracture may properly be called ununited. When the condition char- acterizing delayed union gives place to that of ununited fracture some special management of the case becomes neces- sary. Rubbing the fragments forcibly together, by provok- ing irritation and congestion of them, may occasionally effect something in the way of a renewed effort at the repara- tive process. If of a bone of the lower extremity, some form of apparatus may be applied, which, while giving fixation, will permit the use of the limb, and will by means of this use tend to excite the exudation of reparative material. To the same end the fragments may be drilled in various direc- tions, with thorough aseptic precautions against infection, for, while the object of the drilling is to produce inflamma- 22 A CLINICAL TREATISE ON FRACTURES. tion, the inflammation should be wholly traumatic and non- infectious. Never very satisfactory, these various methods of temporizing with ununited fractures have fallen into disuse, because more radical operations, which formerly were dan- gerous, have, through present surgical technique, become comparatively safe. Any fracture which has failed to unite after three months of careful treatment may be regarded as a proper one upon which to perform some operation. Whether the defect is in the forearm, arm, leg, or thigh, the operation consists of exposing by a vertical incision and dissection the site of fracture, isolating the fragments from their closely adherent surroundings, and, after freshening their ends, uniting them by some form of suture. The ends may be scarfed or drilled, if the length of the bone is not already too much lessened to warrant further shortening. The scarf-joint, united by the single screw, a method which will be described in the treatment of compound fractures, would appear best suited for the tibia, femur, and humerus. I have not, however, had the opportunity to use it for ununited fractures. After suture by wire, silkworm-gut, pins, or screws, the case is managed in all respects as is a recent compound fracture similarly dealt with. The Treatment of Fractures. — The essential ele- ments in the treatment of fractures are reduction and fixa- tion. By reduction is meant the restoration of the broken fragments as accurately as possible to their natural relation to one another : the object is to make them fit as nearly as possible. This, like the process of modelling, may often be done by simple manipulation, by which the fragments INTRODUCTION. 23 can readily be moved about until they are felt to be in proper position and the normal contour of the part is ob- served to be restored. Such manipulation requires practice and dexterity, while the correct idea of form necessary to the full appreciation of contour would seem to be intuitive, — possessed by some without education, denied to others in spite of it. Reduction may be facilitated by the postural relaxation of certain muscles ; it may be difficult, requiring the exercise of force, as in greenstick or impacted fractures, or it may be painful, necessitating the use of an anaesthetic for its accomplishment. Should the fracture resist reduc- tion, it is said to be refractory, and then other means than manipulation, force, and anaesthesia must be resorted to in order to bring the fragments into proper apposition. As refractory fractures are more commonly met with in those which are compound, their management will be de- scribed under the treatment of the latter. Fixation signifies the retention in a state of immobility of the broken frag- ments of bone until they have united. It may be obtained in a variety of ways : for some fractures, rest in the recum- bent posture alone is sufficient ; while for others, some form of dressing, apparatus, or splint is necessary to accom- plish the result. Whatever the appliance may be, the greatest care and most constant watchfulness, both in its manner of application and in noting the effects it produces upon all the tissues concerned, are necessary. Damage to the integument from pressure of splints, compresses, or dress- ings not only inflicts needless discomfort upon the patient, but seriously embarrasses the treatment of the fracture. 24 A CLINICAL TREATISE ON FRACTURES. Too tight a bandage may, if it does nothing more, cause a cellulitis which will retard recovery or perhaps interfere with the ultimate restoration to function of the part ; or it may cause pressure paralysis. As in fractures of the extrem- ities, fixation of the fragments can be made complete only by retaining the adjacent joints in a state of immobility, to guard against permanent rigidity of these joints, partic- ularly if the fracture involves them or they have been subjected to traumatism, is imperative. The reduction of greenstick fractures requires, as already stated, the exercise of more or less force. This should be applied in such a manner as immediately and completely to overcome the angularity; for, although the fracture may be thus made complete, the result is definite and accomplished, and is therefore much more satisfactory than any effort to restore the bone to proper line by gradual pressure. This is also true of certain impacted fractures, and of fractures which have become partially united in a faulty position. Should union of the latter have become so firm as to resist manual force, the osteoclast may at times be advantageously employed to accomplish the result. After reduction the frag- ments seldom show much tendency to become again dis- placed, and their fixation is obtained and their subsequent management proceeded with by the method appropriate for the fracture. CHAPTER II. FRACTURES OF THE UPPER EXTREMITY. FRACTURES OF THE HAND. Phalanges. — The phalanges are usually fractured either by force directed against the tips of the fingers or knuckles, as in a faulty attempt to catch a ball or in striking a blow with the fist, or by being crushed between two hard objects, such as parts of a machine or a heavy stone and the ground. The former less severe violence is illustrated in Fig. 9; the latter, a severe crushing force, in Fig. 10. The deformity occurring after fracture of the phalanx, depending princi- pally upon the inclination of the plane of fracture, is slight if this plane is transverse ; greater if it is oblique (Figs. 9, 10). The fracture may involve a joint. Diagnosis. — Pain and swelling, indicating the possible presence of fracture of one of the fingers, abnormal mobility and crepitus, may, in some instances, be readily elicited by palpation. A fracture is distinguished from a luxation of a phalangeal or metacarpo-phalangeal joint by a much more noticeable deformity of the latter, and by the ease with which the deformity may be overcome in fracture. If the whole hand has been injured, careful examination of each finger in turn becomes necessary in order to recognize the full extent of the injury. Treatment. — As the force required to fracture a phalanx 25 26 A CLINICAL TREATISE OX FRACTURES. is great, the pain following such an injury requires relief. A lotion of lead-water and laudanum may therefore be used during the first day or two. A splint made of a cigar-box or a piece of wood of like thickness is shaved with a penknife Fig. q. m 1 Skiagraph of fracture of the fourth proximal phalanx. into a shape approximately that of the flat hand. If the sur- geon prefers not to depend upon his eye in modelling such a splint, its outline can be easily traced around the sound hand, the hand surface of the splint then being reversed, of course, for the opposite side. A mass of oakum, sufficient when compressed to fill out the hollow of the hand, is retained with a bandage. Upon this a single layer of FRACTURES OF THE UPPER EXTREMITY. 2J canton-flannel or patent lint is laid, and the hand is allowed to rest upon it. A little cotton is inserted between each finger, in order to prevent the contact of opposing skin surfaces, which, particularly about the fingers, become Fig. io. Skiagraph of multiple fractures from crush of hand. extremely foul from retained perspiration. In many in- stances the finger that is broken requires no special atten- tion. It is well supported between the fingers adjoining, the splint beneath, and the retaining bandage above. This latter should be two inches wide, and is most neatly applied 28 A CLINICAL TREATISE ON FRACTURES. in the form of a spica of the hand. Should any particular tendency be found to displacement in some one direction, it may be prevented by a compress of muslin above at a suit- able point. This compress may be prevented from slipping out of position by a half-inch rubber adhesive strip, carried from the under surface of the splint around and over the compress and back to the under surface of the splint. If the dressing is found after the first application to have become displaced from any cause, the narrow strip of rubber adhe- sive plaster may be applied in a figure-of-eight turn, includ- ing tips' of fingers and wrist in order to give increased sup- port to the bandage. In some cases in which it is prudent to give greater liberty to the patient than is possible when the entire hand is confined, very neat splints, somewhat pear-shaped, corresponding in form to the palm of the hand and the injured finger and the finger next to it, retained in the manner just described, will be found to give sufficient support and fixation to the broken fragments. Such splints are very useful in fractures of the distal phalanges, particularly of the ring and little fingers; cardboard, the thickness of cigar-box wood, is also a convenient material of which to construct these splints. Metacarpal Bones. — Fracture of the metacarpal bones is caused by direct violence, as by the hand being caught in machinery or beneath a falling object. The fracture thus produced is inclined usually to be transverse, and is accom- panied by the minimum degree of deformity (Figs, n and 12). When caused by indirect violence, as by a blow of the fist or a fall upon the knuckles, the overlapping of the FRACTURES OF THE LFPER EXTREMITY. 2 9 fragments produces sufficient deformity to be at times plainly noticeable. The bowing usually observed is dorsal, but occasionally palmar. Fig. 13 represents a remarkable fracture of three metacarpal bones in line. fig. 11. Skiagraph of fracture of fourth and fifth metacarpals. Diagnosis. — The hand becomes swollen very soon after the receipt of such an injury, considerable tension of the integument upon its dorsum, with perhaps effusion of blood in mass into the subcutaneous cellular tissue, occurring immediately. In all cases, therefore, presenting these appearances very careful examination should be made of 3° A CLIXICAL TREATISE OX FRACTURES. each metacarpal bone in turn. The first step of the exami- nation consists in thrusting the finger against the head of its metacarpal bone. The object of this manoeuvre is both to reveal any yielding that may exist and to locate pain. Fig. 12. Skiagraph of oblique fracture of fourth metacarpal. If these movements cause pain in the hand, a fracture will generally be discovered. The next step is the attempt to sway backward and forward the head of the metacarpal bone whilst the middle of the shaft is grasped between the thumb and finger of the other hand, making an attempt at a counter-movement. Mobility can usually be detected in this way without using force sufficient to cause much FRACTURES OF THE UPPER EXTREMITY. 31 pain. The final step in the examination, if a fracture has been found, consists in locating- as far as possible its posi- tion by direct palpation. As force, either directly or indi- rectly applied, which has been violent enough to fracture a metacarpal bone, may very likely have fractured more Fig. 13. Skiagraph of fracture of the three metacarpal bones. than one, the exploration should be persisted in until each bone has been thoroughly examined. Prognosis. — In most hands the metacarpal bones are so superficially situated beneath the dorsal integument that a resulting deformity too trifling to interfere with the ulti- mate usefulness of the hand may yet be plainly noticeable 32 A CLINICAL TREATISE ON FRACTURES. on inspection. In cases, therefore, in which decided dis- placement exists immediately after the injury, it is unwise to promise too perfect a result, so far as appearance is con- cerned. Treatment. — Whether one or more metacarpal bones are fractured, the careful adaptation of a palmar splint is equally appropriate for the management of the injury. Shaping a thin plank either by the eye or by tracing the outline of the sound hand and forearm upon it, it is shaved to correspond nicely with the latter, and a mass of oakum, which when compressed will be about a quarter of an inch in thickness, and a ball of oakum sufficient comfortably to fill out the cavity of the hand, is retained with the bandage ; or, if more positive pressure upward at this point is required, combined with flexion of the fingers, in order best to effect adjustment, sufficient eminence may be obtained by the use of a roller bandage placed on the splint and covered with oakum. The limb being placed upon this splint, a little cotton is inserted between each finger, and, modelling the hand upon it, it is made to fit nicely. Should any dorsal bowing be found to exist, a small compress of muslin should be retained upon the refractory fragment by a quarter-inch strip of rubber adhesive plaster carried around splint and hand, the splint having been retained with a neatly applied two-inch roller bandage. The dressing is completed by the adjustment of a handkerchief sling, which supports the splint from end to end. This dressing should be inspected after twenty-four hours, and, if the limb is found in a satisfactory condition, the dorsum of the hand and forearm may be bathed with FRACTURES OF THE UPPER EXTREMITY. 33 alcohol and a new bandage applied without removing the splint. The interval between the succeeding changes of the dressing should be four days, passive motion being made of every controlled joint from the third dressing throughout the treatment. The splint should be worn five davs after the fracture appears firm, which will usually be found to be in three and a half weeks. Carpal Bones. — The force required to fracture one or more of the bones of the carpus is so great that damage to the adjacent soft parts almost invariably accompanies the fracture. Such an injury usually involves a crush of the hand, or at least a compound fracture. FRACTURES OF THE FOREARM. Fractures of the Radius. — The radius may be broken by direct violence, as from a blow, or by indirect violence — that is, force directed from below upward, from above down- ward, or from a crushing force acting between the elbow and wrist in the direction of the long axis. As with other bones, a fracture caused by direct violence is likely to be transverse; when by indirect violence the tendency is gen- erally towards obliquity. For convenience of description, fractures of the radius may be divided into (1) fractures of the lower extremity, (2) fractures of the shaft, and (3) fractures of the upper extremity. (1) Fractures of the Lower Extremity of the Radius. — In a very large proportion of fractures of the radius the lower extremity of the bone is the seat of fracture. As all fract- ures in this vicinity, whether involving the joint or occur- 3 34 A CLINICAL TREATISE ON FRACTURES. ring a short distance above, present peculiar characteristics, they may be classified under the heading given above. Colles long ago described this fracture as occurring at about one inch and a half above the joint, and for all clinical purposes his original definition may well stand. No other fracture, certainly of the upper extremity, has been for nearly a cen- tury the subject of so much discussion and such a vast amount of literature as this. This is not only because of its great frequency, but also because permanent deformity, producing an unsightly result and interfering with the functions of the limb, so often follows its occurrence. Fig. 14. Recent fracture of lower end of the radius. The deformity (Fig. 14) following a fracture of the lower end of the radius consists of dorsal displacement of the lower fragment, the latter, besides occupying a position above the axis of the shaft of the bone, being usually turned somewhat inward, causing thereby undue prominence of the lower end of the ulna. The hand is, therefore, elevated to a higher plane than natural and is more or less abducted. The result of this displacement is the characteristic "silver fork" deformity of hand and wrist. The position assumed by the fragments producing this deformity is shown in Fig. 15. If the deformity persist, the strength and useful- ness of the hand are permanently lessened, for the flexor and FRACTURES OF THE UPPER EXTREMITY. 35 extensor muscles, instead of acting on a straight mortise at the wrist-joint, act on a mortise the plane of which is oblique. The obliquity of the plane on the articular surface of the Fig. 15. Skiagraph of fracture of lower end of the radius, the dim shadow of the soft parts showing the deformity. radius allows force directed by a muscle upon the hand and fingers to be to a considerable extent lost by the sliding Fig, 16. Skiagraph of fractures of both radii. movement of the carpus. This is well shown in Fig. 16, a skiagraph of fractures of both radii. The other cause of impairment of function is rigidity of 2,6 A CLINICAL TREATISE ON FRACTURES. the wrist and fingers. The fracture is caused most fre- quently by falls upon the palm of the hand; occasionally, upon the back of the hand. The fracture in such instances has been said to be caused by forced extension and forced flexion. I think, however, in most cases direct impact, communicated through the carpus, best describes the mode in which the injury is usually produced. This opinion depends upon experiments in producing fractures on the cadaver, as illustrated in Fig. 17, in which the blow was Fig, 17, Experimental fracture of the radius ; frozen section at the outer side of the middle finger. (From a drawing by Dr. J. Madison Taylor.) delivered directly upon the base of the carpus; and upon the conviction that the hand in most individuals can be extended to a right angle with the forearm without causing a ligamentous strain sufficient to produce fracture. When the carpus has reached the limit of its motion in either flexion or extension, as when the hand is caught in machinery, the radius may yield from the lever-like force exerted upon its lower extremity at the wrist. Force so act- ing is called a cross-breaking strain. While force applied in such a way may at times operate in this manner, that FRACTURES OF THE UPPER EXTREMITY. 37 it does so frequently has not been demonstrated. Often the internal lateral ligament of the wrist-joint is itself torn, or else it is detached from the lower end of the ulna, carrying with it a portion of the styloid process of the latter. Undue prominence of the lower end of the ulna results. Recent observations, demonstrated by skiagraphy, Fig. 18. Fig. 19. Skiagraph of fracture of the styloid process Skiagraph of fracture of the lower end of the radius, including the dorsal lip of of the radius, just above the articula- ble articular surface. Barton's fracture. tion. indicate that this ulnar prominence accompanying Colles's fracture is more frequently produced by detachment of the tip of the styloid process than was formerly believed. The curious error, however, has occurred of mistaking the lower epiphysis of the ulna for fracture. While, as stated, the fracture is most commonly situated from three-quarters of an inch to an inch and a quarter above the tip of the styloid process of the radius, the latter 38 A CLINICAL TREATISE ON FRACTURES. Fig. 20. may be involved, as shown in Fig. 18, constituting the fract- ure described by Barton ; or the line of fracture may extend just above the articular surface, as in Fig. 19 ; or, again, as in Fig. 20, somewhat higher. Diagnosis. — Pain, swelling, loss of power, and deformity of greater or less degree, as shown in Fig. 14, indicate the probable existence of fracture, before the examination has proceeded as far as palpation. Prominence of the lower end of the radius on the dorsal aspect of the forearm ac- companied by a depression at a corresponding point on its palmar aspect, slight turning of the hand to the radial side, and more or less projection of the ulna are signs sufficiently indicative of the existence of the injury. Crepitus frequently cannot be obtained, and so much force is usually required to reveal preternatural mobility that it is far better to make no effort to elicit this latter sign until reduction is about to be accomplished. Reduction. — The importance in this fracture of imme- diate reduction, and that as complete as possible, cannot be over-estimated. If the patient shows himself unable to bear pain well, if the fracture has remained unreduced for twelve or twenty-four hours, or if an effort at reduction has failed, it is entirely proper in most instances to use an anaesthetic. Skiagraph of fracture of the lower end of the radius, just above the articulation. FRACTURES OF THE UPPER EXTREMITY. 39 If reduction is not complete, a slight displacement, almost inappreciable at first, will, as the swelling subsides, steadily make itself more and more apparent at each inspection, until, finally, when the soft parts have resumed their natural con- tour, an ugly deformity, too firm to correct, will remain. While sometimes easily reduced under the proper manipu- lation, many cases require considerable force. Every fract- ure should, therefore, be approached as if it were known to be refractory. Seizing with the right hand the lower third of the forearm, with the fingers placed upon its palmar aspect, the thumb rests upon the dorsal surface of the lower fragment ; with the left hand the hand is grasped, the fingers upon its dorsum, while the thumb rests upon the palmar surface of the upper fragment. The right thumb presses directly upon the lower fragment, with counter-pressure of the fingers upon the upper fragment ; with the left hand direct pressure is made upon the upper fragment with the thumb, while counter-pressure is made upon the hand and wrist with the fingers. In my hands this manipulation has never failed, in a recent fracture, to accomplish immediate reduction. Treatment.— Much fault may be found with the Bond splint unless it is carefully and intelligently applied ; but perhaps no dressing for fracture of the lower end of the radius could escape criticism, unless used with great care and attention to necessary details. A Bond splint (Fig. 21) applied with a tight bandage, the forearm resting upon scanty padding and the hand elevated high upon a wooden block, will give all the conditions needed to retain 40 A CLINICAL TREATISE ON FRACTURES. the characteristic deformity of the fracture, or even repro- duce it if it has been overcome ; and yet I have never seen FlG 2I any dressing for this fracture which better fulfils the neces- sary requirements if it is prop- erly employed. Its length Bonds splint. should correspond to the dis- tance from the inner condyle of the humerus to the meta- carpophalangeal joints of the hand, while its breadth should be equal to or slightly greater than that of the forearm, wrist, and hand at these respective points. In order to preserve the natural arch of the radius and ulna, a large mass of oakum should be placed upon the splint, and if the injured limb approximates at all the size of the surgeon's, he should place his corresponding forearm upon it and pack the oakum uniformly beneath it. Placing a single layer of patent lint or canton-flannel upon the oakum is all that is necessary to complete the preparation of the splint. One detail relating to the application of the retaining bandage — that is, the propriety of confining the fingers so that that they shall be beyond the control of the patient — is worthy of consideration. Little has been said on this matter in treatises on the subject, the recommendation by the surgeon of the splint or dressing employed by him, as one which retains or releases the fingers, implying, as a rule, his tacit approval of the one plan of treatment or the other. A few surgeons advise the use of a splint which reaches to the tips of the fingers ; but perhaps FRACTURES OF THE UPPER EXTREMITY. 4 1 a greater number of fractures in this locality are treated o by splints which extend no lower than the metacarpo- phalangeal articulations ; and such splints, used as they commonly are, permit of voluntary motion of the fingers and thumb. That the patient frequently avails himself of the liberty thus given him, not only to assist his sound hand in performing numerous acts about his person and at his work, and in showing his friends that he can use the fingers, but also in carrying out the prevalent belief that the more he does so, the more limber will they be, is abundantly shown by the quantity of foreign matter, as crumbs of bread, tobacco, sawdust, and dirt, frequently found to have accumulated in the lower portion of the dressing, and by the evident dissatisfaction which control- ling his fingers, at any dressing after the first, causes him. The flexor and extensor tendons of the fingers as they pass down the forearm and beneath the annular ligament are in close proximity to the radius. Any alteration in the con- tour of the bony bed upon which they rest encroaches upon the space allotted to them. When a fracture occurs in this vicinity more or less damage to the adjacent soft parts results. The tendons and their sheaths, the nerves, blood- vessels, and connective tissue are all liable to injury, any extent of bruising, stretching, or tearing being possible even in a simple fracture. The tendons and their sheaths suffer most, as, especially the deep flexors, they are bound down so snugly to the bone. If the deformity resulting from the fracture be at once and entirely overcome, whatever mischief was done by the fracture or by the force producing it, to the 42 A CLINICAL TREATISE OX FRACTURES. neighboring soft parts, remains ; but no new irritant is applied. If, on the contrary, the fragments of bone have not been replaced in accurate apposition, a persistent source of irritation results which is in direct proportion to the extent of the deformity remaining and to the sharpness of the pro- jecting fragments of bone. These, then, are two factors productive of inflammation. Is not a third added if we permit the patient to use his fingers ? Voluntary motion of a joint involves tension of the tendons which impart the motion. Passive motion, on the other hand, may be prac- tised without putting the tendons materially upon the stretch. There can be no doubt that the principal cause of impaired movement of the fingers and wrist after this fracture is to be found in the organized inflammatory exudates along the course of the tendons and their sheaths. That this is true becomes apparent when attempts at passive motion are made, during which, if at an early stage, young adhesions along the course of the tendons will be frequently felt, with a distinct impression of crackling, to give way and release the fingers, while, if made later on, the rigidity will be found to be of a springy, yielding, cadaveric character, unlike joint ankylosis, — tendinous rigidity. Continued voluntary action of these tendons about the wrist, whose sheaths have been more or less damaged and perhaps their calibre lessened, would appear to promote the inflamma- tion already started and to increase its products. The tendencv of muscular contraction to reproduce displace- ment, in the exceptional cases in which after restoration the fragments are inclined to become displaced, must also be FRACTURES OF THE UPPER EXTREMITY. 43 borne in mind. In one case of this injury which came under my observation the lower fragment of the radius was reduced with ease, but on the patient's flexing her fingers the frag- ment immediately slipped out of its proper position and marked deformity was reproduced. After a second reduction, the patient, although warned to keep her fingers still, made another movement with the index and middle finders, followed by a like result. The fragments after this were supported until the limb was placed upon a splint. To over- come this tendency greater pressure of the retaining dressing becomes necessary. It is therefore desirable, in my opinion, to confine the fingers bv a few recurrent turns of the bandaee over them before proceeding to retain the limb to the splint. In this way the advantages of the comfortably flexed position are combined with perfect rest. In order to prevent contact of the skin surfaces a little cotton should be placed between the fingers. Passive motion, being open to none of the objections that have been urged against voluntary motion, should be begun at the second dressing and continued at every subsequent change. Each finger in turn should be once fully flexed and fully extended ; the wrist should be once flexed and extended, once pronated and supinated. These movements may be made without causing pain if they are done gently and slowly. The forearm should in the meantime be supported by the fingers and thumb of the left hand placed at the seat of fracture ; the skin is bathed with alcohol at each dressing. The fingers are kept at rest by the recurrent bandage during the acute inflammatory stage, which usually subsides at the end of ten days. 44 A CLINICAL TREATISE OX FRACTURES. After the second dressing, which is applied twenty-four hours after the first, the limb should be dressed every three or four days for a period of three and a half to four weeks, when the splint may usually be discarded. For the next ten days various light exercises for the fingers and hand should be encouraged, and their activity grad- ually increased until strength is fully restored. (2) Fractures of the Shaft of the Radius. — Fractures of the shaft of the radius, if the ulna is not broken, seldom Fig. 22. Skiagraph of fracture of the lower portion of the shaft of the radius. cause great deformity. The condition is well illustrated in Figs. 22 and 23. The forearm is very slightly shortened, and what displacement of fragments exists is, so far as its direction is concerned, caused more by the inclination of the plane of fracture than by the contraction of any muscles attached to the bone or acting upon it. The biceps, which has always been considered an important factor in causing forward displacement of the upper fragment, in reality probablv exerts, when the forearm is flexed, little influence unless the fracture has occurred just below the tuberosity. FRACTURES OF THE UPPER EXTREMITY. 45 The action of the quadratus in drawing the lower frag- ment into closer proximity with the ulna has, it seems to me, been very much overestimated. Diagnosis. — Pain, swelling, and loss of power are gen- eral signs indicating the existence of fracture. Mobility at some point between the elbow and wrist can readily be revealed by gently grasping the radial aspect of the forearm between the thumb and finger. No force is required in Fig. 23. Skiagraph of fracture of the shaft of the radius. conducting this examination ; the tissues do not require to be firmly seized in order to elicit motion, and the patient need be caused little pain. As elsewhere, the seat of fract- ure having been once distinctly located by palpation, any great effort to elicit crepitus is wholly uncalled for. The fragments may be so placed that, instead of rubbing against each other they simply sway to and fro ; and, if there be no overlapping or bowing which requires cor- 46 A CLINICAL TREATISE OX FRACTURES. rection, the immediate management of the case can be pro- ceeded with. Treatment. — The internal right-angled splint (Fig. 24), extending from the middle of the arm to the tips of the fingers, of a width corresponding to the diameter of the arm, should be prepared by retaining with a bandage upon its surface a mass of oakum, which should vary in thickness at three points : (1) From the upper extremity of the arm to the elbow a mass of oakum should be placed which when compressed will make a comfortable resting-place for the arm and elbow, particularly avoiding pressure upon the internal condyle of the humerus. (2) In order further Fig. 24. Internal right-angled splint. to protect this very sensitive point from pressure, and also to preserve the natural arch of the forearm, the quantity of padding from the elbow to the wrist should be consider- ably increased in bulk. (3) At the palm of the hand the oakum should take something like the form of a dome, in order to adapt itself to the concavity. To get, as elsewhere, the best effect of the elasticity of the oakum, it should not be compressed too firmly by the retaining bandage. Upon the padded splint is placed a single layer of patent lint or canton-flannel, cut to correspond in form to the FRACTURES OF THE UPPER EXTREMITY. 47 right-angled splint. The limb is then placed upon the splint, and, carefully inspecting the seat of fracture and making gentle pressure upon it with the hand, about equal to that which will presently be made by the retaining bandage, any displacement which exists should be overcome. If the effect from the padding is found insufficient, as evidenced by the radius being too flat, more oakum should be insinuated beneath the lint covering. If the internal condyle of the humerus seems to be subjected to too much pressure when the elbow is pressed upon, a small ring of oakum may be inserted beneath the lint lining to protect it. In order to prevent contact of the skin surfaces, small pledgets of cotton should be inserted between each finger, and, if the forearm is fleshy, also in the fold at the bend of the elbow. While an assistant, or, better, two assistants, seize the upper extremity of the splint, holding it firmly to the arm, and the lower extremity is held steadily with sufficient support given to the fingers to keep the hand in proper place, the retaining bandage, extending from the tips of the fingers to the upper extremity of the splint, is applied. The tension of this bandage should be carefully regulated in each case. If the fracture has been accompanied by severe contusion of the soft parts, as a result of which a good deal of swelling is anticipated, the bandage should be almost slack at the first dressing, and as long after as any tendency to ascending inflammation continues. The limb should never be allowed to throb nor should the fingers be allowed to swell out of proportion to the rest of the limb. A broad handkerchief- sling is then nicely adjusted so that it will take the entire 48 A CLINICAL TREATISE ON FRACTURES. weight of the limb. At the end of twenty-four hours the first dressing should be carefully examined, and, if the patient complains of the least pain at any point, it should be removed. The presence of a welt of padding, corner of splint, or a turn of bandage may be suspected of causing undue pressure. On removing the bandage, preferably with scissors, the whole dorsal aspect of the forearm and hand may be bathed with alcohol without in the least dis- turbing the limb. If the splint fits well and the condition of the skin everywhere is satisfactory, the bandage may be reapplied without disturbing the limb further. This dress- ing, if entirely comfortable, and if the retaining bandage is found to be giving sufficient support to keep the fractured fragments fixed, may be allowed to remain on four days, and this interval between dressings may be continued throughout the treatment. Union usually takes place at the end of three or four weeks ; but the splint should be retained for one week longer. Retention of the forearm in a state of supination for fracture of the shaft of the radius above its middle, in order to overcome the action of the biceps muscle in ele 1 vating and rotating the upper fragment outward, is unneces- sary ; for, in my experience, no muscle in the body relaxes more completely than does the biceps after fracture. Any power it exerts upon the radius is voluntary, never spas- modic. Tenotomy of its tendon, therefore, in order to dis- able it, must seldom, if ever, be indicated. Nor is, I think, the deforming action of either the supinator brevis or the pronator radii teres important. The supine position, if it FRACTURES OF THE UPPER EXTREMITY. 49 is not required to effect nice apposition of the fragments, is not advisable, because it is likely to be so uncomfortable to the patient; nor is it essential to the greatest inter- osseous separation. (3) Fractures of the Upper Extremity of the Radius. — Fractures at this part of the bone are less frequent than at its shaft, and are very rare compared with those at its lower extremity. When caused by direct violence they not infrequently form a part of some general injury to the elbow-joint. When produced by indirect violence the latter is likely to be of a twisting or wrenching character. Fract- ure in this locality, either above or below the tubercle, seldom causes much deformity. When the forearm is in a state of right-angled flexion tension of the biceps is not a factor of as great importance, I think, as has been ascribed to it. The pain and disability incident to fracture will •always be found to cause relaxation of the biceps and con- sequent slackness of its tendon, certainly within a very short time. The traction it exerts at its point of inser- tion, therefore, is usually feeble. If the fracture be in the neck of the bone, the biceps, of course, tends to draw the lower fragment forward and rotate it outward. If, on the other hand, the fracture is below the tubercle, the upper fragment is then acted upon similarly by this muscle. The clinical history of this fracture, however, shows that there is seldom much displacement, and what displacement exists can hardly be determined by palpation. Indeed, the bare detection of the existence of fracture is not easy, and in many instances requires anaesthetization to verify it; 4 50 A CLINICAL TREATISE ON FRACTURES. while very exact localization may be impossible even with the aid of an anaesthetic. Hence the Roentgen apparatus ma}', in a suspected fracture in this locality, be of great use. Diagnosis. — Swelling and pain on motion of the elbow- joint, accompanied by marked tenderness on pressure at one spot over the upper portion of the radius, suggest the prob- ability of the existence of fracture at that point. Seizing the elbow with the left hand, the thumb searches for the head of the radius in its proper place in front of the ex- ternal condyle of the humerus. In some subjects it can readily be detected, while in others it is masked to a greater or less extent by fat or recent cellular infiltration. When found, the thumb is kept upon it, while with the other hand the forearm is completely pronated and supinated. If the head of the radius is felt to rotate, the continuity of the bone is, of course, proved to be intact, either because there is no fracture or, there being a fracture, there is, owing to impaction, no mobility. While conducting the movements of pronation and supination crepitus may be communicated through the forearm to the surgeon's hand, or it may be felt approximately located beneath the thumb which is held over the supposed seat of fracture. While this is the prescribed method of detecting fracture, I think too much stress should not be laid upon it, because in many sub- jects the head of the radius is too deeply placed to be readily mapped out, and is also too smooth to convey the impression of being rotated upon its axis. The fracture may often be recognized by seizing the shaft of the bone a little above its middle and lifting and depressing it FRACTURES OF THE UPPER EXTREMITY. 5 1 forcibly and repeatedly while the fingers of the left hand palpate over its upper portion. Preternatural mobility and crepitus may in this way often be elicited, and the position of the fracture approximately located. This is, however, a manoeuvre requiring so much force that an anaesthetic, if practicable, should be used. Treatment. — While on anatomical grounds more con- strained and less comfortable positions for the limb have been employed, the state of right-angled flexion of the fore- arm, with the degree of pronation obtained when the plane of the hand is vertical, probably best overcomes any ten- dency to displacement of the fragments which may exist. An internal right-angled splint, therefore, employed in all respects as described for the management of fracture of the shaft of the bone, is applicable. Fractures of the Ulna. — Fracture of the styloid process of the ulna, while it may occur alone, more fre- quently accompanies fracture of the lower end of the radius. When it alone is fractured the injury is usually caused by direct violence, though at times it may be ascribed to trac- tion exerted through strain of the internal lateral ligament of the wrist-joint. If the fracture accompanies a fracture of the lower end of the radius, its existence may be overlooked in attending to the major injury. The treatment of the latter, however, is not in any way modified by its presence. The diagnosis is easily made by palpation if attention is drawn to the injury. If not, it may readily escape notice, as little or no deformity results. Localized pain and tender- ness suggesting the possibility of such a fracture, the styloid 52 A CLINICAL TREATISE ON FRACTURES. process when seized beneath the thumb and finger will be found movable, and crepitus can usually be elicited. Treatment. — As there is only a slight displacement of the fragments, if indeed there be any, to retain them in a state of fixation a properly applied palmar splint, so formed that it will retain the hand in a state of moderate adduction, fulfils every requirement. This splint should be prepared by shaving it into a somewhat pistol-shaped form, well padded with oakum retained by a bandage. It should extend from the tips of the fingers to a point just below the internal condyle of the humerus. When covered by a layer of lint, it is applied to the forearm by a bandage, the pressure of the latter being distributed over the seat of injury by the intervention of a layer of cotton. The dressing is completed by the application of a broad handkerchief- sling extending from the elbow to the tips of the fingers. The splint should be removed at the end of twenty-four hours, and afterwards at intervals of five days, for a period of two and a half weeks, when a nicely moulded cardboard splint will usually be found to give sufficient support for the succeeding ten days or two weeks required to insure union. As there is seldom any difficulty in re-establishing perfect restoration of function after this fracture, the case is likely to require little attention when the splint has been dis- carded. Fracture of the shaft of the ulna is most frequently caused by direct violence, as from the blow of a heavy object, the bone usually yielding directly beneath the point of impact. The plane of fracture is consequently transverse, FRACTURES OF THE UPPER EXTREMITY. 53 and the tendency to relapse is relatively slight. Although the deformity in a very large number of cases is as described, downward bowing or dorsal bowing, the brachialis anticus, the action of which would tend to cause palmar bowing, has had a certain importance attached to it, as has also the pronator quadratus, in tending to abduct the lower fragment and draw it toward the radius. That the direction of the deformity is determined by either of these muscles may well be questioned, for not only does interlocking of the frag- Fig. 25. Skiagraph of fracture in lower third of the shaft of the ulna. Lower fragment perhaps acted upon by the quadratus. ments, preventing complete loss of continuity, interfere with their deforming tendency, but the action of the former is at too great a disadvantage to operate forcibly, and the strength of the latter has been probably overestimated, unless the fracture be situated low down (Fig. 25). Fig. 26 illustrates fracture of the middle of the shaft of the ulna, and Fig. 27 the rare condition of comminution of a hacture at this point. Figs. 28 and 29 show fractures at the upper third of the bone. 54 A CLINICAL TREATISE ON FRACTURES. Diagnosis. — The ulna lies so superficially beneath the integument that its whole shaft is frequently demonstrable to palpation. Mobility may be elicited by lifting and depressing the bone with the thumb and finger while the Fig. 26. Skiagraph of fracture of the middle of the shaft of the ulna. wrist is steadied with the other hand. Crepitus may be felt, but often cannot be, as the fragments are prevented Fig. 27. Skiagraph of comminuted fracture of the shaft of the ulna. from grating together by being more or less interlocked. Green-stick fracture of the ulna unaccompanied by radial lesion is rare, as the force causing the injury is much more likely to act with approximate equality upon both bones. Fig. 30 well illustrates this unusual condition. FRACTURES OF THE UPPER EXTREMITY. 55 %\ Treatment. — An internal right-angled splint, applied as has been described above in the management of fract- ures of the shaft of the radius, is a simple and effective plan of treatment for fracture of the shaft of the ulna. Fracture of the Olecranon Process of the Ulna (Fig. 31). — Though this process fig'. 29. may be fractured by muscular violence through the action of the triceps alone, it is much more frequently broken by direct force, as by a fall upon the elbow, to which is added, I suspect, in some cases the element of muscular I action. The upper fragment may be very small, consisting only of the ex- HMf treme eminence of the process, or it may include half or more of the artic- ulating fossa. The smaller the frag- the shaft ment which has been detached, the high up. more likely is muscular violence to have been the chief factor in the causation of the injury. The upper fragment may be drawn far up the arm by the action of the muscle, but more frequently it is little sepa- rated from the shaft. Some remaining continuity of fibres of the deep fascia, which continues down the forearm in a fan-like extension of the tendon of the triceps over this part of the bone, accounts for the slight separation of the fragments in many cases. Diagnosis.— As does the shaft, the upper extremity of Fracture of the shaft of the ulna at its upper third. 56 A CLINICAL TREATISE ON FRACTURES. the ulna lies so superficially beneath the integument that loss of its continuity, especially if the separation be con- Fig. 30. Skiagraph of green-stick fracture of the ulna, unaccompanied by fracture of the radius. siderable, can easily be detected. Preternatural mobility of the upper fragment, and perhaps crepitus, can best be Fig. 31. Skiagraph of fracture of the olecranon process of the ulna. elicited by palpation when the forearm hangs relaxed in a state of complete extension. Treatment. — In the majority of cases separation of the FRACTURES OF THE UPPER EXTREMITY. 57 fragments is too slight to require any special local appliance to correct the upward displacement of the upper fragment. While extreme extension of the forearm anatomically meets the requirements for the best coaptation of fragments, extreme extension is a very trying position for the patient, whether he is on his back or is up and about. A splint, therefore, which will retain the forearm in a state of only moderate extension, a very obtuse-angled splint, applied anteriorly, in the great majority of cases effects satisfactory coaptation without the aid of such adjuncts as compresses or adhesive plaster. These applied in a perfunctory manner may do more harm by provoking exudation and infiltration about the joint than good by promoting coaptation. They are seldom needed. Approximation of the fragments by suture in rare instances may be justifiable, but should never be resorted to in unhealthy or aged subjects, nor under surgical conditions which can be regarded as imperfect in any partic- ular. An obtuse-angled splint, or a long, straight splint, so padded that it will allow of slight flexion at the elbow- joint, extending from the metacarpophalangeal articulations to the head of the humerus, is retained to the arm by a bandage. The turns of the latter should not be made too tense over the hand and forearm lest they, combined with the dependent posture necessarily assumed by the limb, should cause uncomfortable throbbing or swelling. No sling is used. Passive movement of every joint, except flexion of the elbow, should be practised at each dressing. The matter of passive motion of the elbow-joint is one of the greatest importance. If the fragments are only slightly separated 58 A CLINICAL TREATISE ON FRACTURES. and appear to be held in situ by tendinous fibres, passive flexion of the elbow-joint may safely be made as soon as complete voluntary control can be got of the triceps muscle. This may usually be obtained in one or two sittings, but in some individuals such control is extremely difficult to teach. In the uncommon cases in which separation of the frag- ments to a considerable extent requires long retention of the splint combined with some controlling device, the time at which passive motion should be begun may be very hard to decide. Confronted by the alternative, however, of a rigid elbow-joint or the risk of disturbing newly formed callus, the conditions obtaining in any individual case must deter- mine the time most appropriate for the commencement of passive motion and the extent to which it may be conducted. Fracture of the Coronoid Process of the Ulna. — The coronoid process may be detached by any force which will cause a backward luxation of the elbow-joint. This luxation it often accompanies, though that the latter can happen only after fracture of the process, is disproved clinically. The natural displacement after fracture of the coronoid process is backward luxation at the elbow-joint, for it furnishes the most definite bony support the joint has anteriorly, that given by the head of the radius being variable and uncertain. Diagnosis. — The presence of this fractnre is usually dif- ficult to detect. The process in health can seldom be demon- strated by palpation, and, as it is usually but slightly sepa- rated, crepitus does not exist, nor can the detached fragment be felt. All cases of backward dislocation which after reduction immediately relapse, or after reduction can be FRACTURES OF THE UPPER EXTREMITY. 59 thrown out again and once more reduced by slight back- ward and forward efforts, may generally be assumed to have fracture of the coronoid process accompanying them. This, for reasons which will appear in speaking of treatment, is a prudent and useful assumption, even if no more positive signs of fracture can be discovered. Treatment. — Flexion of the forearm, as completely as is consistent with the patient's comfort, approximates the lower fragment (shaft of the ulna) to the upper. The application of a Velpeau bandage, therefore, without the use of any splint, is the only dressing necessary. As this treatment is applicable also for a backward dislocation of the forearm, it obviously becomes necessary only to vary the length of time for the management of the one injury or for the two combined. A backward dislocation of the elbow which after reduction can- not be reproduced by any ordinary effort may be considered cured in ten davs and released. A backward dislocation of the elbow-joint which either will not remain reduced or recurs on small provocation evidently has had accompanying it either a fracture of the coronoid process of the ulna or such extensive laceration of ligaments anterior to the joint that the course of treatment necessary to restore the one is as long as that required for the other. The Velpeau dress- ing, after adjusting a single layer of lint at every joint where skin surfaces will be in contact, is applied in the following manner : placing the hand of the injured extremity on the opposite shoulder, a two and a half-inch muslin bandage, starting over the spine of the scapula on the sound side, is carried across the back to the injured side by the following 60 A CLINICAL TREATISE OX FRACTURES. course : the middle of the summit of the shoulder, the middle of the outer aspect of the arm, behind the elbow, across to the axilla on the sound side, and under it to the starting-point. Repeat this turn to fix the bandage. On reaching the scapula the second time, make a circular turn around the thorax, including in it the arm on the injured side. The external condyle of the humerus is the point over which the middle of the roller passes on its way back to the starting-point. A shoulder-turn is now made, which overlaps the fixing turn three-quarters toward the median line of the body ; then another ascending spiral turn over- lapping the preceding turn one-half. So, shoulder-turns and spiral turns alternate until the former support the point of the elbow, which should be protected by a lint pad having a small hole in its centre. After this, spiral turns alone are continued until the entire injured extremity up to the wrist is thoroughly supported. Xo sling is used in this dressing. Pins or adhesive plaster must be generously used at all intersections of turns. The dressing should be removed on the third day, and reapplied after the skin has been thoroughly cleansed with alcohol. Subsequent dressings should be removed every three or five davs. Passive movement of the elbow-joint sufficient to extend the forearm to a right angle with the arm may be made cautiously at the end of two weeks. Pronation and supination of the hand may be done passively at the same time. After three and a half or four weeks the Velpeau dressing may be discarded and the forearm simply carried in a sliny for ten davs longer, when efforts to restore FRACTURES OF THE UPPER EXTREMITY. 6 1 complete extension must be persisted in if any tendency to rigidity remains. Fractures of the Shafts of the Radius and Ulna.— Fracture of both bones of the forearm causes an injury of far greater impor- & Fig. 32. tance, both regarding 1 its management and its results, than does fracture of the shaft of either bone alone. It is well represented in Figs. 32-36 and 40, Showing the Seat of L ^~ g ~ ph of fracture f both bones of the forearm. fracture at slightly different points in the two bones. They seldom give way at a corresponding point, but the line of fracture is more uniform in both, and the fractures them- I selves are more likely to be transverse, if caused by direct vio- lence, than if by force communicated through the hand or elbow indirectly. If Skiagraph of fracture of both bones of the forearm. the fractures are transverse, the deformity most frequently consists of ulnar bowing (Fig. 36) or dorsal bowing, the former depending principally upon the sagging downward of the fragments 62 A CLIXICAL TREATISE OX FRACTURES. while the hand is supported by a sling or by the sound hand. Dorsal bowing, if it exists, is usually caused by the preponderance in strength of the flexors over the extensors FIG. 34. Skiagraph of fracture of both bones of the forearm. of the forearm. Bowing in either direction may be pro- duced by the force causing the fracture, the position Fig. 35. Skiagraph of fracture of both bones of the forearm. assumed having been determined by the direction of this force. This is particularly true of green-stick fractures of the forearm, presently to be mentioned. Bowing towards the FRACTURES OF THE UPPER EXTREMITY. 63 ulnar side is the deformity which most frequently must be combated throughout the treatment. Even where the plane of fracture is oblique there is seldom any considerable over- lapping of the fragments ; for the action of the muscles Fig. 36. Skiagraph of fracture of both bones of the forearm, showing ulnar bowing. concerned tends more to produce bowing at the seat of fracture than overlapping of the fragments. In children in- complete or green-stick fracture of the radius and ulna is fre- quently observed. Green-stick fracture may be characterized by no other sign than deformity ; there being often no mo- bility nor crepitus. The condition is well illustrated in Figs. 37-39. The bow- ing, having been caused in most cases bv the original Fig. 37. injury, may assume any direction, and the incom- pleteness of the fracture may manifest itself in One Green-stick fracture of the radius and ulna, with avulsion of arm in belting. bone or in both bones, the bone not so affected being- either sound or the seat of a 64 A CLIXICAL TREATISE OX FRACTURES. complete fracture. A remarkable example of the character of the deformity being determined by the mode of action of the force which caused the injury occurred in the case of a boy, twelve years of age, whose hand was caught in a heavy belting. The limb was carried into the wheel and Fig. 38. Fig. 40. Skiagraph of green-stick fracture of both bones of the forearm Fig. 39. Skiagraph of complete fracture of the radius with green- stick fracture of the ulna. Fracture of both bones of the forearm. dragged off at a point just below the shoulder-joint at the moment the boy's chest struck the wheel. The curve given to the forearm corresponded to the curve of the wheel, between the surfaces of which and the heavy belting the arm was caught. The avulsed extremity is shown in Fig. 37. FRACTURES OF THE UPPER EXTREMITY. 65 Diagnosis. — Fracture of the shaft of both radius and ulna may often be distinguished from fracture of the shaft of one bone only, upon mere inspection, by the greater deformity it produces. All support of the forearm is gone. It is markedly bowed in some direction, usually to the ulnar side. Mobility is so complete that the patient is likely to dread any change in posture on account of the pain it causes. As, therefore, the nature of the injury is often patent, any rough handling to elicit crepitus is quite unnecessary; and it only remains to locate the seat of fracture in each bone by delicate manipulations. Allowing the forearm to rest upon a pillow, the pivotal point of motion in each bone can be accurately determined by gentle swaying motions with the index finger and thumb, while the wrist is supported by the other hand. Treatment. — If the fracture in both bones is complete, it is not necessary to make efforts at reduction until the dressing is ready to be applied. The indications in the treatment of this injury, after reduction, are : (1) Absolute fixation. In order to obtain this perfect rest, the elbow as well as the wrist-joint must be immobilized. (2) The reten- tion of the forearm in such a manner that not only shall the coaptation of the fragments be as perfect as possible, but the natural dorsal arch of the bones of the forearm shall also be retained and the interosseous space preserved. Forcible reduction by extension and counter-extension applied to the forearm to correct overlapping is seldom needed, the muscular relaxation which usually occurs immediately upon or very soon after the receipt of the injury allowing reduc- 66 A CLIXICAL TREATISE OX FRACTURES. tion of the displacement to be made without difficulty. The injunction occasionally given to force the radius and ulna apart from each other at the seat of fracture by press- ure with the fingers, to prevent fusion of the two bones, is unnecessary. If the object were attained, the result would be only temporary; and, moreover, in evidence afforded both clinically and by skiagraphs of a very large number of these fractures, tendency to fusion has been demonstrated to be a displacement by no means the most important. "While hesitating to criticise adversely prescribed methods of treatment, I must deprecate the use of the double (dorsal and palmar) splints in the management of this injury. The intention of the double splint is to preserve the form of the interosseous space by pressing the muscles into it from above and below. I have found the dorsal splint wholly unnecessarv for the fulfilment of this indication, and I have rarelv removed it, even after it has been applied by experi- enced hands, without observing an incipient splint-sore over the carpus. Applying pressure as these two splints do, in parallel planes, sufficient support is not given to the forearm to prevent ulnar sagging, and the palmar splint is seldom padded sufficiently to preserve the natural arch of the forearm. Not only is the elbow-joint uncontrolled, but if the fracture is as high up, in either or both bones, as the junction of the middle with the upper third, not even are the upper fragments controlled. That this is true can easilv be demonstrated by our ability to recognize the existence and approximately the locality of the fracture, while the splints are still in place, by simply seizing the FRACTURES OF THE UPPER EXTREMITY. 6j splints with one hand and the elbow with the other. The seat of fracture will then be felt to be imperfectly controlled and freely movable. Every surgeon who has had the opportunity of seeing many fractures of these bones treated is aware that delayed union and ununited fracture in healthy subjects occur relatively with greater frequency than elsewhere, and I believe that one important cause for such untoward results may be found in imperfectly controlled upper fragments. An internal right-angled splint, applied in the manner described on page 46, is, in my opinion, uni- versally applicable. This dressing, if entirely comfortable, and if the retaining bandage is found to be giving sufficient support to keep the bones fixed, need be changed only once in four days. At each change passive motion of the wrist and fingers may be made. The splint should be retained for one week after both bones are found to be firm, which they usually are in from three and a half to four and a half weeks. The splint may therefore generally be discarded in from four and a half to five and a half weeks. FRACTURES OF THE HUMERUS. Fractures of the humerus may be described under three headings, as fractures of the lower end, of the shaft, and of the upper end. Fracture of the lower extremity of the humerus is especially an injury of childhood, except when produced by a crushing force, as between the buffers of cars. Fracture of the shaft, as it usually presents itself, occurs in adult life, while fracture of the upper extremity belongs to advancing- or old aee. 68 A CLINICAL TREATISE OX FRACTURES. Fractures of the I^ower End of the Humerus.— Fract- ure in this neighborhood may or may not involve various portions of the articular surfaces of the bone. The line of fracture may thus extend transversely just above both con- dyles, constituting a supracondyloid fracture (Figs. 41 and 42); Fig. 41. Skiagraph of supracondyloid fracture of the humerus. or such a fracture may have intersecting it a vertical fracture between the condyles, producing the so-called T-fracture. (See Fig. 46.) The epitrochlea of the external condyle, or the epicondyle within, may be broken off without FlG any involvement of the elbow-joint ; or, finally, the line of fracture may extend from between the condyles to a point a short distance up the shaft. If such a fracture emerges at the outer side, it causes a fracture of the external con- dvle; while if on the inner side, a fracture of the Supracondyloid internal condyle. Fig. 43 represents a fracture fracture of the of the external condyle which involved so much of the articular surface of the bone that that portion remain- ing intact readily slipped by the coronoid process of the ulna, thus permitting a backward dislocation of the forearm. FRACTURES OF THE UPPER EXTREMITY. 69 Fractures of the lower end of the humerus are usually pro- duced by indirect violence, a most frequent cause being falls upon the hand. The complex character of the ossification Fig. 43 Skiagraph of fracture of the external condyle of the humerus. of this portion of the bone beginning in early childhood determines the various lines of fracture to a considerable extent at this tender age, but it is a factor which steadily Fig. 44. Skiagraph of separation of the lower epiphysis of the humerus, accompanied by backward dislocation of the forearm. diminishes towards adult life. Occurring before the eigh- teenth year, they are apt to be epiphyseal separations rather than fractures, but their general character is not thereby altered. Fig. 44 illustrates such a separation with dislocation. yo A CLINICAL TREATISE ON FRACTURES. Diagnosis. — As fractures about the elbow-joiut cause rapid swelling and are extremely painful on motion and exquisitely sensitive to pressure, and, finally, as upon their accurate recognition and consequently their proper management, restoration of function largely depends, the use of an anaesthetic is to be strongly advised. Deformity, which, if it exists, furnishes sufficient evidence of fracture, may be of little aid in suggesting the particular line which the fracture has followed. It is a symptom to which too much importance should not be attached. In many fract- ures of the humerus about the elbow-joint the deformity suggests a luxation as much as it does a fracture, and in a great many cases there is no deformity observable (Fig. 45). With this understanding, it may be stated that Fig. 45. Skiagraph of supracondyloid fracture of the humerus, unaccompanied by deformity. the width of the joint is increased in any fracture involv- ing the articular extremity of the bone, whether of the external or the internal condyle, or the splitting of the bone between them, the line of fracture terminating either a considerable distance up on the shaft or in a supracon- FRACTURES OF THE UPPER EXTREMITY, 71 dyloid fracture. Fracture of the internal condyle allows the forearm to be drawn inward, while fracture of the external condyle causes outward displacement. Having gone through the manipulations appropriate for the detection Fig. 46. of fracture of the neck of the radius and of the upper end of the ulna, which have eliminated any involvement of these bones, the forearm is fully extended, and, grasping the hand in one hand while the thumb and fingers of the other seize the elbow, a swaying lateral movement T-fractureofthe lower extrem- is made. If the fracture involves the troch- ity of the hu . lear surfaces of the joint, preternatural lateral merus. mobility towards the side implicated will be found to exist. Crepitus can probably also be elicited. If the mobility is equal on both sides and is not arrested abruptly, but, on the other hand, it seems possible to turn the elbow out- wards and inwards indefinitely, the fracture is either above the condyles or is comminuted (Fig. 47). Valuable indi- fig. 47- cations as to the existence and position of fracture of the lower end of the humerus may often be gotten by flexing the forearm to a right angle, holding the arm firmly, and thrusting the wrist backward with a Comminuted fract- movement which, if made forcibly, would ure of the lower tend to dislocate the forearm backward; and extremity of the humerus. the reverse, made by traction upon the hand while the arm is held firm, which would tend to dislocate the forearm forward. In thinly covered elbows, particu- larly of children, in which the signs of fracture are not so J 2 A CLINICAL TREATISE ON FRACTURES. obscure, the in: mediate deformity resulting from the injury often gives a probable clue to the nature of the latter, and, moreover, projecting fragments may not infrequently be felt beneath the skin which indicate the general line of fracture. In distinguishing supracondyloid fracture from fracture of either the internal or external condyle the important landmark, the relation the condyles bear to the olecranon, must be carefully observed. In supracondyloid fractures these relations are not disturbed. Prominence of the olec- ranon too, frequently found in supracondyloid fracture, is a symptom rarely seen in fractures of either external or internal condyle. The deformity assumed in supracondy- loid fracture is usually anterior bowing of the lower end of the humerus with overriding of the lower fragment behind the upper fragment, thus simulating backward luxation at the elbow-joint. But the plane of fracture being at times laterally oblique, will, according to the direction of this obliquity, cause external or internal lateral deviation of the elbow-joint, displacing it well inside or outside of the humeral axis. Again, in many such fractures there is so little deformity that the natural bony contour of the elbow- joint is modified to such a slight extent as to be completely masked by the swelling. Treatment. — An anterior splint (Fig. 48) which is right-angled or obtuse-angled is applicable for most cases. As the former is so much more comfortable for the patient if he is up and about, it should, if found to fulfil suffi- ciently the indications, have the preference. Such a splint should have a width approximately that of the diameter FRACTURES OF THE UPPER EXTREMITY. 73 of the elbow-joint, and should extend from the upper part of the arm to the tips of the fingers. Certain precautions are necessary in the applica- FlG 3 tion of this splint. Care must be taken that the bend of the elbow does not receive undue pressure from the angle of the splint ; the splint . 111 -1 11 1 • Anterior right-angled splint. should be so bevelled at its upper inner corner that it will not press upon the integument of the chest ; and the sling should be so contrived as not to risk pressure-paralysis, because the dressing is heavy. The short splint sometimes used in conjunction with the internal right-angled or anterior right-angled splint is rarely needed. Any tendency to displacement which occurs after the latter has been applied may be best corrected by a care- fully adapted cardboard cap. In applying the anterior right-angled splint, it must be borne in mind that in order to make two flat boards, joined to one another at a right angle, adapt themselves nicely to the contour of the arm and forearm flexed at a similar angle, the splint must be carefully adjusted. In order that this may be done the more intelligently, the general contour of the anterior aspect of the arm and forearm as it appears in profile may be studied with advantage. The anterior profile of the arm presents a generally straight plane, though there may be a muscular swell at its upper portion and another at its middle. The bend at the elbow when the hand is in a state of supination, a position necessitated 74 A CLINICAL TREATISE ON FRACTURES. by the anterior splint, is an easy, rounded curve; while the line of the forearm from the elbow to the tips of the fingers presents in profile a long concavity looking upward. The pad of oakum having been so placed on the splint that it will correspond as nearly as possible to this very irregular form of the arm and forearm, and the sharp angle of the wooden joint sufficiently covered to prevent any undue pressure at the bend of the elbow, the splint is tried on; that is, it is held in the position which it is to be made to occupy, and careful inspection is made to ascertain if it gives even and equable support throughout its length. If the bend of the elbow appears to get too much pressure, a little more oakum should be insinuated beneath the lint cov- ering just above and below the latter. It will now usually be found for the first time that the splint is much too long; the forearm portion, which, measured upon the sound limb, was made to extend to the tips of the fingers, will now probably project two inches beyond the tips of the fingers. The arm portion will probably be in very imperfect contact with the arm, and also too long. In order to avoid these defects the splint should be sawn off to the proper dimen- sions before the padding is retained with the bandage. The most common cause for splint-sore at the anterior bend of the elbow is so easily prevented by the simplest precaution that it deserves mention. In the application of the retain- ing bandage to the hand and forearm the arm portion of the splint is frequently allowed to droop forward, its upper extremity being removed from the arm a distance corre- sponding to the degree of extension at the elbow-joint. FRACTURES OF THE UPPER EXTREMITY. ?$ When the bandage reaches the elbow the forward displace- ment of the splint is overcome, and in so doing its angle is pressed with the force of a lever into the bend of the elbow. No integument will stand this. The splint should, there- fore, be held accurately in position at the hand, the elbow, and the shoulder during the application of the retaining bandage. As a limb hangs very heavily with this splint applied, a broad handkerchief-sling extending from the fingers to the elbow should give comfortable support, and in order to encourage the patient to allow the arm to hang completely relaxed the sling should be padded at the back of the neck with sufficient thicknesses of lint to distribute the pressure at this point. In many cases of fracture of the external condyle and of supracondyloid fracture the deformity will be found to be very fully corrected by the use of the internal right-angled splint. It is so much more comfortable to the patient, and is so much less likely to give trouble, either by becoming disarranged or by causing pressure-sores, that it should have the preference, if it is found to retain the fragments in good apposition. On the second day the dressing should be removed, the skin bathed with alcohol and carefully inspected at every point. In reapplying the dressing, the bandage on this occasion may be applied with a little more tension than at the first dress- ing. It is not desirable, as a rule, to make passive motion at this, the second, dressing. Succeeding changes should be made every five days. One complete extension and one complete flexion, one movement of pronation and a return to the state of supination, are the passive movements which j6 A CLINICAL TREATISE OX FRACTURES. should be conducted, and the} - are very rarely contraindi- cated by any tendency of the fragments to become displaced. Though the time required for union of fractures of the elbow varies somewhat with the nature of the fracture, a period of four weeks is in most cases long enough for the fragments to be at least safely if not firmly joined. Another fortnight, during which careful attention is paid to the restoration of function, is usually all that is required in the management of the case. It is unfortunate that in fracture about the elbow-joint, a joint so prone to rigidity after injury, early passive motion cannot always be employed without risk of disturbing the fragments. It is, however, so important a part of the treatment in preventing rigidity and in restoring function that it should be attempted in every case, and abandoned onlv on the positive evidence that it does disturb the fragments. In many cases rough handling would disturb them, while by maintaining the utmost gentleness, by securing perfect muscular relaxation, by getting the con- fidence of the patient, and assuring him that no sudden or forcible movements will be made, one complete move- ment as detailed above may be satisfactorily performed at the second dressing; and if the supporting hand at the elbow feels no crepitus, no mobility, nor change in the posi- tion of the fragments, these movements may be conducted at each succeeding dressing, in many cases without in the least retarding union. I have rarely found difficulty in so adjusting the fragments as to correct any tendency to overriding. The practice of overcoming this tendency FRACTURES OF THE UPPER EXTREMITY. 77 in certain refractory cases by the suspension of a weight of two or three pounds hung on the elbow, seems to rely too much upon the probability of the patient's maintaining for a large part of the day an attitude which will make the weight act efficiently. An individual with a broken elbow being unable to work, is likely to recline a great deal on a lounge or on a bed, and when thus recumbent he will probablv keep his arm across his chest or try to make him- self comfortable in some other way, while he gets rid of the weight either by placing it beside him or by removing it altogether between the professional visits. Fractures of the Shaft of the Humerus.— Fractures of the shaft of the humerus are more frequently produced by indirect than direct violence. Thev may also be produced by muscular action ; and although the latter is an infrequent cause, the humerus is, of the long bones, the one most liable to yield to it. Several in- stances of fractures produced in this way have come under my observation, among them one in a voung man who, while throw- ing a baseball, fractured the mid- dle third of his right humerus. For another, a large, muscular colored man was injured in a similar manner by directing a blow with his fist which failed Skiagraph of oblique fracture of the shaft of the humerus. 7 8 A CLINICAL TREATISE OX FRACTURES. to strike. A third occurred in a woman fifty-five years of age, who sustained a fracture high up in the shaft of her right humerus while lifting a tub of water from a chair to the floor. Such fractures are more commonly oblique (Figs. 49 and 50) than transverse (Fig. 51). While anterior bowing Skiagr&ph of oblique fracture of the shaft of the humerus. is the more frequent displacement (Fig. 52), bowing in any direction is quite possible, and is caused by overlapping and tilting of the fragments according to the direction of the line of fracture and the inclination of its plane. In some transverse fractures of the shaft the bowing at the seat of fracture seems influenced in its direction wholly by the manner in which the forearm happens to be supported, the direction frequently being observed to change in a moment from anterior to internal or external lateral, or posterior bowing. "While, therefore, the deformity following fracture of the shaft of the humerus is often variable or dependent upon the direction in which the fragments were forced by the injury, the relation which the fracture bears to the insertion FRACTURES OF THE UPPER EXTREMITY. 79 ox certain muscles will at times be found to exert an influ- ence ; thus, if the fracture occur above the insertion of the fig. si. deltoid or below the in- sertion of the pectoralis major, teres major, and latissimus dorsi muscles, the upper fragment will be drawn upward and for- ward, while the lower fragment is tilted inward. In the middle third of Fig. 52. Skiagraph of transverse fracture of the middle Recent fracture of the shaft of the third of the humerus. humerus. the shaft below the insertion of the deltoid muscle, muscular action usually exerts less influence. As has been stated, bowing in any direction is observed with more or less short- ening in the length of the arm. At the lower third muscular action seldom exercises any influence on the direction and character of any displacement which may exist. Diagnosis. — Loss of natural contour of the arm with 8o A CLINICAL TREATISE ON FRACTURES. bowing in some direction, moderate pain, and complete loss of power, accompanied by free and universal mobility with or without crepitus, indicate at once the existence of fracture. Treatment. — The indications for treatment of fractures in the shaft of the humerus are mainly the accurate coapta- tion of the fragments and their retention in a state of abso- lute fixation. As there is usually little tendency of any deformity to relapse after it has been properly corrected, the most important drawback to guard against is motion at the seat of fracture. Emphasis may well be laid upon this, as ununited fracture of the shaft of the humerus is not very uncommon. Perfect fixation cannot be depended upon with any dressing that does not control the shoulder-joint. An internal right-angled splint, therefore, supplemented by the use of a shoulder-cap, is a simple dressing, and is very gen- erally applicable. An internal right-angled splint extending from the axilla to the tips of the fingers, of a width corre- sponding to the diameter of the arm, should be prepared by retaining with a bandage upon its surface a mass of oakum, which should vary in thickness at three points. The arm portion of the splint must not be so long that its upper extremity will be unduly thrust into the axilla when the arm is brought to the side of the body, lest the integu- ment or the structures beneath be damaged or the circulation in the arm interfered with. From the upper extremity of the arm to the elbow a mass of oakum is placed which when compressed will make a comfortable resting-place for the arm and elbow, particularly avoiding any pressure upon the internal condvle of the humerus. In order further to FRACTURES OF THE UPPER EXTREMITY. 8 1 protect this very sensitive point from pressure, and also to conform to the natural arch of the forearm, the quantity of padding from the elbow to the wrist should be considerably increased in bulk. At the palm of the hand the oakum should assume a somewhat dome-shaped form, in order to adapt itself to the latter. To get, as elsewhere, the best effect of the elasticity of the oakum, it should not be pressed upon the splint too firmly with the bandage. Upon the splint thus prepared is placed a single layer of patent lint or canton-flannel, cut to correspond in form to the right- angled splint. The limb is then placed upon the splint and, carefully inspecting the seat of fracture and making gentle pressure upon it with the hand about equal to that which will presently be made by the retaining bandage, any displacement which exists should be overcome. If the effect from padding is found insufficient, more oakum should be insinuated beneath the lint covering. If the internal condyle seems to be getting too much pressure when the elbow is pressed upon, a small ring of oakum may be in- serted beneath the lint lining to protect it. In order to prevent contact of the skin surfaces, small pledgets of cotton should be inserted between each finger ; and, if the forearm is fleshy, also in the fold at the bend of the elbow. While an assistant, or, better, two assistants, seize respectively the upper extremity of the splint, holding it firmly to the arm, and the lower extremity held steadily with sufficient support given to the fingers to keep the hand in proper place, the retaining bandage, extending from the tips of the fingers to the upper extremity of the splint, is applied. Then a 82 A CLINICAL TREATISE ON FRACTURES. heavy cardboard shoulder-cap should be so modelled that it will cover the entire shoulder, and, extending down the arm to the elbow-joint, will reach the margins of the splint in front and at the back of the arm. It should be cut from cardboard one-eighth inch thick, and the upper portion should be so scored that it is possible to adapt it neatly to the rotundity of the shoulder. When cut into this form it is immersed for a moment in boiling water, and immediately mopped as dry as possible with a towel. While the limb with the internal right-angled splint in place is held away from the trunk just far enough to allow of the passage of the roller bandage, the cardboard cap, nicely adapted to the form of the arm and shoulder with four layers of canton- flannel or patent lint lining it, is retained by spiral turns of a bandage to the arm and inner splint as far up as the extremity of the latter extends. At this point the retaining bandage becomes an ascending spica of the shoulder to retain the cap properly in position. The following day this latter part of the dressing is removed, the internal right-angled splint, if found to be entirely comfortable, remaining undisturbed. The cardboard cap being now dry, can be firmly fixed to the arm portion of the internal right- angled splint by broad strips of rubber adhesive plaster, sup- plemented by the spiral turns of a bandage and ascending spica of the shoulder. By this dressing the entire upper extremity will be found to remain in a state of absolute immobility; and as change of such a formidable appliance involves considerable movement of the fracture, it may be allowed to remain undisturbed, provided no discomfort at FRACTURES OF THE UPPER EXTREMITY. 83 any point is complained of, for a week or ten days. At the end of this time the whole dressing is to be removed, the skin carefully bathed with alcohol, and the shoulder-, elbow-, wrist-, and finger-joints all made to execute their natural movements. The dressing is then reapplied, and if it is found still to give sufficient support everywhere to prevent any motion at the seat of fracture, it may now remain undisturbed for two weeks. The dressing should be retained for one week after the fracture is found to have united, which it usually does in from three and a half to four weeks; after this the cardboard cap alone may be used, discarding the internal right-angled splint. Massage and gentle exer- cises for two weeks longer conclude the treatment. At times, when it is desirable that the patient should be kept a few days or a week in the recumbent posture, no splint need be used during the early part of the treatment, but the arm may be allowed to rest in a comfortable position upon a pillow. Such a course as preliminary to the appli- cation of a fracture dressing becomes especially applicable when there is great contusion of the soft parts or extensive extravasation of blood. Fractures of the Upper Extremity of the Humerus. — Fractures of the upper extremity of the humerus include those of the surgical neck and those of the anatomical neck. Fractures of the anatomical neck involve the bone within the capsule, as do also those extending in various directions through the head of the bone. The tuberosities may be detached or epiphyseal separations may occur during early periods of life. In advanced age the structural chanees 84 A CLINICAL TREATISE ON FRACTURES. occurring in this portion of the bone render it increasingly liable to fracture. Fractures of the upper extremity of the humerus are caused by falls directly upon the shoulder or crushing forces applied to the trunk. Such constitute the more common applications of direct violence. Fracture of a tuberosity of the humerus is usually the result of direct violence. Falls upon the hand or elbow may fracture the upper extremity of the humerus by violence indirectly applied. The bone may be broken through the surgical neck in efforts at reduction of old dislocations of the shoulder-joint. Fracture through the surgical neck of the bone, either approximately transverse or with an obliquity of its plane which carries it more or less down the shaft, is by far the most common fracture of the upper extremity of the humerus. Fractures of the head are usually com- minuted, and are rare. Fractures of the anatomical neck are likewise rare. Fracture of a tuberosity occurs as a complication to dislocation of the shoulder more frequently than as a simple injury. Diagnosis. — Pain, swelling, loss of power, inability .to perform any movement of the shoulder-joint, particularly that of elevation, are signs which, while not characteristic of this particular lesion, may point to its existence, if injury to other bones contributing to the construction of the shoulder-joint has been eliminated. As fractures in this locality are extremely difficult to locate even if their presence has been determined, and as the somewhat for- cible manipulations which must necessarily be made cause much pain, an anaesthetic should always be administered, FRACTURES OF THE UPPER EXTREMITY. 85 unless some special contraindication to its use exists. Seiz- ino- the slioulder-ioint over the head of the humerus with one hand, the shaft of the bone along with the elbow-joint is ro- tated through a large arc; during this manoeuvre crepitus will probably be elicited. The upper extremity of the bone may or may not be felt to rotate independently of the head. If the subject is fleshy— and these fractures occur more fre- quently in fleshy subjects — very little clue may be obtained as to the exact locality of the fracture by this manipu- lation. Seizing the shoulder while the arm is forcibly thrust upward by pushing the elbow in the direction of the humeral axis may demonstrate some mobility in this direc- tion and crepitus; and flattening of the shoulder, which perhaps was present, disappears and the normal contour is restored. Forcible traction downward will, under these cir- cumstances, reproduce the deformity and crepitus will be again felt. While these will usually be found reliable means for ascertaining the existence of fracture of the neck, they show little which can be depended upon to indicate what portion of the neck the latter has involved. Fortunately, the importance of distinguishing between these locations is not great so far as treatment is concerned, though having a bearing upon prognosis. Fracture of the Surgical Neck of the Humerus. — Fracture at this point may be produced by direct or indi- rect violence of a kind which, slightly modified, is capable of fracturing the shaft on the one hand or the anatomical neck on the other. Falls upon the shoulder or falls upon the hand; direct blows, as the kick of a horse; or twisting, 86 A CLINICAL TREATISE ON FRACTURES. wrenching strains, as those applied in efforts to reduce old dislocations of the shoulder-joint, are all liable to cause the injury. The line of fracture involving the surgical neck of the. humerus is outside of the capsular ligament of the shoulder- joint and below the tuberosities. As, therefore, it is below the insertion of the muscles inserted into the latter — sub- scapularis, infraspinatus, and teres minor — the upper frag- ment, which is the head of the humerus, may be subjected to extreme rotation and abduction. The lower fragment, which is the shaft of the bone, losing its support at the shoulder-joint, may be drawn inward and tilted toward the trunk principally by the action of the pectoral is major, latis- simus dorsi, teres major, and deltoid muscles. The charac- teristic deformity resulting is more or less flattening of the shoulder accompanied by an outward inclination of the arm, resembling, but less marked than, that accompanying sub- glenoid luxation. Fracture of the anatomical neck of the humerus, which is an intracapsular fracture, can in thin subjects be distinguished from fracture of the surgical neck; but usually only with the aid of an anaesthetic. As fracture at this point deprives the head of the bone of blood-supply, the latter remains either as an inert foreign body, or, becoming necrotic, causes suppuration in the joint, necessitating removal. On the other hand, fortunately for the future function of the limb, the force producing the fracture may cause firm impaction of the fragments. On purely theo- retical grounds, the less such a fracture is disturbed the FRACTURES OF THE UPPER EXTREMITY. 8/ better, for even moderate manipulations made to determine the character of the injury might readily relieve the impac- tion and make the fracture complete. As the diagnosis, however, of fracture involving the anatomical neck is not easv, given a fracture in which the deformity is inappre- ciable and in which no preternatural mobility or crepitus can be elicited, the evidences which would render the exist- ence and nature of the injury conclusive are wanting; and the injunction occasionally heard, not to risk disturbing the impaction of an impacted fracture at the anatomical neck of the humerus, is unreasonable unless, indeed, a particu- larly clear skiagraph should have demonstrated the lesion. Diagnosis. — The examination should, if possible, be made under ether. Conducting the rotary movement, crep- itus will probably be readily elicited, and, seizing the shoulder-joint, the head and neck of the bone can easily be sufficiently isolated, even through a mass of fat, to feel that they remain motionless while the shaft is rotated. The slight deflection of the axis of the arm outward will be found to be readily corrected if the fist is placed in the axilla and the elbow carried to the trunk; but as this deformity is produced by the combined action of the trunk muscles attached to the upper end of the lower fragment, it is reproduced the moment the pressure is released. Fracture of the head of the humerus, as already stated, is usually comminuted, caused in most cases by direct impact upon the shoulder; the bone being crushed by the counter-resistance of the glenoid cavity. It is so rare an injury and may be so difficult or impossible to detect that 8S A CLINICAL TREATISE ON FRACTURES. its existence is more than likely to be overlooked. There may be no deformity, no crepitus; and the symptoms of pain and disability, being common to the several other fractures in this locality, furnish little help in making a diagnosis. Fracture of the Tuberosities of the Humerus. — Any tuberosity may be chipped off by direct impact, or it may be torn away when the head of the bone is dislocated. The presence of such a fracture may be discovered,.by pal- pation, though in fleshy subjects it is likely to escape notice altogether. The injury is to be recognized by the continuity of the shaft with the head of the bone, and the presence of an abnormal depression below the acromion, where the detached fragment may be felt if the subject is not too fleshy. Epiphyseal separation of the upper extremity of the humerus is uncommon. Twisting strains and forcing the bone in any direction beyond the natural limits of joint- motion are the causes usually ascribed as producing the injury. As the separation occurs in the anatomical neck of the bone, if loss of continuity is made out in a subject under twenty years of age, the lesion may be regarded as epiphyseal separation. The symptoms of this lesion are, therefore, precisely those of fracture of the anatomical neck, except that there is no bone crepitus if the separation is purely epiphyseal. There may be the dry creak of carti- laginous surfaces rubbed together; or, if a small portion of bone is detached from either fragment, faint crepitus. Treatment of Fractures of the Upper Extremity FRACTURES OF THE UPPER EXTREMITY. 89 OF THE HUMERUS. — As the indications for the reduction and general management of all the more common fractures of the upper extremity of the humerus are similar and vary only in detail, they may perhaps well be considered together. Fracture of the surgical neck is much the most common of them, and is characterized, as already stated, by adduc- tion of the upper end of the lower fragment and inclination of its axis outward. The elbow will thus be placed some- what away from the trunk. This tendency must be cor- rected, and, what is of more importance, must be prevented from recurring, by carrying the upper extremity of the lower fragment outward to a line which will as accurately as pos- sible coapt it to the upper fragment. This can best be done by placing base upward in the axilla a pad composed of a mass of oakum wrapped in lint, modelled into a somewhat wedge-shaped form, and of a thickness which is found suf- ficient for the purpose. The pad so placed is retained by the second roller of Desault, applied in the following manner: Fix the initial extremity of the roller by two circular turns, which include the thorax and the arm on the injured side. They pass over the head of the humerus and under the sound axilla. Descend the chest and arm by spirals, over- lapping one-half. These turns must constantly increase in tension until the elbow is reached, when the bandage is pinned. The spirals may somewhat converge on the sound side, so that they overlap three-quarters of their width. In this way the elbow is drawn to the body and the upper extremity of the humerus forced outward by the action of the low spiral turns, which press the shaft of the 9° A CLINICAL TREATISE OX FRACTURES. humerus upon the pad, as upon a fulcrum. As the upper fragment seldom requires any attention, except that it be controlled as far as possible from voluntary or involuntary muscular efforts, the remaining requirement is that fixation should be maintained. This is best done by the employ- ment of a nicely fitting cardboard shoulder-cap extending well down to the elbow. It is very desirable that this cap should have been moulded and thoroughly dried before the application. The latter may, therefore, be delayed for a day or two for this purpose if a cap already prepared is not at hand. It may be retained bv turns of a bandage extending- around the chest ; but a more secure and neat method is by wide rubber adhesive strips. A broad handkerchief-sling supports the forearm and hand. This dressing, if entirely comfortable to the patient, may be allowed to remain undis- turbed for two days, when it should be removed, elevating support being given meanwhile to the elbow, and the skin bathed with alcohol at every part that has been confined by the bandage. After this change, it will not usuallv be found necessary to remove and reapply at less intervals than five days or a week. In many cases it is possible to begin passive motion at the shoulder-joint early, if such motion is conducted with great care in order to avoid disturbance of the fracture. As there is much tendency to rigidity at this joint, early motion of it is very important, and it must always be borne in mind that even the slightest movement made with the utmost gentleness and gradually increased at each dressing will prove of the greatest use in restoring function after the fracture has united. Seizing the upper FRACTURES OF THE UPPER EXTREMITY. 9 1 portion of the arm with the left hand the ringers are thrust into the axilla and the upper fragment is pressed between them and the thumb in order to make it follow, if possible, the movements of the lower fragment conducted by elevat- ing the elbow. At the end of four weeks union will have begun, but it is seldom firm before six weeks. The dressing should be discarded ten days after no motion can be detected at the seat of fracture. For the succeeding two months, every care, by the employment of gentle exercise and mas- sage, should be taken to prevent permanent disability, for few of the major joints seem so liable to be neglected by the patient if he is not carefully supervised. Paralysis of the deltoid, an occasional complication of this injury, may be caused by the original impact producing the fracture, for it not infrequently follows mere contusions at the shoulder. It is tardy in its course and disappointing in its management. Electricity and massage are the agents which prove most efficient for its relief. Fractures of the anatomical neck may be managed in very much the same way ; but the necessity of forcing the shaft of the bone outward being much less the axillary pad need not be so thick. The flattening of the shoulder which is caused by drooping of the arm requires elevation of the latter. The third roller of Desault will best accomplish this, applied in the following manner : Place the initial extremity of the roller under the axilla on the sound side, and carry it obliquely across the front of the chest to the middle of the summit of the shoulder on the injured side. Down behind the humerus, and parallel with it to the elbow ; 92 A CLINICAL TREATISE ON FRACTURES. under the latter, and across the front of the chest to the axilla on the sound side, where the initial extremity is met and fixed. The roller now passes under the axilla, obliquely across the back to the middle of the summit of the shoulder on the injured side. Down in front of the humerus, and parallel with it to the elbow ; under the elbow, and across the back to the axilla on the sound side, which completes one entire turn — an anterior and a posterior triangle. From this point it emerges, and is in position to cross the front of the chest to the shoulder on the injured side as before, and descend behind the humerus, and pass under the elbow, back again to the axilla. Another posterior turn is then made. In this way three anterior and three posterior tri- angles are formed, which exactly repeat each other, and the end of the roller is pinned at any point in front. Each intersection also must be secured by pins or adhesive plaster, and a sling to support the forearm and hand completes the dressing. Fractures of the head, of the tuberosities, or epiphyseal separation of the upper extremity of the humerus, are appro- priately treated by the application of a similar dressing to that used for fractures of the anatomical neck. Non-union of fracture of the anatomical neck does not perhaps occur as often as is supposed. Union, however, is likely to be long delayed, but ultimate restoration of func- tion, partial or complete, may not thereby be prevented. As already stated, an impacted fracture at this point, unless the impaction be relieved by the manipulations made dur- ing the examination, may readily escape detection, for fre- FRACTURES OF THE UPPER EXTREMITY. 93 quently no sign pointing to it exists which is not also present after a severe contusion or sprain of the shoulder- joint. Dislocation of the detached head accompanying this fract- ure is occasionally met with. Through what process this combined lesion occurs it is difficult to demonstrate ; but it is reasonable to suppose that the force producing the injury fractures the bone and tears the capsular ligament, and permits the head of the bone to be easily dislodged from the glenoid cavity and tilted out by the lower frag- ment. In dealing with the dislocated detached head of the bone, the first consideration relates to the possibility of replacing it by manipulation. This, unfortunately, can rarely be successfully accomplished, the collapsed capsular ligament seldom permitting of re-entry through its tear. If the fragment cannot be so restored, the chance of estab- lishing a new shoulder-joint by articulation, more or less perfect, of the fractured extremity of the humerus with the glenoid cavity remains. The head of the bone may, pro- vided it causes no trouble, be ignored as an inert foreign body ; otherwise it should be removed. Opening the shoul- der-joint and replacing it is a practice that cannot be advised under the conditions likely to obtain. A surgical injury allied to this is the occurrence of a fracture of the shaft or neck of the humerus produced by efforts made to reduce an old dislocation at the shoulder-joint. Such a fracture, particularly if high up, is by no means to be con- sidered a surgical calamity. Like other accidents which ma}* result from this procedure, it should be mentioned 94 A CLINICAL TREATISE ON FRACTURES. to the patient beforehand as a possibility. Should the line of fracture fortunately be above the insertion of the deltoid, no attempt at fixation is indicated. The fracture should remain ununited in order to establish a false joint at its seat. FRACTURES OF THE SCAPULA. Fractures of this bone occur in four principal localities, and may be so divided into (i) fractures of the body, (2) fractures of the acromion process, (3) fractures of the cora- coid process, and (4) fractures of the glenoid cavity. (1) Fracture of the Body of the Scapula. — The line of single fracture in the body of the scapula may extend in such a direction that only the lower angle is separated ; it may extend obliquely in any direction, including in its course the spine ; or it may involve only that portion of the bone above the spine. The part most commonly fractured is some portion of the broad, thin plate below the spine (Fig. 53), both on account of its greater exposure to the effects of blows and falls and because it is so frail. Almost invariably broken by direct violence, this por- tion of the body is frequently the seat of comminuted fracture. The spine being structurally the strong- est part of the bone, seldom yields to direct, indirect, or muscular vio- lence, except at its surgical neck. From this point outward to its acromion process it is increas- ingly liable to fracture. Fig. 53. Fracture of the body of the scapula. FRACTURES OF THE UPPER EXTREMITY. 95 Diagnosis of fractures of the body of this bone may occasionally be made by palpation, especially if they involve the spine and are accompanied by displacement. Carrying the fingers along the spine, particularly in thin subjects, even a slight deviation from its natural contour is felt. Seizing the bone on either side of the supposed deformity, crepitus may be elicited together with slight mobility. Should the fracture involve only the body of the bone below the spine, no deformity may be apparent, and yet the presence of fract- ure and approximately its line may be determined by the following manipulations : Carrying the elbow well back, the inferior angle of the scapula will be made prominent ; and it will be found possible to thrust three fingers of the other hand well under the bone, in many subjects as far as an inch and a half. Good control of it is obtained in this way, and it will be found very easy to make a satisfactory explor- ation of its whole lower surface by movements with one hand and counter-movements with the other, aided by a variety of motions imparted to the shoulder. This manip- ulation, although I have never seen it described, is a very simple and effective one in furnishing positive or negative information of an injury which is likely to be otherwise obscure. (2) Fracture of the coracoid process of the scapula as a simple injury is of so rare occurrence that it hardly needs consideration. Many of the separations of this pro- cess which are recorded are epiphyseal. Whether it is detached by fracture of bone or cartilage, however, has little bearing on its presence or its management. 96 A CLINICAL TREATISE ON FRACTURES. Diagnosis. — In thin subjects, if an injury about the shoulder is unaccompanied by great swelling, the coracoid process can be felt with the fingers. If fracture is present, this process will be felt to move in conjunction with the motions of the humerus, while the scapula is held firm. The slight forward displacement of the shoulder which accompanies this fracture may be reduced by forcing the head of the humerus backward well into the glenoid cavity, to recur on removing the pressure. (3) Fracture of the Acromion Process of the Scapula. — From its intimate connection with the clavicle, the acro- mion process is liable to fracture from any force which would either fracture or dislocate the acromial end of the clavicle, particularly such forces as blows and falls upon the shoulder. It may be fractured anterior to the acromiocla- vicular articulation, through and involving it or behind it. Fracture anterior to the articulation of the clavicle is an injury which is unimportant in all respects. No displace- ment occurs; there is no change in form or risk of inter- ference with future function of the shoulder-joint; and .pro- viding the accompanying contusion causes no paralysis of the deltoid muscle, no complication need be feared. Its diagnosis is not difficult; but as the movements of the shoulder-joint necessary for its detection are painful, the examination for it, as well as for other fractures in this locality, had better be made, if possible, during anaesthesia. Having eliminated the clavicle from injury, and the sterno- clavicular articulation being found intact, crepitus can usually be elicited by elevation and rotation of the arm FRACTURES OF THE UPPER EXTREMITY. g 1 / while the fingers of the other hand are firmly pressed upon the acromion. As already stated, deformity is slight or absent, especially in fleshy subjects. If the fracture includes a portion of the articular sur- face or is posterior to it, there may be enough deformity to be felt by carrying the finger along the spine of the scapula, when, the point of fracture being reached, a slight cleft or depression will be felt. The point of fracture may also be accurately located by free movements of the shoulder-joint in various directions while the fingers are placed at differ- ent points long the spine of the scapula. Treatment of Fractures of the Scapula. — The indications for treatment of fracture involving any portion of the scapula are usually simple. In the large proportion of cases, there being little or no deformity to combat, the simplest kind of dressing will be found to give sufficient fixation to secure the occurrence of early union. This is true of fractures of the body of the bone and of its proc- esses. The arm should be retained at the side by the application of spiral turns of the broad roller bandage, a broad handkerchief-sling supporting the hand and forearm. If all opposing skin surfaces are protected by single layers of lint, the dressing will prove comfortable, and may be retained five days or a week undisturbed. At the end of three weeks it may be discarded. If there is drooping of the head of the humerus after fracture of the coracoid process, the position maintained by Velpeau's bandage will be found the one which best corrects tendency to this condition. In fractures of the body, especially when comminuted, useful 98 A CLINICAL TREATISE ON FRACTURES. support to the fragments will be obtained by the employ- ment of a neatly fitting cardboard shoulder-cap, so shaped that it will extend down over the whole bone. This can well be retained by the Velpeau bandage. Since after fracture of the scapula there is little tendency to deformity, and as the original injury has not unlikely caused either a sprain or a contusion of the shoulder-joint, early passive movement of the latter is practicable, and should be begun immediately. These movements should be performed gently, but may without risk be given considerable lati- tude. FRACTURES OF THE CLAVICLE. As fractures of the clavicle are often far from satisfactory in their results, either because they unite with unsightly deformity, or by delayed union cause impairment of func- tion, through rigidity of the shoulder by long disuse, or by failure to unite altogether, they have received their full share of surgical thought and attention. Though occasionally broken by direct violence, which causes an approximately transverse fracture, the clavicle is more fre- quently fractured obliquely by force indirectly applied, and in some instances by muscular action. Its external extrem- ity, usually broken by direct violence, such as the kick of a horse, is an uncommon seat of fracture. In describing a fracture which is of such frequent occurrence, the subject can only be properly presented by sufficiently emphasizing the conditions as they are usually found. In a very large proportion of instances the bone is fractured in its middle FRACTURES OF THE UPPER EXTREMITY. 99 third, the shoulder is drawn forward and inward, carrying down with it, principally by gravity, the outer fragment, which, with its axis deflected backward, overlaps the inner fragment. These alterations in the position of the outer fragment cause the inner fragment to be relatively elevated and brought forward into prominence: and it is, therefore, the inner fragment which always appears to be, but is not, chiefly at fault. The action of the clavicular insertion of the sternocleidomastoid muscle, which has always been credited with elevating the inner fragment, has in reality, I think, little effect. The evil consequences resulting from a continuance of this characteristic deformity are narrowing of the shoulder, which causes deficient purchase for the perfect action of the shoulder-joint; a sharp bony promi- nence upon the shoulder, which prevents the carrying of loads upon it; and, finally, especially in women, whose cos- tumes may expose the neck, a lasting defect which, justly or unjustly, reflects upon the treatment. The cause for ununited fracture is mainly want of fixation, though an extent of overlapping which brings shaft surfaces, instead of fractured surfaces, in contact, would seem to exercise an influence in certain cases. It must be remembered that the deformity alluded to above is excessive deformity — deformity great enough either to be very noticeable or in some way to interfere with the functions of the shoulder-joint or the upper extremity. But the clavicle is so superficially situ- ated beneath the integument that even slight loss of its natural contour can be plainly felt or seen; and it may therefore be fairly stated that no complete fracture, where 100 A CLINICAL TREATISE ON FRACTURES. there has been any overlapping at the outset, will unite with the fragments in such ideal apposition that slight deformity will not remain. Diagnosis. — The means employed for the detection of fracture of the clavicle, either at its more common seat, the middle third of the bone, or at its sternal or acromial end, are the same. There is pain, much increased on attempt to move the upper extremity ; there is contusion of the integument over the clavicle in the exceptional instances in which the fracture has been caused by direct violence ; and there is usually sufficient deformity of the character above described to be plainly apparent on inspection. Pal- pation is made over the length of the bone with the object of both noting any loss of contour which may exist and of locating, if possible, the seat of fracture. In young children such an examination is often all that is necessary, for their outcries cause convulsive respiratory movements which disturb the fragments and produce distinct crepitus. In conducting a further examination in adults, the patient should lie upon the back without a pillow. In this posi- tion the whole shoulder will usually become so relaxed that various manipulations can readily be made. Seizing the shoulder-joint with one hand, the clavicle is grasped between the thumb and fingers of the other, and, while the shoulder is alternately elevated and depressed, carried forward and backward, corresponding counter-movements with the fin- gers grasping the clavicle are made. Preternatural mobility and crepitus will thus in most cases become distinctly ap- parent, and the seat of fracture can, as a rule, be accurately FRACTURES OF THE UPPER EXTREMITY. IOI located. If the inner fragment stands out prominently beneath the integument, its tendency to obliquity can be ascertained by its sharpness. If the fracture is situated at either the sternal or the acromial extremity, crepitus with very slight or no mobility, and either slight or no deformity, are usually present. By the aid of these various manipula- tions difficulty will rarely be found in making an accurate diagnosis. Treatment. — The very large number of appliances of various sorts which are recommended and employed in the treatment of fracture of the clavicle give the best evidence of the difficulties which are encountered in managing it satis- factorily. The principal indications are universally recog- nized, and almost every apparatus suggested fulfils them in the same general line, though bv various means. The shoulder droops, it must be elevated ; it is drawn forward, it must be thrown backward ; it is narrowed, it must be restored to its natural breadth. Whatever apparatus is used is designed in its own particular fashion to correct these abnormal tendencies. But the correction of deformity is not the only consideration. Fixation after the displacement has been overcome, at least as perfect fixation as can be obtained, is absolutely essential. Fixation depends not only upon retaining the shoulder-joint and upper extremity at rest, as the patient stands before you, but also upon so controlling voluntary muscular actions by the dressing that he will not immediately move the fragments unwit- tingly. This he may do in performing various acts with his sound arm, in lying down, turning in bed, or in dressing 102 A CLINICAL TREATISE ON FRACTURES. and undressing. Two very important details in the appli- cation of any dressing which tends to promote the perfect fixation of the fragments are : (i) To employ a dressing which will both in position and in degree of tension remain unchanged between visits. (2) To employ a dressing that will be sufficiently comfortable to the patient in all respects to avoid his being tempted to meddle with it with his other hand. It will at once be seen that the use of many appli- ances is negatived by carrying out these two details only. Slings, handkerchiefs, and bandages, as frequently applied, become so slack in a few hours that they accomplish nothing. All apparatus made fast by tapes, buckles, or knots are to be avoided in most cases, as the patient readjusts them to suit himself ; no discretion must be given him but with the full knowledge of the surgeon. Many more appliances will be found undesirable if the matter of comfort is con- sidered. This observation can be appreciated by any one who has ever had any injury about the shoulder-joint, and who has experienced the extreme discomfort of certain apparatus. A dressing must be applied which will not excoriate any part of the integument, will not obstruct respiration in the recumbent posture, and will not confine the arm and forearm in an intolerable position. A dressing which will be found almost invariably applicable in meeting these various indications, if it is used with careful atten- tion to every necessary detail, in subjects of both sexes and all ages, is the dressing of Desault, perhaps slightly modi- fied. When this is to be applied there should first be a few days' confinement to bed, if practicable. The patient FRACTURES OF THE UPPER EXTREMITY. IO3 should lie flat on his back upon a rather hard mattress and a low pillow, which position, if maintained con- tinuously, will generally overcome the deformity com- pletely. Desault's dressing may then be applied in the following manner: A large pad in the axilla, best made of oakum, folded into a piece of canton-flannel or patent lint in the form of a wedge can be perfectly retained in position by the application of the second roller of Desault. Having placed two layers of lint upon the injured shoulder, beneath the elbow, and in the sound axilla, the third roller is applied. The forearm will then be found to rest against the abdomen, and contact of skin surfaces is pre- vented by the insertion of one layer of lint. If the subject is fleshy, lint should also be placed in the fold at the bend of the elbow. A comfortable sling padded at the back of the neck and beneath the wrist supports the hand, with the fore- arm in a state of right-angled flexion. In applying the third roller, the numerous turns across the injured shoulder should be made to intersect close enough to the root of the neck to press upon the inner fragment if possible ; but a compress at this point is seldom necessary. Remembering that many yards of roller bandage are carried around the chest in the application of these two parts of Desault's dress- ing, and that each turn increases the aggregate constriction of the chest, too much tension should not be employed. In order to prevent any of the turns becoming disarranged, and also to lessen the tendency of the roller bandage to become slack, one-inch straps of rubber adhesive plaster two yards long should follow the turns of the third roller, and be 104 A CLINICAL TREATISE ON FRACTURES. also carried around the chest and upper and lower parts of the arm. By this dressing fixation as complete as by any other is perhaps obtained ; and it may be further promoted by warning the patient to allow his injured shoulder and arm to hang as relaxed as possible ; certain it is, that if he is ignorant of the harm he does, he may move his shoulder at will and disturb the fragments, no matter how securely they are retained by any dressing. The position thus maintained Sayre, of New York, accom- plished by an ingenious application of broad adhesive strips. The first of these, which is long enough to encircle the arm and one-third more than the circumference of the trunk, of a breadth of three and a half inches, is looped by its initial extremity around the middle of the arm. The loop is held secure by a pin, or, better, two or three stitches, while the free end is carried transversely across the back, around the front of the chest, and again to the back, its terminal end being fastened to that portion just beyond the spine on the sound side. This encircling strip surrounds the chest on a level with the middle of the arm and retains the arm somewhat back of the vertical line. The second strip, long enough to traverse a circumference corresponding to a plane from the middle of the sound shoulder to the injured elbow, has its initial extremity fixed over the sound scapula, whence it is carried obliquely downward across the back to the injured elbow, to which it is made to give a decided but not forcible support, up the chest, including in its course the forearm and hand, to the shoulder on the sound side and to the starting-point, its terminal end should be securely FRACTURES OF THE UPPER EXTREMITY. 105 attached to its initial end. In order that the point of the elbow shall not receive undue pressure a small hole is made in the plaster at a corresponding point to the latter, which, with the addition of a little lint padding, will protect this very sensitive part from excoriation. Even a slight growth of hair upon the forearm, or elsewhere, should invariably be removed with a razor before the application of this or any similar adhesive plaster apparatus. In order that the arm-loop shall not disturb the circulation in the forearm and hand, it should not be made to encircle the arm too tightly. Close attention should be paid to the edges of the adhesive plaster at all points lest they excoriate the skin. The dressing of Desault should be removed in two days, and, after thorough bathing of the skin with alcohol, reap- plied. During this process upward pressure of the elbow and backward pressure of the shoulder will retain the frag- ments at the seat of fracture in proper apposition. After this the dressing may often be allowed to remain undisturbed for four or five days throughout the treatment, but it must always be changed at any time it becomes loose. Under favorable conditions the bone will appear firm in three weeks ; but as it is not strong, the dressing should be con- tinued for ten days after apparent union occurs. After discarding the special dressing the arm may be retained to the chest and the hand supported by a single turn of a bandage and a sling until they can be prudently released. Passive movements of the shoulder-joint may usually be begun in the second week, and continued at every dressing thereafter. CHAPTER Hi. FRACTURES OF THE LOWER EXTREMITY. FRACTURES OF THE FOOT. Fractures of the Phalanges. — Usually fractured by direct violence — that is, by being crushed beneath some heavy falling object — the phalanges of the toes are occa- sionally fractured by force indirectly applied to their tips. As with fractures of the phalanges of the fingers, the force required to break the toes is so great that the injured toe is frequently the seat of severe damage of the soft parts as well as of the bone. In simple fractures there is seldom much displacement, though almost invariably considerable contusion of the soft tissue. Diagnosis. — By extension exerted upon the tip of the toe, alternated with a movement which thrusts it toward the foot, and by rotation in various directions while the suspected seat of fracture is held between the thumb and fingers, pain on pressure, moderate preternatural mobility, and usually crepitus can be elicited. Phalangeal joints are so frequently already distorted that little evidence can be obtained from inspection of contour. Treatment. — Any deformity present can usually be over- come by manipulation. The patient, if possible, should be put to bed and an evaporating lotion applied to the injured toes. To retain the fracture in a state of fixation, 106 FRACTURES OF THE LOWER EXTREMITY. \OJ a cardboard splint cut to conform to the margin of the foot, very much in the shape of the sole of a shoe, should be applied. Three or four layers of patent lint furnish suf- ficient padding, and the splint is applied in a macerated condition and retained by a spica bandage of the foot. At the end of one week the patient may be allowed out of bed, and the splint should be continued for three weeks, after which no retaining dressing is required unless the fracture be of one of the phalanges of the great toe, which, as the latter takes a more important part in the function of the foot, should be kept at rest for four and a half weeks. Fractures of the Metatarsal Bones. — Fracture of the metatarsal bones is much more likely to be caused by direct than by indirect violence ; and among the various ways in which the force may be applied, the falling of heavy objects upon the foot is much the most frequent. Diagnosis. — The detection of fracture of the first and fifth metatarsal bones is usually easy; of the intervening ones, difficult, as the dense tissues constituting the ten- dinous and ligamentous structures of the foot are made extremely tense by the contusion accompanying the fract- ure. It is often impossible, particularly without the use of an anaesthetic, to obtain positive evidence of fracture of a metatarsal bone ; and it is not uncommon that, a fracture of one metatarsal bone having been demonstrated, a fract- ure in one or more of the others is overlooked. Again, the nearer the fracture is to the base of the bone the more diffi- cult it is to eliminate the mobility of the tarsometatarsal articulation and to obtain crepitus. These conditions are io8 A CLINICAL TREATISE ON FRACTURES. shown in Fig. 54, illustrating transverse fracture at the base of the second, oblique fracture of the third, and transverse fracture of the fourth metatarsal bone. By alternately lifting and depressing the head of each metatarsal bone in turn, while a counter-movement is made with the thumb and Fig. 54. Skiagraph of fracture of three metatarsal bones. fingers of the other hand at the middle third of the shaft, preternatural mobility and crepitus may be detected, but overlapping sufficient to produce deformity apparent through the integument is uncommon. Pain as a diagnostic symp- tom is of little value, as a contusion of the foot will fre- FRACTURES OF THE LOWER EXTREMITY. IO9 quently cause as much pain and tenderness on pressure as a fracture of a metatarsal bone. Treatment. — As there is rarely any deformity requiring correction, efforts should be directed primarily to reducing the tension. This may be best accomplished by elevation and the application of evaporating lotions. During the first fortnight the patient had far better remain in bed ; and while there, there is little tendency of the fragments either to become displaced or to be movable ; the application of a FIG. 55- Skiagraph of fracture through the middle of the os calcis. plantar cardboard splint, retained with a spica bandage, promotes the patient's comfort by giving him confidence to change the position of his foot without risk of doing harm. Where the swelling is not excessive, or subsides in a few hours, a plaster-of-Paris dressing, including the foot from the tips of the toes to the ankle, furnishes an excellent method for the treatment of this fracture. Fractures of the Tarsus. — Considered as a whole, sim- ple fracture of the tarsus is more common than simple no A CLINICAL TREATISE ON FRACTURES. Fig. 56. fracture of the carpus. Simple fractures of the smaller bones — the scaphoid, cuboid, internal, middle, and external cuneiform — are very rare. Fracture of the astragalus is also rare, the os calcis being the one bone of the tarsus which is most liable to yield through the action and degree of forces applied in such a manner as to cause a simple fract- ure. Of these, falling or jumping from a height and light- ing on the feet is the most usual cause of fracture. Fracture may result from violent contraction of the tendo Achillis, when there is usually merely a tearing off of a thin plate of bone immediately under- lying the insertion of the tendon. The plane of fract- ure involving the os calcis is apt to be vertical and, approximately, through the middle of the bone, as shown in Fig. 55. More rarely the line of fracture is anterior to this, as shown in Fig. 56. The fibrous envelope of this bone is so dense and complete that little deformity results. The sustentaculum tali is rarely fractured ; but occasionally a sudden and forcible inversion of the foot breaks it off. Fracture of the astragalus, very rare as a simple injury, may be caused by a fall from a height upon the foot. Fig. 57 represents a fracture through the neck of the bone, the diagnosis of which was definitely made before the skiagraph was taken. Fracture of the os calcis. FRACTURES OF THE LOWER EXTREMITY. II I Diagnosis of Fractures of the Tarsus. — Os Calcis. — If the fracture involve the body of the bone behind the insertion of the lateral ligaments, preternatural mobility may be detected by swaying the heel from side to side, while the foot is grasped firmly; and during the performance of Fig. 57. Skiagraph of fracture of the neck of the astragalus. these movements crepitus may be elicited. If in front of the insertion of the lateral ligaments, the signs of fracture are much more difficult to obtain; indeed, it is often impossible to detect mobility or crepitus without the exercise of a degree of force which is perhaps unjustifiable unless the patient is anaesthetized. Should the fracture involve the posterior extremity of the bone, the surface for insertion of the tendo Achillis having been dragged off by the latter, there will be observed complete inability to extend the foot, 112 A CLINICAL TREATISE ON FRACTURES. the calf will be completely relaxed, and the contour of the ankle will be so altered that a depression will be observed upon its posterior aspect, instead of the sharply defined prominence of the tendon. The symptoms observed in the rare instances in which the sustentaculum tali has been torn off are eversion of the foot with complete inability to invert it, the foot thus assuming the position of valgus ; and shortening of the heel by slight forward displacement of the os calcis. When these conditions are observed in the absence of a fracture of the lower end of the fibula, producing Pott's fracture deformity, or laceration of the internal lateral ligament of the ankle-joint, fracture of this process may be suspected. Astragalus. — As already stated, fracture of this bone is so rare that when it occurs it is likely to escape observation if the fracture involves any other part than the neck. The case, a skiagraph of which is reproduced in Fig. 57, occurred in a very large, heavy man who had fallen a considerable distance. Pain just in front of the ankle-joint suggested the examination of the astragalus, which revealed crepitus, and slight preternatural mobility at a point corresponding to its neck. But there was no deformity. Treatment of Fractures of the Tarsus. — Os Calcis. — If the os calcis is fractured but not displaced, or if the displacement is so slight that it can be detected only by a skiagraph, rest for a period of a fortnight (after which the swelling will usually have receded) is the most important part of the treatment. During this time a fracture-box may well be employed to keep the foot at rest. At the end of FRACTURES OF THE LOWER EXTREMITY. I I 3 two weeks a plaster-of- Paris bandage, extending from the tips of the toes to a point just above the ankle-joint, will give the patient sufficient support to enable him to get out of bed and sit in a chair with the leg elevated. After three weeks he may safely walk on crutches, but should not put weight upon his foot until the plaster-of-Paris dressing has been cut and removed, which may be done at the end of four and a half or five weeks. As the deformity resulting from fracture through any portion of the posterior part of the bone consists in either tilting or complete separation of the posterior fragment through the action of the gastrocnemius and soleus muscles, the greatest relaxation of these must be obtained in order more readily to bring the posterior fragment forward. Re- tention of the foot in a state of complete extension still further favors coaptation, which is best obtained, after an anterior obtuse-angled splint has been placed in position, bv the application of a basket-like arrangement of rubber adhesive strips made to envelop the calf completely, each strip converging at the heel and anchored on the sole of the foot. Should these measures fail to secure approxima- tion sufficient to warrant the assumption that good union will occur, it is quite proper, provided the surgical require- ments for operation are complete, to cut down and suture the fragments with silkworm-gut or silver wire. Astragalus. — As there is no deformity after fracture of the astragalus, the treatment is very simple, and consists of rest. The limb is therefore conveniently placed in a fracture-box for a few days until any swelling has subsided, 114 A CLINICAL TREATISE ON FRACTURES. when a plaster-of-Paris dressing is applied and retained for four weeks. At the end of this time gentle use of the extremity may be begun. FRACTURES OF THE LEG. Fractures of the leg include fracture of (i) the tibia, of (2) the fibula, or of (3) both these bones. (1) Fractures of the Tibia. — Fractures of the tibia may be conveniently considered under (a) the lower extremity and (b) the shaft. Fractures of the upper extremity not involving the knee- joint possess so few characteristics not common to fract- ures elsewhere in the shaft that they need not be separately described. (a) Fractures of the Lower Extremity of the Tibia {Fractures of the Internal Malleolus). — The internal malle- olus may be broken at a point so low down that merely its tip, remaining attached to the internal lateral ligament of the ankle-joint, is broken off ; or it may be fractured at its base, so that the lower fragment consists of the entire process. Little deformity may result, though the tendency is to eversion of the foot. The line of fracture may extend through the lower extremity of the bone just above the articular surfaces, or its plane may be slightly oblique in any direction ; if so, the deformity resulting is determined in its direction by the inclination of the oblique plane, though any overlapping present is caused by muscular contraction. (b) Fractures of the Shaft of the Tibia. — Fractures of the shaft of the tibia incline to be transverse if the fracture FRACTURES OF THE LOWER EXTREMITY. 115 has been caused by force directly applied ; and incline to be oblique if the force producing the fracture has been indirect (Fig. 58). Fractures of the upper third incline more to be transverse, while fractures of the middle and lower thirds are more frequently oblique. The extent of deformity after fig. 58. Skiagraph of oblique fracture of the shaft of the tibia. fractures of the tibia is usually in direct proportion to the obliquity of the fracture ; and while this deformity is clearly influenced by the direction of the plane of fracture, it is most commonly observed to result in anterior bowing with prominence of the upper fragment. If the plane of fracture assumes a somewhat spiral form, rotation inward or n6 A CLINICAL TREATISE ON FRACTURES. outward in the direction of this spiral results, constituting what has been described as corkscrew fracture (Fig. 59). The anterior bowing depends not only upon the predomi- nance in strength of the posterior group of muscles, but probably also to some extent upon the weight of the foot. This latter, though an unimportant element in the produc- tion of the original deformity, should not be lost sight of in Fig. 59. Fig. 60. Skiagraph of corkscrew fracture of the Skiagraph of green-stick fracture of the shaft of the tibia. tibia. treatment. Green-stick fracture of the tibia is rare, but Fig. 60 represents such a fracture which apparently had immediately sprung back into position. Diagnosis. — The diagnosis of fracture of either the lower extremity of the tibia or of its shaft is seldom diffi- cult. At the lower extremity, while there may be no de- formity, preternatural mobility and crepitus can usually be FRACTURES OF THE LOWER EXTREMITY. WJ readily elicited by forcibly inverting and everting the foot, while the fingers of the left hand are placed over the lower portion of the tibia. If no deformity is apparent, and none can be produced by manipulation, and no undue mobility or crepitus can be detected, important data bearing upon the subsequent treatment have been secured. If the fract- ure is situated in the shaft, the deformity, preternatural mobility, and crepitus are in the vast majority of cases so distinctly apparent that the diagnosis is rendered entirely simple. Fractures of the Upper Extremity of the Tibia. — As has been stated, fractures of the upper extremity of the tibia possess few characteristics not common to fractures situated elsewhere in the bone. Fractures just below the tubercle are very liable to be transverse. In their diagnosis, therefore, the fact that there is seldom any overlapping must be borne in mind. Preternatural mobility and crepitus are readily detected, but any deformity present will be found to be due, not to overlapping, but to rotation of the lower fragment, either external or internal, or to deflection in any direction of its long axis away from that of the upper frag- ment. Fractures of the head of the tibia, involving the joint, extend from somewhere about the middle of the artic- ular surface to the inner aspect of the shaft or to its outer aspect. If, therefore, the broken fragment includes the inner portion of the articular surface, a deformity resembling genu varum is induced ; and in the same manner, if the broken fragment involves the outer portion of the articular surface, the condition of artificial genu valgum will probably be Il8 A CLINICAL TREATISE OX FRACTURES. produced. These signs, however, are not sufficiently charac- teristic of fracture of the head of the tibia, nor are they so generally present as to be regarded as reliable. A more searching examination frequently being necessary, an anaes- thetic should, if possible, be used, as fractures about the Fig. 6i. Skiagraph of comminuted fracture of the head of the tibia, with accompanying fracture of the fibula. knee-joint are extremely painful. Fig. 61 shows a comminuted fracture of the head of the tibia, the head being separated from the shaft and itself divided into two fragments. The skiagraph also shows fracture of the head of the fibula. Fractures of the Fibula. — Fractures of the fibula, while they may occur at any point in the shaft or at either ex- tremity, will be described in the order of their importance. Those occurring at the lower portion of the shaft, at a point between the junction of the middle and lower thirds and the articular, or malleolar extremity, will first be considered. Because of certain peculiarities possessed by it, which were FRACTURES OF THE LOWER EXTREMITY. I 1 9 first pointed out by Pott, fracture at this point has since been known as Pott's fracture; and while not invariably causing deformity, it is very liable to do so. The deformity when marked can hardly be overlooked, but it is often so slight that it may readily escape detection. Particularly is this true when no weight is borue by the limb. Fig. 62 illustrates this condition. The photograph, of which it Fig. 62. Pott's fracture of the fibula, with slight deformity. is a reproduction, was of a recent fracture accompanied by very slight deformity, which could, however, be easily increased by putting weight upon the limb. In such cases it is very important to detect the slightest tendency to deformity at the first examination. After Pott's fracture, the continuity of the shaft of the fibula being lost, the fragments show a tendency to cant inward. The external malleolus, which forms the outer wall for the ankle-mortise, is thereby deflected laterally and permits the trochlea of 120 A CLINICAL TREATISE OX FRACTURES. the astragalus to follow it. This increased latitude of movement allows of eversion of the foot and a condition of artificial talipes valgus is induced. The loss of func- tion resulting from failure to overcome the tendency to this deformity depends partly upon the diminished firmness of the ankle-mortise, and partly upon the axis of weight being directed abnormally to the inner side of the foot. This latter defect stretches the internal lateral ligament of Fig. 63. Skiagraph of oblique fracture in the lower third of the shaft of the fibula. the ankle-joint, breaks down the arch of the foot, and causes a weakness which is progressive. Both of these conditions tend to force the astragalus still further outward against the slanting wall of the external malleolus, should the deformitv not have been wholly corrected or should the patient be put upon his feet before union is entirely firm. Fractures of the external malleolus, whether transverse or, as shown in Fig. 63, oblique, if they are so situated that FRACTURES OF THE LOWER EXTREMITY. 121 no latitude of movement of the astragalus is allowed and the ligamentous attachments with both tibia and tarsus have not been disturbed, will frequently be found to exist without deformity. The fibula taking no part, strictly speaking, in the support of the body, its fracture above this point does not necessarily even interfere with locomotion, seldom produces much deformity, and can therefore be properly regarded as among the least serious of fractures of the leg. Diagnosis. — Diagnosis of fracture of the upper portion of the shaft of the fibula is often difficult to establish ; the pain present may well depend upon contusion of the soft parts, if the fracture has been induced by direct violence, as by the passage over it of a light wagon-wheel. Should the seat of fracture be situated between the junc- tion of the lower with the middle thirds and the upper extremity of the bone, preternatural mobility, in thin sub- jects, and possibly crepitus may at times be produced, but there is seldom any deformity. If the leg just above the ankle is forcibly pressed between the thumb and fingers or grasped between the two hands, pain is often complained of at a point up the leg, remote from pressure. Such pain is strongly indicative of the existence of fracture, and careful palpation at this point will often reveal slight preternat- ural mobility. The diagnosis of fracture of the lower third of the bone is usually simple, and fortunately so, for its ex- istence at this point is often more serious. Alteration of contour just above the ankle, increased concavity of the outer line of the limb, slight or marked eversion of the foot, 122 A CLINICAL TREATISE ON FRACTURES. greater or less prominence of the internal malleolus — all point to fracture of the lower third of the fibula. Touching the bone at this point with the thumb and fingers while the foot is firmly grasped with the other hand, forward and backward swaying of the foot, alternated with its eversion and inversion, will usually reveal crepitus and preternatural mobility clearly enough to indicate not only the presence of fracture, but also to localize its seat with sufficient accuracy. Should the line of fracture extend through the external malleolus in such a direction that only a portion of the articular surface of the bone is involved, and there is no separation of the fragments to cause deformity and no tearing of ligaments to increase the mobility of the ankle- joint in any direction, the presence of fracture may be dif- ficult to determine. In such cases, however, the external malleolus, seized with the tips of the fingers and thumb, will be found to be slightly movable, and perhaps to yield indistinct crepitus. The pain present under these circum- stances, being in all respects the pain of a severe sprain of the ankle, is valueless as a diagnostic sign. Fractures of Both Bones. — Fractures of both bones of the leg possess characteristics in common with fractures of the tibia or fibula alone and other peculiarities separate and distinct from those. Fracture of the tibia at one point, and of the fibula at a point remote from it may cause a double set of symptoms. Thus, fracture of the upper third of the tibia and Pott's fracture of the fibula will present all the symptoms of both of these injuries. On the other hand, if the two bones are broken at points approxi- '■., FRACTURES OF THE LOWER EXTREMITY. 1 23 mately similar, the characteristic symptoms of fracture of the tibia, the overlapping, the bowing, the preternatural mobility will all be greatly exaggerated by fig. 64. the fracture of the fibula. And finally the » r symptoms of Pott's fracture of the fibula, the loss of natural contour, the eversion of the foot, the prominence of the lower ex- tremity of the tibia will all be greatly accen- tuated by a fracture of the lower extremity of the tibia, or by its luxation inward. Comminuted fractures, as illustrated in Fig. 64, are also more commonly observed. The conditions present, therefore, in fractures of both bones of the leg may not only combine those belonging to fracture of either bone, but also have added to them . . . ...... ., /^S, ■ others which serve materially to increase the . Comminuted fract- gravity of the 1111 ury. There is greater * J J J ° ure of the tibia liability of damage to the integument and and fibula. perhaps to the muscles and bloodvessels because the force required to break both bones is greater than that required to break one, and because, neither bone deriving any support from its fellow, the fractured fragments are free to be thrust in all directions. For the same reasons, over- lapping, bowing, rotation may all be more marked, than in fracture of one bone. Reduction is often facilitated by the complete mobility at the seat of fracture, but perfect fixation in true position is rendered more difficult. On this account, the liability to union with deformity, or to ununited 124 A CLINICAL TREATISE ON FRACTURES. fracture, is increased. Union of the two bones with one another is also liable to occur during repair, if the fract- ures are at the same point. Such a condition, by destroying the natural elasticity between the bones, may perhaps pre- dispose to subsequent fracture (Figs. 65 and 66). Fig. 65. Fig. 66. Co-union after fracture of tibia and fibula. Fracture of tibia after co-union of bones. Treatment of Fractures of the Leg. — The manage- ment of fractures of the leg, whether involving the tibia alone, the fibula alone, or both of these bones, may well be considered from a general point of view; because modifica- tions of the treatment usually applicable to all, made neces- FRACTURES OF THE LOWER EXTREMITY. 1 25 sary by the peculiarities of any particular fracture, are in most instances modifications of detail only. The indications to be met are the retention of the broken fragments, after being brought into as perfect apposition as possible, in a state of absolute fixation, and its continuance throughout the treatment. Among the causes for impairment of func- tion resulting from fractures of the leg, delayed union and ununited fracture are not to be lost sight of. They result more frequently after fracture high up, than fracture low down; and as the former is more liable to be imperfectly controlled by the dressing than the latter, I believe that in most cases in which, without other assignable cause, the fragments fail to unite, fixation will be found to have been incomplete. A fracture-box, or other splint, which extends only a short distance above the seat of fracture, controls only the lower fragment; it does not control the upper fragment. With such a fracture-box, the foot and lower fragment are held firm, while the upper fragment follows the various movements of the patient whenever he changes his position in bed. If the fracture is above the middle of the shaft, it is doubtful whether complete control of the upper frag- ment can ever be obtained by a fracture-box or by any dressing which does not extend at least as far as the middle of the thigh. Measurable control of lateral movements may be secured; but control of rotary movements, caused by turn- ing of the pelvis in either direction, cannot be had; and such movements are perhaps the most insidious ones to be dealt with. Anterior bowing, as mentioned above, being 126 A CLIXICAL TREATISE OX FRACTURES. the most common tendency for the deformity to assume, should be entirely overcome and even slightly overcorrected before the dressing is applied, as it is extremely inclined to reassert itself through sagging of the foot. Rotation of the lower fragment inward or outward should also be care- fully avoided, as subsequent in-toeing or out-toeing of the foot may produce more serious permanent interference with function than a slight bowing or slight overlapping. There is a prevalent tendency to apply all fixed dressings to the lower extremity with the foot more or less extended. This is to be particularly avoided, as any rigidity at the ankle- joint remaining after the treatment is discontinued leaves the foot in a position of talipes equinus. This may often require the use of an anaesthetic and the exercise of consid- erable force to correct. The single and simple dressing employed almost universally is that of plaster-of-Paris. Excessive swelling of the limb, however, at the seat of fracture, accompanied by phlyctense and blebs, contraindi- cates the application of a plaster-of-Paris dressing, for not only does such a dressing mask subsequent sloughing of the integument or suppuration of the cellular tissue which may occur, but the amount of soft padding which it is necessary to apply beneath the plaster-of-Paris in such cases also prevents the latter from giving the required support to the broken fragments. If applied immediately after the injury, over- tension from swelling must be guarded against, either by the application with the initial flannel bandage of a certain amount of a soft, yielding padding, by applying the plaster- of-Paris bandage rather loosely, or by cutting a vertical FRACTURES OF THE LOWER EXTREMITY. \2J incision through the dressing as soon as the plaster-of-Paris has set. These precautions are usually unnecessary if the application of the dressing is delayed long enough for the swelling to have receded. There is no objection to this delay, and it is, therefore, usually desirable, provided that the limb meanwhile is made comfortable and properly con- fined in a fracture-box extending far enough above the seat of fracture to give fair control of the upper fragment ; for a dressing applied after the limb has nearly resumed its normal dimensions fits better throughout the treatment. An excep- tion to this rule worthy of mention is when a patient is threatened with an attack of delirium tremens. Then a very heavy, strong, fixed dressing should be applied immediately, as the best safeguard against the damage liable to be done, if the patient, losing control of himself, thrashes his leg about. Tenotomy of the tendo Achillis may be indicated to prevent serious damage at the seat of fracture from muscular con- traction in cases of very active delirium tremens, but seldom as a procedure required to overcome displacement. A plas- ter-of-Paris dressing may usually be applied without the employment of an anaesthetic. If, however, deformity exists which cannot be reduced, or if, after reduction, it cannot be kept reduced during the application of the dressing, it is better to get thorough control of the limb and complete muscular relaxation by anaesthesia. The limb should be perfectly under control while the plaster-of-Paris bandage is being applied. Three trained assistants are required : one to support the thigh, another to support the leg and foot, and the third to assist the surgeon with the plaster bandages 128 A CLINICAL TREATISE OX FRACTURES. and the manipulation of the plaster-of-Paris. If so much help is not at command, some device which will support the limb in proper position may be used. One can be quickly extemporized on any bedstead. Two uprights (clothes-props) attached vertically to the head and foot of the bed are joined at the top by a third horizontal piece resting upon them, and held fast by wire nails. The patient rests in bed m such a position that his fractured leg is directly beneath the horizontal bar. The fractured leg is then placed upon two pillows which will elevate it about five inches from the bed, which involves slight flexion of the knee-joint. Rubber adhesive suspension straps are then applied to the middle of the thigh and to the foot. These are turned upon them- selves so that they shall have a loop above, through which a cord can be passed, which, being drawn taut, is made fast to the horizontal bar. On removing the pillows the limb may be found sufficiently supported. If a third point of support is needed, it should be in the form of a prop from beneath the limb to the bed. For this purpose a slender stick, like a lead-pencil, cut to the proper length and padded with a little knob of muslin, is placed at the desired point, there to remain until the application of the plaster-of-Paris bandage is completed. By a little experimental slackening and tightening of the suspending cords the limb will finally be suspended in very correct position without any manual aid. Gentle pressure with a finger or between the fingers and thumb at some point where slight deformity persists may at times be necessary to perfect the modelling process. In order to insure perfect fixation of the fragments in FRACTURES OF THE LOWER EXTREMITY. 1 29 various fractures, a rule always to be observed is to control the knee-joint by carrying trie dressing from the toes to the junction of the lower with the middle third of the thigh for all fractures of either or both bones of the leg ; except fract- ures of the internal or external malleolus without deformity. For the latter it is not necessary that the dressing should extend above the tubercle of the tibia. As has been stated, the knee-joint being slightly flexed during the application of the fixed dressing, it remains in this position throughout the treatment. In order, therefore, to give the limb com- fortable support a light pillow should be kept beneath the leg. In fractures about the ankle, if the tendency of the deformity is to inversion of the foot, care must be taken while applying the plaster-of-Paris dressing that this ten- dency be entirely corrected. In like manner, if the deformity inclines to thrust the foot forward or allow it to droop backward, critical inspection of its profile will demonstrate whether these tendencies have been satisfactorily overcome. In Pott's fracture, the rule is different ; the foot being everted, it is necessary not only to bring it back to the proper line, but also beyond that line, even into a posi- tion of moderate inversion. Slight traction upon the external lateral ligament is thus made, and through it upon the lower fragment. Excellent coaptation can in this way be obtained. Careful attention to this detail in the application of a fixed dressing for Pott's fracture will fulfil all the indications required. The classical treatment of this fracture is by Dupuytren's splint, which consists of a straight splint ex- tending from the knee-joint to the sole of the foot, so applied 130 A CLINICAL TREATISE ON FRACTURES. that when placed upon the inner aspect of the leg the pad- ding will support the tibia throughout its length, while the deformity is corrected by bandaging the foot to the splint so that it will be retained in a state of moderate inversion. But this dressing will seldom be found to fulfil the require- ments as well as the method of application of plaster-of-Paris bandaging just described. The plaster-of-Paris dressing may be retained for four weeks, in all cases, whether employed for fracture of one or both bones of the leg, for while union may occur sooner than this in certain localities, and under peculiarly favorable circumstances, it is not a union of suf- ficient firmness to bear weight. At the end of four weeks, the dressing having been cut and removed, careful examina- tion should be made of the limb in order to ascertain as definitely as possible the conditions existing at the seat of fracture. If union appears firm, complete rest, afforded by the adjustment of two lateral cardboard splints for two weeks more, should be continued. At the end of this period slight weight may be borne by the leg, though the patient should still be upon crutches for another week. Should it be found upon examination, on the other hand, that there is little or no attempt at union at the seat of fracture, time will be saved by applying a fresh plaster-of- Paris bandage, because if little or no union occurs in four weeks, union will not be completely firm in six. While these observations are general, they apply to almost every fracture of the leg. Union does not occur so quickly if deformity remains, if both bones are broken, if fixation has been incomplete, or if there has been fracture of one or FRACTURES OF THE LOWER EXTREMITY. 131 more bones elsewhere. When it may be assumed, therefore, that for any reason union will be more or less delayed, it is quite proper to allow the original dressing to remain undis- turbed for six or seven weeks ; always remembering, how- ever, that more or less temporary rigidity of the ankle- and knee-joints will result from such protracted confinement. The ambulatory treatment of fractures of the lower ex- tremity relates principally to fractures of the leg. It is designed to retain the fragments in a state of such fixation that the ordinary movements incident to the patient's being up and about will not disturb them. It is recommended on the ground that by preserving the general health and strength the fracture benefits ; that the reparatory processes show greater activity than when the recumbent posture is maintained ; and that the prospect of early union is thereby increased. The cases to which it may be applicable, there- fore, are those to whom confinement to bed proves injurious. It is a measure requiring so much skill to insure the avoid- ance of any mishap that it cannot perhaps be prudently recommended for general use. FRACTURES OF THE PATELLA. The functions and location of the patella are such that not only is it constantly and normally subjected to great tensile strains in the ordinary performance of the movements of the lower extremity ; but it is also very liable to injury either from the excess of these normal strains, or from blows and falls. The tensile strain conveyed through the patella, by the action of the quadriceps extensor muscle acting upon I32 A CLINICAL TREATISE OX FRACTURES. a lever of such immense disadvantage, with such a range of action, is great, even in the performance of the most simple movements of extension of the leg ; such movements as ascending steps, mounting a horse, and the like ; while in running, jumping, and various athletic performances, and the heavy work done by many mechanics the strain becomes inordinate. The bone, however, rarely gives way under these circumstances. When fractured by muscular action other conditions will invariably be found to have accompanied the strain. The muscle acting on the patella has been sur- prised, so that, instead of the strain being put upon the patella voluntarily, it has come unexpectedly, and hence with a jerk ; this fact is frequently shown by the existence of fracture of the patella of an individual who could not voluntarily exert sufficient power with his muscles to pro- duce the result, but who in falling backward, and attempting to catch himself with one leg, has suddenly applied the strain in a spasmodic effort to resist the flexing of his knee. Another condition which I believe is a frequent con- comitant of muscular action in producing fracture of the patella is impact upon the bone while it is being subjected to tensile strain. In fractures in which it can be demon- strated that the lesion is caused by muscular action, the subordinate element of direct impact may well be looked for; while in the smaller group of fractures produced by direct impact careful analysis of the method of production of the fracture will not infrequently reveal the coexistence of the element of muscular action. After numerous tests, which were made with difficulty because of the inability to grip the FRACTURES OF THE LOWER EXTREMITY. I 33 tendon of the quadriceps firmly enough to prevent its being pulled out under a strain of between six and seven hundred pounds, a patella belonging to a subject twenty-seven years of age was subjected to a tensile strain of 1845 pounds. This reading was recorded at the instant of rupture of the ligament of the patella, and, therefore, it did not repre- sent the strength of the bone. If the patella can resist such a pull as this, there must be other elements contributing to its fracture in those cases which are regarded as fractures Fig. 67. Skiagraph of recent transverse fracture of the patella. from muscular violence alone. For one, it is certainly true that the bone is subjected to a strain produced by forces acting not in line, but at a greater or less angle to one another, and that the patella by the resultant of these forces is broken over the condyles of the femur as a stick may be broken over one's knee. Possibly another element is sug- gested by the position assumed by the fragments after fract- ure. Fig. 67, a skiagram of a recent fracture, shows a tilt 134 A CLINICAL TREATISE ON FRACTURES. of the fractured surfaces in divergent directions from one another, a condition frequently observed. If this tendency exists whilst the limb is in a state of complete extension, it would evidently be increased progressively by flexion, and the greater the flexion the more would the force of the mus- cular effort be concentrated on the exterior surface of the bone, instead of being distributed uniformly throughout its substance. If this view is entertained, the curious proposi- tion presents itself, that the bone, so far as the texture of its surfaces is concerned, is from a mechanical point of view structurally deficient, because the exterior surface of compact character is better fitted to resist crushing than tensile strain, and the inferior surface of dense, fibrous, more elastic material is better able to withstand stretching. The variety of fracture when, as so often happens, no satisfactory account can be got of the manner in which it was caused, may often indicate its probable manner of production ; thus a longitudinal fracture without displace- ment may be attributed with some certainty to direct impact. To the latter may also be attributed every instance of comminuted fracture ; and it is hardly necessary to mention that contusion and laceration of the integument over the patella usually leave no room for doubt regarding the manner in which the fracture was caused. In a transverse fracture — the variety observed in such a great preponderance of cases that the term fracture of the patella, if unqualified, has come to signify transverse fracture — the extent of separation of the fragments, while not in the least conclusive, probably in many cases bears some relation to FRACTURES OF THE LOWER EXTREMITY. 1 35 the causation of the injury. If the separation is great, the indication favors muscular violence ; while if slight, direct impact. Separation of the fragments, however, depending, as it does, on other conditions than those obtaining at the moment of injury, can hardly be considered as of much value in reaching a decision regarding the method of production of the fracture. Such fractures usually occur somewhat below the middle of the bone, as shown in Fig. 68. Fig. 68. Skiagraph of transverse fracture of the patella. Diagnosis.— Pain, loss of function, and the frequent consciousness of the patient that he has felt something give way in his knee, and at times has observed an audible snap, sufficiently attract the attention of the surgeon to the prob- able existence of fracture. Examination of the knee-joint, even very shortly after the occurrence of the injury, reveals marked effusion. On palpation a distinct sulcus, varying in width according to the degree of separation of the frag- 136 A CLINICAL TREATISE ON FRACTURES. ments, is clearly felt (or it may be seen, Fig. 69), as also are the fragments. The upper fragment is usually observed to be larger than the lower fragment, constituting perhaps two- thirds of the dimensions of the bone. Crepitus may be elicited (1) if there is no interposition of soft tissue, and (2) if the displacement of the fragments can be sufficiently over- come to bring them into contact. Ability to obtain crepitus furnishes an important suggestion regarding the treatment. If crepitus be elicited by swaying the fragments laterally with the thumbs and fingers, seizing each and bringing them together with the exercise of little force, it indicates not only that the separation present is readily overcome, but also demonstrates the absence of any considerable quantity of shreds of capsule, other tissues, or blood-clots between them. While simple transverse fracture is usually easy to recog- FlG. 69. Recent transverse fracture of the patella. nize, fractures unaccompanied by separation may often be overlooked, particularly if there is severe contusion of the overlying integument. In this group, although commin- uted fractures are occasionally found, a longitudinal fracture occupying the median line of the bone is the one most difficult to detect, even after careful examination. Seizing the bone laterallv, instead of above and below, with the FRACTURES OF THE LOWER EXTREMITY. 1 37 thumbs and fingers, an effort at vertical swaying may give faint crepitus, with almost imperceptible mobility. Treatment. — The object sought in any plan of treat- merit is not only to get as close union of fragments as possible by a uniting medium which will resist, without breaking or stretching, subsequent strains to which it will be put, but also to prevent future impairment of function resulting from rigidity of the knee-joint or of the patella itself. It may be that efforts to obtain either bony or very close fibrous union have at times occupied so much atten- tion, that sufficient care has not been given to that other important element in the cure, the perfect flexion and extension of the knee-joint. Impairment of motion of the knee-joint after fracture of the patella depends, on the one hand, upon the inflammatory exudates following the original injury, or produced by some irritating element in the treat- ment or by some constitutional peculiarity of the patient which impedes recession of inflammatory processes ; and, on the other hand, by too long retention of some fixed or permanent dressing, which, while intended to perfect union of the fragments, will, when removed, be found to have also, incidentally, caused partial or complete rigidity of the knee-joint very difficult to overcome. The methods of treatment may be divided into two classes, the operative and the non-operative. In determin- ing upon a choice between these, apart from the individ- ual preference of the surgeon, the degree of separation of the fragments, the ability to bring them into close approx- imation, the evidences of intervention of periosteal or other I38 A CLINICAL TREATISE ON FRACTURES. tissues, the perfection of asepsis and surgical technique attainable, and the age and health of the patient, are general factors to be considered in reaching a decision. In most cases of fracture of the patella operation is, in my opinion, inadvisable. The cases in which operation may be desirable are those where there is a very wide separation of the frag- ments, evidence of the intervention of an unusual amount of soft tissue between the fragments, and the failure of efforts to obtain anything like a close approximation of them, either by efforts with the fingers or some one of the various devices which may have been employed for the pur- pose. Those cases which either after the lapse of weeks show no tendency to unite, or months or years after the fracture present themselves for treatment, because of inter- ference with function from widely stretched fibrous union or no union at all, are clearly suitable for operation; provided the conditions mentioned above favor its perform- ance. Certain it is, however, that operation should under any circumstances be contemplated only by the practised hand, under conditions which may be regarded as surgic- ally perfect. Of the various operations practised, the open method is to be preferred, because (1) it insures nice contact with the opportunity to remove all material which has become interposed between the fragments. (2) While more formidable in appearance, it has proved equally safe with the subcutaneous method. The latter makes no attempt at brinsfinsf fractured bone surfaces in contact, freed from interposed tissue, and, therefore, fails to meet one of the chief indications for operative interference. While a great FRACTURES OF THE LOWER EXTREMITY. 1 39 number of appliances have been devised and are used for the management of this fracture, the object sought alike in them all is to effect close approximation and retention of the fragments until union has occurred. Since in the separation the upper fragment is the one principally at fault, to it efforts at approximation must be mainly directed. The lower fragment remains practically in situ, and is brought up to its highest level by complete extension of the leg. This done, very little more attention need be paid to it, than that it shall be kept at rest. At the end of five days or a week pain, effusion, and swelling about the joint will have subsided, and the irritability of the quadriceps extensor, due to its having lost its power of action, will, when the muscle has become accustomed to its altered conditions, relax. Then, and not before, will any form of apparatus be of use. During this period, elevation of the limb in some splint which will keep it at rest will, with the use of an evaporating lotion, be found sufficient to promote absorption of the effused products. But some surgeons apply an elastic rubber bandage to the knee for several days after the injury. If it is purposed to use elastic or other pressure, a warning to be borne in mind is, that pressure of any sort does harm to what may be called an ascending inflammation. Not until the latter shows the first signs of receding, as evidenced by improvement in color, temperature, and texture of the skin, is pressure applicable. Aspiration of the knee-joint is sometimes used, without waiting for absorption, with a view of get- ting rid of the effused products at once. A like result 1/j.O A CLINICAL TREATISE ON FRACTURES. has been satisfactorily obtained, more deliberately, by massage. Probably the plan of non-operative treatment in most common use may be in general terms described as follows: the limb, with the leg slightly elevated, is placed upon a straight posterior splint; a compress is applied above the upper fragment and secured to the splint in such a manner as to produce downward traction; a roller bandage retains the whole apparatus; and the limb is elevated on pillows or an inclined plane. If the posterior splint be a broad one, provided with cross-pieces, rotatiug-pins, or notched edges, these furnish points of attachment for the strips which draw down the compress above the upper fragment. Malgaigne's hooks, which are usually considered among the non-operative methods of treatment, have their advo- cates. The apparatus consists of hooks arranged to fasten above the upper and below the lower fragment, and so placed as to be approximated by a screw working on a bar connecting them. Their method of application is as fol- lows: the skin about the knee-joint having been repeatedly sterilized during a period of at least twenty-four hours, and the usual aseptic technique having been carried out, the upper fragment is brought down and held in as accurate apposition as possible by the hands of an assistant. The lower pair of hooks is inserted with sufficient force to insure the engagement of its points into the lower portion of the lower fragment, the integument meanwhile being slightly drawn downward. The integument is then drawn upward until it is quite tense, and the upper pair of hooks is made FRACTURES OF THE LOWER EXTREMITY. 141 to engage firmly in the upper portion of the upper frag- ment. Coupling of the parts, so that the screw may act, is readily done by a little adjustment. The screw is set up by a key with a number of turns sufficient to make a nice coaptation of the fragments, without risk of dragging out the hooks, and the application is completed by insinuating a small quantity of gauze beneath and around the instru- ment. If the integument has been properly drawn upon Fig. 70. Author's Indian puzzle apparatus for fracture of the patella, showing the basket-like arrangement of adhesive straps upon the thigh with the extension applied. before inserting the upper and lower pair of hooks, an objectionable puckering of it between the latter will be avoided. In the cases in which it has been decided not to operate, the choice of the mode of treatment most appropriate for the conditions which present themselves must be deter- mined by the circumstances of the individual case. The apparatus shown in Fig. 70 is one I have long used, and prefer. It will be seen to act like an Indian puzzle, I42 A CLINICAL TREATISE OX FRACTURES. which is a small cylinder of wickerwork, and which, owing to its peculiar arrangement, closes more tightly about the finger the more it is drawn upon. The appa- ratus consists simply of a basket-like series of half-inch rubber straps, so applied that their lower ends terminate at points to the outer and inner side of the knee and are attached to rings. To these the ordinary extension appa- ratus with pulley and weight of about six pounds is fas- tened. This part of the apparatus is intended to relax and draw down all the tissues of the thigh, while traction upon the upper fragment of the patella is obtained by two or three rubber straps carried across the latter and made fast to the rings. After the appliance has settled into place the lower fragment may, if necessary, be supported by one or two straps carried upward. The essential feature, and the only one which is novel in the device, is, of course, the basket-like arrangement of the straps, as extension with adhesive plaster or leather has long been employed. It is very comfortable to the patient and entirely satisfactory in all cases where there is not too great separation of frag- ments. It paralyzes the muscles of the thigh by its steady, unremitting pressure, and draws down the upper fragment, and yet causes no tendency to swelling of the limb below, no harsh pressure upon the integument over the upper fragment, as may be caused by a compress held firmly in place by adhesive plaster, and no infiltration of the tissues about the knee, so often observed when firm straps are applied to the lower, as well as the upper fragment. While not criticising the various methods based on other princi- FRACTURES OF THE LOWER EXTREMITY. 143 pies, it may be proper to observe that any one of them is likely, unless carefully and judiciously used, to keep up or increase the irritation and consequent infiltration about the joint, and thus retard repair. The extension apparatus remains on undisturbed through- out the treatment, or may require renewal once. The limb is allowed to rest upon a long pillow, with a cradle to keep the bed-clothes off the toes. It has been found desirable during the course of treatment with this apparatus to make, every day or two, movements of the knee-joint by elevating it gently about three inches from the bed, without removing the extension weights, provided this can be done without provoking muscular contraction upon the upper fragment. When such passive movements can be conducted without retarding union, much time in the complete restoration of motion is gained. Depending upon the firmness of the union observed, the apparatus is retained for a period of from five to seven weeks, at the end of which the patient is allowed up, with some simple device provided to support the upper fragment for a month or more longer. A plaster-of-Paris dressing is seldom required, and in my opinion is usually undesirable, not only because it prevents all motion of the knee-joint, but because, having slackened out when dried, it does not check the action of the quadriceps upon the upper fragment, when the patient is up and about on crutches. For practical purposes operations for simple fracture of the patella may be divided into (1) those performed through an incision exposing the joint, and (2) those which are 144 A CLINICAL TREATISE OX FRACTURES. performed subcutaneously. The open method is in most cases obviously much better adapted to meet the conditions than any form of subcutaneous operation could possibly be, for the points which indicate operation may be briefly restated as follows: to clear out extraneous tissue, blood-clots, etc., which interfere with approximation of fragments, and to bring the fragments together and secure their fractured surfaces in apposition. On the other hand, the dangers attendant upon the open method are not avoided by the use of the subcutaneous plan because infection can occur as readily along a suture-track as in an open wound. There are many plans by which the open operation may be performed, but the essential steps are: (i) an absolutely perfect aseptic technique ; (21 by an incision five inches long, carried down directly in front of the joint, the interior of the joint should be thoroughly exposed; (3) the fract- ured surfaces should be brought in close apposition, all intervening substances being removed ; (4) the edges of the periosteum and the tendon of the quadriceps and ligament of the patella should be united by chromicized catgut, silk- worm-gut, or kangaroo-tendon sutures; (5) the wound should be closed by continuous silk or gut suture; and no drain- age being necessary, a dressing applied, and the limb placed at rest with the foot elevated. But few surgeons now attempt to secure the fragments by drilling the bone, the sutures in the periosteum and through the tendon and ligament of the patella being sufficient for that purpose. If the subcutaneous method of operation is used, that which is known by the name of Barker is probably the FRACTURES OF THE LOWER EXTREMITY. 145 most popular. This consists in passing a curved pedicle needle under the patella from below upward, entering at a point just beneath the inferior extremity of the lower fragment which will carry it through the middle of the ligamentum patellae, behind the lower fragment upward behind the upper fragment through the middle of the tendon of the quadriceps, whence it emerges. Re-entering at this point, freshly armed with the free end of the ligature, the needle is carried downward in front and in close proximity to the upper fragment, and continued in a similar manner in front of the lower fragment until it reaches the primary point of entrance. Emerging from there and unthreaded, the needle is withdrawn ; the two free ends being drawn upon when tied will complete a loop including in it both fragments. The knot is allowed to drop into the skin opening. Stimson formerly used a subcutaneous method devised by himself, and which is known by his name. He frankly states, however, that the dangers of infection through the points of entrance and exit of sutures is so great that he has abandoned it, and now uses only the open method. In every case of simple fracture of the patella in which the question of operation is raised, one should consider that the operation is not at all necessary as a life-saving meas- ure ; that it is attended with very considerable risk unless done under absolutely perfect surgical conditions; and that non-operative treatment without being attended by any of these risks is often perfectly successful. The only persons qualified to perform the operation are surgeons of experi- ence, who have at their command the technique only to be 10 146 A CLINICAL TREATISE ON FRACTURES. obtained in a properly equipped hospital. The patient must not be enfeebled, nor suffering from visceral disease, as such persons succumb readily to its perils. The dangers attend- ant upon the operation should be fully stated to the patient at the time his consent to it is sought. The operation should be reserved for cases in which there is wide separa- tion of fragments, extensive lateral tears of aponeurosis, or the presence of extraneous matter between fragments, simul- taneous fracture of both bones, and, as a secondary measure, either after failure of other treatment or after refracture. The open method is the only one to be considered. It must be aided by early massage and mobilization of the joint. Perfect motion of the knee-joint after fracture of the patella is indispensable to the complete restoration to func- tion of the limb. Indeed, if the alternative were presented of a closely united patella with a rigid knee-joint, or an imperfectly united patella with a movable knee-joint, the latter would usually be ac- FlG. 71. J cepted as a lesser evil than the former. A case of old fracture of the patella came under my observation which strikingly illustrated this matter. It had never, either at the time of its occurrence Wide separation of fragments after fracture n0r Subsequently, received of the patella. any treatment. The upper fragment was drawn far up the thigh, and had no connec- tion whatever with the lower fragment. The knee-joint FRACTURES OF THE LOWER EXTREMITY. 1 47 was so freely movable that the leg could be flexed com- pletely on the thigh. The man walked on the level with a hardly noticeable limp, and in mounting steps threw his foot up without apparent effort. Fig. 71 is a reproduc- tion from a plaster cast I made of the limb. The result looked for in any plan of non-operative treat- ment, though not bony, is much closer fibrous union than that shown in Fig. 72. Cases have come under my observa- tion years after the occurrence of the fracture fig. 73- in which the bone showed no trace of the fig. 72. original lesion, but was smooth, firm, and movable, and the re- sult to all appearances ideal ; nevertheless the union, even in these, was probably a close fibrous one, not bony; one which would yield to post-mortem after fracture boiling- Comminuted fracture of the patella. of the patella, which has been thought, on account of the greater inflammatory reaction following the violence of the direct impact producing it, to unite with a stronger and more durable fibrous band than transverse fracture, is well illustrated in Fig. 73. Showing fibrous band of union, Showing strong fi- brous union, after comminuted fract- ure of the patella. FRACTURES OF THE FEMUR. Fractures of the femur may be considered under three headings, fracture of the shaft, fracture of the upper extrem- ity, and fracture of the lower extremity. At any point the injury is described as fracture of the thigh. Unlike fract- I48 A CLINICAL TREATISE ON FRACTURES. ures of the leg, which possess many characteristics in com- mon, fractures of the femur differ widely according to their locality in many features relating to their history. Fractures of the Shaft. — Like fractures in other long bones, fractures of the shaft of the femur incline to be oblique, if produced by indirect violence ; and transverse when they are produced by direct impact, though not in so marked a degree as in the humerus or tibia. Fracture fig. 74. Recent fracture of the femur, before reduction. at any point of the shaft, if complete, almost invariably causes overlapping of the fragments, and the consequent shortening of the limb indicates approximately the degree of that overlapping. The directions assumed by the two fragments, while depending upon the direction of the plane of fracture, are in many instances anterior deflection of the upper fragment and posterior deflection of the lower frag- ment, accompanied by more or less rotation outward of the latter. The characteristic appearance of the deformity produced is well shown in the photograph of a recent FRACTURES OF THE LOWER EXTREMITY. I49 fracture, reproduced in Fig. 74; while the tendency of the fragments to the overlapping, rotation, and angularity is graphically illustrated is Figs. 75, 76, and yy, which repre- fig. 75. Fig. 76. Fig. 77. Union after fracture of the femur with slight bowing, marked rota- tion outward of lower fragment, and little overlapping. Union after fracture of the femur with marked overlapping, angular- ity, and rotation out- ward of the lower frag- ment. Union after fracture of the femur with marked overlapping and slight rotation inward of the lower fragment. sent a series of specimens of firmly united fractures with varying degrees of deformity. Though great force is required to fracture the femur of a healthy adult, less damage is frequently done to the soft parts than would be expected. This, no doubt, is partly accounted for by the i5o A CLINICAL TREATISE ON FRACTURES. Fig. 78. Incomplete fract of the femur. fact that the bone lies so deeply imbedded in strong fasciae and muscles- To this is also due the comparative infre- quency of compound fracture caused by pene- tration of the integument by a fragment. Diagnosis. —Diagnosis of fracture of the shaft of the femur is usually extremely sim- ple. Loss of the natural contour of the thigh, which is particularly manifest in its shortening and thickening (Fig. 74); deform- ity in some one direction, usually anterior bowing ; eversion of the foot, leg, and knee are signs which frequently upon inspection alone reveal the presence of fracture. Pain on motion is severe, preternatural mobility becomes at once apparent on lifting the limb, and crepitus may be elicited, if the overlapping is too slight to have separated the fractured surfaces of upper and lower fragments from each other. In incom- plete (Fig. 78) and green-stick fractures (Fig. 79) there can be no crepitus produced, but the other signs may all be present in a modified degree. In thin subjects, if a very sharp point of either fragment can be felt, information may be obtained regarding the exact line of fracture. The reverse, however, is much more often the case, the fragments being covered by a mass of tissue suf- ficient to mask not only the line of fracture, but also its exact seat. Fracture situated at the upper third of the bone or thereabouts frequently causes troublesome anterior displace- ment, accompanied by rotation outward of the upper frag- FRACTURES OF THE LOWER EXTREMITY. I 5 I inent. An extraordinary imitation of this deformity is illus- trated in Fig. 79. The case was one of green-stick fracture at the junction of the middle, with the upper third of the femur occurring in a child, whose femur was markedly bowed forward. Slight mobility revealed the presence of fracture, and as a moderate anterior curve was observed in the sound femur the combination of an abnormality and a lesion was assumed, but it remained for the skiagraph to Fig. 79. Skiagraph of a green-stick fracture occurring in a bowed femur of a child. demonstrate the true nature of both. The fracture was made complete and the limb straightened, as would have been done after osteotomy. The tendency to forward dis- placement and rotation outward of the upper fragment, produced principally by the action of the psoas and iliacus internus muscles and by the gluteal muscles, increases the higher up the shaft the seat of fracture is. The combined action of extensors, as well as flexors, through their vari- ous attachments, both direct and indirect, is to draw up the 152 A CLINICAL TREATISE ON FRACTURES. lower fragment. The latter, however, will usually be found to point in a measurably straight direction. It causes the overlapping, but seldom contributes in any marked degree to the angularity of the deformity, which is produced almost wholly by the position assumed by the upper fragment. The shortening may not be excessive, but this troublesome ten- dency is quickly recognized by an ugly prominence at the upper anterior aspect of the thigh, which is found difficult to reduce. The degree of shortening present, immediately upon the receipt of the injury, is apt to be, in an adult, about three inches. It is possible to reduce this shortening, in most cases one half, by steady, moderate traction without the aid of an anaesthetic, the full amount immediately return- ing on discontinuance of the extension. Fractures of the Upper Bxtremity of the Femur. — Fractures of the upper extremity may be vertical, involving fig. 8q. _ the neck and shaft in a long split which does not dissolve the continuity between the head of the bone and the shaft ; they may involve the extreme upper extremity of the shaft ; the great trochanter ; a trans- verse line just below the trochanter ; or, finally, the neck of the bone, the plane of the fracture including the neck either out- Intracapsular fracture & of the femur. side of the capsule, within it, or partly without and partly within it. Fig. 80 represents a specimen of intracapsular fracture, and Figs. 81 and 82 skiagraphs of recent extracapsular fractures. The senile changes which take place in the structure and form of the neck of the femur FRACTURES OF THE LOWER EXTREMITY. 153 Fig. 81. render it so friable that its fracture in the aged is very com- mon. The cancellous structure undergoes fatty changes and its cells enlarge. The angle of the neck in relation to the shaft, from being obtuse, gradually approaches a right angle ; and this alteration in the form of the neck tends further to weaken it. Fracture of the neck of the thigh in elderly per- sons is consequently often caused by force only sufficient to produce the most trifling bruise in a young subject ; the injury to the soft parts accompanying it, there- fore, is often slight, and the cause of the fracture may frequently be an ac- cident of no greater im- portance than a fall on the floor. Fractures of the trochanter major and trochanter minor are ex- ceedingly rare, even as epiphyseal separations. Diagnosis. — The diag- nosis of fracture of the neck of the femur is based upon the existence of marked pain increased upon the slightest motion, complete inability to use the limb, or even move it, change in the contour of the hip which gives it a some- what humped appearance, and eversion of the foot with rotation outward of the leg and thigh. These symptoms alone, if present in a subject over sixty years of age, sug- Skiagraph of a recent extracapsular fracture of the femur. 154 A CLINICAL TREATISE OX FRACTURES. gest the probability of fracture at this point. A study of the change in contour about the hip shows the trochanter major to be elevated above the line which it normally occupies. This line, called Nelaton's, extends from the anterior superior spinous process of the ilium to the tuberosity of the ischium. The change in the position occupied by the great trochanter likewise shortens the base of a triangle, Brvant's, the perpendicular of which is let fall from the anterior superior spinous process of the ilium, the hypoth- enuse formed by carrying a line from the anterior superior Fig. 82. Skiagraph of recent fracture of the neck of the femur, occurring in a youthful subject. spinous process to the great trochanter, and its base a hori- zontal line carried to the perpendicular (the patient being in a recumbent position). The trochanter in fracture of the neck, either intracap- FRACTURES OF THE LOWER EXTREMITY. I 5 5 sular or extracapsular, revolves, when rotated, on the ilium, in the arc of a smaller circle than normal, but the distinction between the arc of a circle thus described is in many sub- jects so difficult to make that it will frequently be found of little clinical value. Allis points to relaxation of the fascia lata between the ilium and the trochanter major as furnishing an additional diagnostic sign of fracture of the neck. Puckering of the integument over the patella is also observed if the shortening be marked. To distinguish Fig. 83. Skiagraph of recent supracondyloid fracture of the femur with angular deformity. between extracapsular and intracapsular fractures is in many instances difficult. Among the numerous differential points usually mentioned, few will be found to possess much clin- ical value. The former occurs in younger subjects than the latter ; is usually produced by greater violence ; may yield more distinct crepitus ; may present greater shortening ; and mav show more contusion and discoloration of the integu- 156 A CLINICAL TREATISE ON FRACTURES. merit. But as these signs are by no means constant, the evidence likely to be furnished by a clear skiagraph should, if practicable, be taken advantage of. Fractures of the I^ower Extremity of the Femur. — Fractures of the lower extremity of the femur may be transverse or oblique. If the plane of fracture is situated just above the condyles, the fracture is called supracondy- loid (Figs. 83, 84, and 88); it may involve the internal con- FlG. Skiagraph of recent oblique supracondyloid fracture of the femur, with overlapping. dyle, the line of fracture extending sometimes to a consider- able distance up the shaft; the external condyle (Fig. 86); it may be situated between the condyles (Fig. 87) (intercon- dyloid); or the line of fracture, involving not only separa- tion of the condyles from the shaft, but also extending between them, may combine the characters of both supra- condyloid and intercondyloid, thereby producing a T-fract- ure (Figs. 85 and 89). FRACTURES OF THE LOWER EXTREMITY. 157 Fig. 8s. As fractures of this part of the bone are more likely to be produced by indirect violence, as falls upon the feet or by lateral strains of the leg or knee-joint, there is usually less injury and consequent swelling of the soft parts. If not involving the joint, such fractures show more or less overlapping, the direction of which, as is already demon- strated in Figs. 83, 84 and 88, is determined by the inclina- tion of the plane of fracture. Overlapping and shortening are not so marked as in fractures of the shaft higher up. Reduction is often easily accomplished, and the fragments once restored may show little tendency to become again displaced. The fractured surfaces being broad and rough settle into place and become engaged in each other. Fixation, too, is perfected with greater ease and less restraint than in fracture up the shaft. On account of these modi- fied conditions, fracture at the lower third of the femur may be a much less serious injury than when the shaft is broken about its middle third. Involvement of the knee-joint, however, adds a complication which may more than offset these circumstances, and wounding of the femoral artery by one of the fractured fragments is a most serious, though fortunately very rare, complication. Supracondyloid fractures, if transverse, may readily be confounded with epiphyseal separations in subjects under twenty years of age. The absence or indistinctness of crepitus will point to the latter, and the fact that separation T-fracture of the femur. i 5 8 A CLINICAL TREATISE ON EKACTURES. of the lower epiphysis is in a plane slightly lower than the common seat of snpracondyloid fracture may suggest the greater probability of one than the other. In a girl of six- teen years of age whose knee had been ankylosed at a right angle since childhood I corrected the deformity after what f ig . 86. was assumed to be an epi- physeal separation; the opin- ion in this case was based upon the faint crepitus elic- ited, the close proximity of the line of separation to the knee-joint, and, finally, upon the assumption that union of Fig. 87. Skiagraph of external condyle of the femur. Intercondyloid fracture. epiphysis with diaphysis had been retarded by the degree of arrest of development observed in the entire limb from disease and disuse. Diagnosis. — Fracture of the lower extremity of the FRACTURES OF THE LOWER EXTREMITY. 1 59 femur, while usually readily recognized, is difficult to map out accurately, particularly in fat subjects. The deformity of genu valgum belongs to fracture of the external condyle, while that of genu varum to that of the internal condyle, but according to the direction of its plane, either deformity may occur after supracondyloid fracture. In the latter if the plane of fracture is anteroposteriorly oblique the con- FlG. 88. Skiagraph of fracture of the lower end of the femur with slight deformity. dyles will ride up in front or behind (Figs. 84 and 88) the shaft according to the direction of the obliquity, whether looking downward and forward or upward and forward. As crepitus is usually very distinct and easily produced in any of these fractures, and as the deformity is readily corrected, they are unlikely to be mistaken for any form of disloca- tion of the knee-joint, properly so called. That a partial dislocation of the tibia occurs after fracture of either ex- ternal or internal condyle of the femur is obvious, but such a joint-displacement, depending as it does upon the loss of l6o A CLINICAL TREATISE ON FRACTURES. opposing bone support, can only be regarded as an incidental dislocation. Treatment of Fractures of the Femur. — The two important indications in the treatment of fracture of the thigh are (i) to overcome shortening, and (2) to prevent by fixation not only angular movements, but rotary movements as well. In the femur, more than in any other bone, the tendency fig. 89. to reproduction of the deformity by muscular i action is most marked. In no other fractures are the muscles, which are among the strongest in the body, observed to be thrown into such a state of spasmodic contraction when their nat- ural support, the continuity of the shaft of the bone, is gone. In most other fractures, the element of muscular contraction in causing de- formity has been, in my opinion, frequently overestimated. The muscles of the upper ex- tremity, both of the arm and forearm, are more T-fracture of frequently relaxed voluntarily by the patient the lower ex- tremity of the t° relieve pain than spasmodically contracted. femur. ^ ot s0 ftie powerful muscles of the thigh. Less perfectly coordinated by volition, they are, after fract- ure, very irritable ; and not until they yield, either through the instrumentality of anaesthesia, the effect of which is temporary, or of traction, which wears them out and the effect of which is permanent, can the overlapping and the incidental deformity be overcome. Traction, if conveyed through the leg, can, of course, influence only those muscles FRACTURES OF THE LOWER EXTREMITY. l6l whose origin and insertion exist directly or indirectly be- tween points affected by the loss of continuity of the shaft of the bone. Muscles, on the other hand, whose origin is at a remote point above and whose insertion is in the upper fragment are not at all affected by traction. In this fact will be found the difficulty in dealing with the upper fragment in fractures of the shaft, particularly toward the upper third. Traction upon the leg will fatigue, relax, and cause the flexor and extensor muscles of the thigh to yield, but will exert no influence upon the psoas and iliacus in- ternus or gluteal muscles. When, therefore, the deformity depends upon the action of the flexor and extensor muscles of the thigh the first indication in the treatment is to combat the deforming action of these muscles. It is gen- erally recognized that in the vast majority of cases this can best be done by extension of the leg obtained by Buck's extension apparatus. Fixation of the fragments, as it can- not be carried out as perfectly as in fractures of other bones, requires, in order that it may be sufficiently complete to insure union, the most careful attention. It must be borne in mind that whatever form of treatment is employed, a collateral aid to fixation is the careful attention to every detail in the management of the patient which will con- tribute to his comfort. If he is obliged to raise himself on one elbow to reach for something on a table at his bedside and to take his food, if his back and buttocks are irritated by crumbs and folds of clothing, or if he is allowed to help himself in using the bed-pan, certain it is that no fracture-dressing will prevent movement of the 11 1 62 A CLINICAL TREATISE OX FRACTURES. fragments many times a day. The mattress upon which the patient lies, while necessarily hard and unyielding, should be made comfortable to his back, the latter bathed and if necessary protected at any point which is found to receive too much pressure. Though it is almost impossible to avoid disturbing the fragments during the various processes which are performed about his person, a great deal can be done to prevent such disturbance by skilful turning and lifting of his pelvis and by drilling him to relax his muscles. Fractures of the shaft of the femur may be treated by simple extension, by the application of splints, or by a combination of extension with splints. The use of a fixed dressing of plaster-of-Paris, either at the start or later on in the course of the treatment, is at times desirable. The treatment by extension is that by Buck's extension appara- tus, which is applied in the following manner : a strip of resin or rubber adhesive plaster two inches wide is cut long enough to extend from just below the seat of fracture to the foot and back again to the same point, leaving a loop below the foot six inches in length. In this loop is placed a block three inches long, the width of the plaster, and the thick- ness of cigar-box wood. In order to retain the block firmly in place and at the same time prevent adhesion to the skin below the ankle, a strip of plaster of like width is applied face to face to the lower portion of the main strip and the block. The edges of the long strip are nicked throughout their length to the depth of half an inch. Heating the free ends of the long strip over an alcohol-lamp, if resin plaster is used, they are applied on the outer and inner aspects of FRACTURES OF THE LOWER EXTREMITY. 1 63 the cleanly shaven thigh and leg, the block meanwhile being held accurately in a transverse position two inches below the sole of the foot. The scoring of the edges per- mits the strips to adapt themselves neatly to the limb. Circular strips one and a half inches in width are applied with very moderate tension around the ankle, below the knee, and, if the fracture is above the lower third of the femur, above the knee. A neat bandage applied in the form of a spiral reverse of the lower extremity completes the dressing. After the strips have become firmly attached to the skin of the leg, an extension weight to the amount of six or eight pounds is attached by a cord to the cross- piece of the stirrup and carried over a pulley at the foot of the bed. Counter-extension may be provided by elevat- ing the foot of the bed, and fixation aided by the applica- tion of two long sand-bags, the one on the outer side extending from the axilla to the sole of the foot and that on the inner, from the perineum to the ankle. In fractures of the upper portion of the shaft, since the sand- bags exercise very little influence on the upper frag- ment, and as the latter shows usually a marked tendency to forward displacement, other means are required to adjust and control it. This may be done by a nicely fitted card- board splint, occupying the whole anterior surface of the thigh and retained by a snug' bandage. Should it be found impossible to get satisfactory adjustment in this way, the lower fragment may be elevated in order to meet its refrac- tory fellow by the careful adjustment of a double-inclined plane. The latter, however, will often be found to give 164 A CLINICAL TREATISE ON FRACTURES. imperfect fixation, the lower fragment being firmly attached to the heavy cumbersome apparatus, while the upper frag- ment is much more controlled by the patient's movements than by the splint. A Smith's anterior splint extending up over the abdomen, where it is retained by a spica of the groin, is intended to meet this objection and may occa- sionally be employed to advantage. Finally, particularly in children, this troublesome deformity may at times best be corrected by vertical suspension. While I have met very few cases of fracture of the upper third of the femur too obdurate to yield to a carefully adjusted cardboard splint, combined with extension, when such occur they can usu- ally be successfully dealt with by one or other of these methods. At times, when Buck's extension apparatus fails suffi- ciently to retain the limb at rest, as when the patient is refractory from delirium or other cause, L,iston's long splint may be employed; it, by retaining the hip-joint, further con- trols the upper fragment. In very young children, in whom there is less tendency to overlapping either because the fract- ure is more transverse than in adults or because it is not complete, very satisfactory correction of the bowing present and good fixation of the fragments may be obtained by a nicely modelled cardboard splint, extending from below the knee to the crest of the ilium, and retained by a roller bandage beginning at this lowest point and terminating in a groin spica. Great care is necessary in young chil- dren to prevent excoriation either from the dressing or from neglect of cleanliness. FRACTURES OF THE LOWER EXTREMITY. 1 65 Whatever form of treatment is decided upon, a general standard of the indications to be fulfilled by it must be made. Absolute correction of overlapping and consequent shortening cannot be hoped for. If the latter is reduced to three-quarters of an inch, the best result possible will in many cases be accomplished. Tendency to angular dis- placement may have to be combated until considerable union has occurred. Rotation of the lower fragment in- ward, or more often outward, which allowed to continue would result in intoeing or outtoeing, should be carefully watched for and corrected from the start. The retaining apparatus is required after union appears firm ; and as the time at which it does so is a very variable one, it is desirable to continue the dressing two weeks after all apparent mobil- ity has ceased. Mobility having therefore ceased at the end of four to six weeks, the dressing is removed in from six to eight weeks. Such a course of treatment, while it is tedious, is the only safe one to guard against recurrence of deformity or refracture. Treatment of Fractures of the Neck of the Femur. — As fracture in this locality occurs with so much greater frequency in the aged, considerations relating to the patient's general condition may prove of equal or greater importance than the technical management of the injury. Many subjects, who have previously enjoyed good health, are so completely prostrated by the shock of the injury, the confinement to bed, and perhaps the nervous depression following the occurrence, that they gradually sink, resisting all efforts at restoration, and die. Any special treatment 1 66 A CLINICAL TREATISE OX FRACTURES. selected, therefore, as it cannot be persisted in if the patient's general condition fails, must be substituted by another less confining, or at times no treatment at all. Moderate extension by Buck's apparatus to the amount of four or six pounds is the usual routine treatment. Combined with it some form of fixation of the pelvis and, if possible, pressure upon the great trochanter should be attempted. A nicely applied binder about the hips, with a broad easy compress over the trochanter, will usually accomplish this. Should the patient not fret under such restraint, it may be continued for eight weeks. Through- out the course of the treatment his general condition requires close attention, and any failure in strength is the signal for its discontinuance. Should such a course become necessary, the reasons for it having been clearly explained to the patient and his people, the surgeon cannot be held accountable for any untoward result of the fracture. Defects in the result, even when the management of the case is not embarrassed by the patient's general condition are, as a rule, shortening to the extent of about one inch, and more or less eversion of the foot. Other modes of treatment looking to better coaptation and more complete fixation of the fragments are by Hodgeu's suspended splint, by the application of plaster-of-Paris with a pin inserted through the dressing so as to bring pressure to bear upon the tro- chanter fSenn), or by the pressure of a metal splint, secured by means of a band, over the trochanter (Shaffer). The latter method seems to be the most effectual means by which we can secure union in old ununited fractures, a FRACTURES OF THE LOWER EXTREMITY. 1 67 number of cures of such cases by its use having been reported. Attempts to secure union in ununited fractures of the upper extremity of the femur by such operative procedures as laying bare the fragments and uniting them by ivory pegs or wire sutures have generally proved highly unsatisfactory. Treatment of Fractures of the Lower Extrem- ity OF THE Femur. — As the element of shortening from overlapping of fragments, though much less marked than in fractures of the shaft, almost invariably exists, exten- sion by Buck's apparatus will be found useful for a period of two or three weeks, or until the broad fractured surfaces have been sufficiently united by provisional callus to pre- vent their overriding one another. Extension employed with this object is generally applicable to fracture of either condyle, fractures above the condyles, or comminuted fract- ures of the lower extremity of the bone, whether involv- ing the joint or not, because no fracture in this locality is likely to be so transverse that its surfaces will butt accu- rately in position and remain so, unaided by any offset to muscular contraction. As the deformity in any direction depends upon the direction of the plane of fracture as well as upon muscular contraction, no rule can be given for its correction except as applicable in an individual case. Should the lower fragment present anteriorly, slight flexion of the leg upon the thigh on a very low double-inclined plane will usually correct the displacement. This may easily be combined with the extension apparatus. If the lower fragment be displaced posteriorly, the posture of 1 68 A CLINICAL TREATISE ON FRACTURES. complete extension of the leg will best reduce it. Fract- ure of the internal condyle, producing the deformity of genu varum, and of the external, genu valgum, may be corrected by the judicious adjustment of the sand-bags in conjunction with extension. As already stated, it is not desirable to continue such treatment long. At the end of two or three weeks all tendency to recurrence of deformity will usually be found to have disappeared. Plaster-of-Paris dressing will then best take its place. It should extend from the foot well up to the great trochanter and peri- neum, but need seldom include the pelvis. The position of the knee-joint is important, and is determined not only upon that position, whether of slight flexion or complete extension, which has previously been found best to correct the displacement, but upon the degree of ankylosis which it is deemed probable may follow. In the former the posi- tion which had been found best to correct the deformity should be slightly emphasized, thus tending to overcorrect it, in order to maintain good correction after the dressing, drying out, has yielded somewhat. In the latter, slight flexion (ten degrees) is the best position that can be assumed in anticipation of rigidity. The plaster dressing, having been retained from four to six weeks, may be removed, and not reapplied if union is found satisfactory. Passive motion, massage, and gentle use for a fortnight will best hasten restoration, after which the patient may walk about freely on crutches or with a cane. CHAPTER IV. FRACTURES OF THE PELVIS. The pelvis is usually fractured by some crushing force, as the falling of a bank of earth, being caught in an ele- vator, or crushed between swinging bales of cotton and a wall. In such cases the ilium or the pubis most com- monly yields. Fractures of the Ilium. — The ilium is a more common seat of fracture than any other bone of the pelvis, and the anterior superior spinous process is the portion of it most commonly involved, although the fracture may cross its body in any direction (Figs. 90 and 91). It is, therefore, fortunate Fig. 90. Comminuted fracture of the ilium. that fractures of the ilium are the least liable of all fractures of the pelvis to damage bloodvessels, bladder, urethra, or rec- tum. In many fractures of the pelvis, where the ilium is the only bone which can be clearly demonstrated to be fractured, 169 170 A CLINICAL TREATISE ON FRACTURES. surprisingly little reaction follows after what appears to have been a very grave injury ; such cases often recover rapidly Fig. 91. ^ Fracture of the ilium. and without a drawback : indeed, so far as my own experi- ence is concerned, I have seen numerous fractures of the pelvis, but very few in which any complication was present. Fractures of the Pubis. — A breaking strain acting upon the pubis in a youthful subject usually results in a diastasis at its symphysis, while in adults such forces may cause fract- ure either at this point or in the ramus. The close proxim- ity of the bladder and the urethra renders fractures of the pubis serious if either of these organs is involved ; the blad- der, if torn, allowing escape of urine into either the perito- neal cavity or the deep fascia adjacent, while laceration of the urethra usually causes extravasation into the perineum or scrotum. Fracture of the pubis in very severe pelvic injuries is apt to coincide with fracture of the ilium, ischium, or sacrum, but particularly in youthful subjects it frequently exists without any discoverable yielding of other bones FRACTURES OF THE PELVIS. 171 contributing to the pelvic cylinder. It is seldom accom- panied by much displacement if uncomplicated by other fracture, and can easily be recognized by forcible manipu- lation of the ilia in opposite directions. Fractures of the Ischium. — While fracture of the tu- berosities of the ischium may be caused by falling upon the buttocks, and even during labor, it is probably one of the rarest bones of the skeleton to be fractured. As a simple injury, there may be little displacement, and any readjust- ment of fragments that may prove necessary will be facili- tated by the introduction of a finger into the rectum or the vagina in the female. Like fractures of the pubis, they become serious in pro- portion to the damage which has been done to important organs in close proximity. Fractures of the Acetabulum. — Fractures of the acetab- ulum may be caused by any injury fig. 92. which acting on the trochanter major may fracture the neck of the femur ; that this socket, however, is amply strong enough for even ex- traordinary requirements is shown by the extreme rarity of fracture involving it and the great frequency of fracture of the neck of the femur. It is evident that Unless the rim of Fracture of the acetabulum. the acetabulum, as in Fig. 92, is so damaged as to allow of the escape of the head of the femur, a diagnosis of the injury would never be reached with any certainty. Should 172 A CLINICAL TREATISE ON FRACTURES. crepitus be elicited, it would be simply crepitus referred to the head of the femur, and could not be discriminated from fracture of the latter without displacement. Were it possi- ble that a skiagraph would indicate its presence, full infor- mation regarding the management of the case would be obtained, for not only would the femur be observed to be intact, but the presence or absence of any displacement of its head would be demonstrated. The TREATMENT of fractures of the pelvis unaccom- panied by visceral or other serious lesions may be summed up in the single indication, recumbency ; to this may, in certain cases, be added the steadying effect of large sand- bags to the hips, with a firm bandage around the pelvis, pro- vided no tendency to displacement of fragments is caused by the pressuie it exerts. Blood in the urine may depend upon laceration of the urethra or of the bladder, or upon injury of the kidney. When caused by the two former, it usually appears in clots ; when originating from the latter, it is so incorporated with the urine as to give it a dark, reddish color. In order to ascertain definitely which organ may have been wounded by the fracture or by the severity of the crushing force affecting also the loin, the urethra should first be examined by means of a catheter. If there be a tear of the urethra, passage of the instrument will probably be arrested before entering the bladder. If, on the other hand, the instrument passes readily into the bladder and allows urine mixed with blood-clots to escape, wound of the latter may be assumed. In order to determine whether the wound of the bladder FRACTURES OF THE PELVIS. 1 73 has caused it to leak, ten or twelve ounces of sterile water should be injected and evacuated. If the portion evacuated is equal to or greater than that injected, the bladder is shown to be probably competent, though valve- like penetrating wounds of its wall have occasionally allowed escape of urine either into the peritoneal cavity or into the perineum, even though all of a good volume of water has, after injection, been withdrawn. If the fluid injected into the bladder is lost and fails to return, exploration of the organ should be made without delay by laparotomy, the wound sutured, and the abdominal cavity freely flushed with normal salt solution. If the urethra be found lacerated, perineal section exposing the wound and allowing the entrance of a sound into the bladder should be made. This section seldom need extend into the bladder. Microscopic examination will readily prove the kidney to be the source of hemorrhage, and should always be made in doubtful cases. CHAPTER V, FRACTURES OF STERNUM AND RIBS. FRACTURES OF THE STERNUM. Fractures of this bone are not of very frequent occur- rence. A condition of diastasis of the manubrium from the body of the bone is occasionally mistaken for fracture, and is more common than the latter in the early years of life. The sternum may be fractured by direct violence or by Fig. 93. muscular action, as in parturition, or by vomiting, though instances of the latter must be very rare. The line fig. 94. of fracture is usually trans- verse, though cases of longi- tudinal fracture have been reported. The most common seat of fracture is at the line of union of the manubrium with the body of the bone (Fig. 93), Fracture of the though the bone may be frac- body of the tured lower down, through its sternum. body, as in Fig. 94, or the ensiform cartilage may be broken off. The most serious feature of fracture of the sternum is the liability to coincident injury of the thoracic viscera. 174 Fracture of the sternum at the junction of the manu- brium with the body. FRACTURES OF STERNUM AND RIBS. IJ$ The extent to which the latter will be damaged depends largely upon the amount of laceration of the posterior lig- ament. If the latter remains intact, but little injury is likely to be done to the viscera; but if extensively torn the liability to visceral complications is greatly increased. The lungs are the organs most exposed to danger in fracture of the sternum, but the heart has been injured, the lesion in such cases always producing a fatal result. Diagnosis. — Owing to the superficial position of the bone, the diagnosis of fracture of the sternum does not, as a rule, present much difficulty. Deformity and mobility are appa- rent, and crepitus is generally readily elicited. There is con- siderable pain, and dyspnoea is a fairly constant symptom. If the lung-tissue has been penetrated, subcutaneous emphysema rapidly occurs ; and to this is occasionally added haemoptysis. Treatment. — Reduction of the displacement is the first indication in the treatment, and very often proves difficult. Direct pressure on the fragments may be aided by placing some hard object in the form of a pad under the back be- tween the shoulders, and then making traction over it upon the shoulders and neck. This manipulation may be rein- forced by instructing the patient to aid the efforts at traction of the surgeon by taking a full inspiration at the moment the shoulders are drawn back. After reduction the chest should be immobilized by the application of strips of adhesive plaster. Firm bony union of the fragments generally occurs within four weeks after the injury ; but a few cases have been reported in which the union was of ligamentous nature. 176 A CLINICAL TREATISE ON FRACTURES. FRACTURES OF THE RIBS. Fractures of the ribs are almost without exception pro- duced by direct violence, though in some extremely rare instances by muscular action. When caused by direct vio- lence, as from a fall, where the body strikes upon some prominent object, as the edge of a wall or curbstone, or where the fracture is produced by a blow from the fist, the kick of a horse, or even from overzealously performed efforts at producing artificial respiration, one, two, or at most three ribs may be broken, and while the injury is a painful one, it does not cause those alarming general symptoms of dyspnoea and shock which occur after col- lapse of the thorax from fracture of a number of ribs on one, or both sides. Such crushes are produced by the pas- sage of a heavy wheel over the thorax, by being caught be- tween buffers or swinging bales of cotton. For the former class of fractures, little or nothing is required but manage- ment of the fracture; while in the latter class of cases the fracture, except as allowing the collapse of the chest, is a very unimportant part of the injury, fatal shock, either from the interference with respiration alone or dyspnoea combined with intrathoracic hemorrhage, constituting the elements of the greatest urgency. A remarkable instance of fracture of the ribs from muscular violence occurred to an acquaintance of mine, who was an athlete of extraordinary strength, during the performance of a gymnasium figure called l 'the flag," a figure consisting in holding the body and lower extremities out horizontally by the extended arms. The figure is per- FRACTURES OF STERNUM AND RIBS. \JJ formed by seizing two iron rings or handles set in a vertical post about four and a half feet apart, and carrying the body straight out at arms' length. As an enormous ten- sile strain is put upon the arm holding the upper ring, it will easily be seen that the ribs would likewise be sub- jected in such an effort to an inordinate strain. One or more ribs were broken, but, unfortunately, the seat of fracture and other particulars cannot be stated. The presence of pneu- matic support to the chest-wall during the application of exterior force is an important factor in enabling the ribs to resist pressure and blows to which without such support they would readily yield. The heavy weights which acrobats can without discomfort allow to rest upon their chests by holding a full inspiration shows the resistance of the chest, when so prepared, to enormous pressure. The resistance to blows upon the chest received in sparring, obtained by air support combined with muscular tension, is always taken advantage of by the expert. Illustrating the importance of such pneu- matic support by its absence, I witnessed the autopsy of a case of opium-poisoning in which several ribs had been fractured by too energetic efforts at artificial respiration. The patient's condition of complete narcosis deprived him of all muscular as well as respiratory power to resist press- ure, and, to the great humiliation of his attendants, though the result was probably not determined thereby, the ribs yielded. The middle and lower ribs from their exposed position are more liable to fracture than the upper. The seat of fracture, while it is more frequently anterior to the angle of the rib, may often be situated posterior to it, par- 12 178 A CLINICAL TREATISE ON FRACTURES. ticularly in crushing forces. Even in adults fracture of the rib is probably often incomplete. Accompanying a complete fracture of an adjoining rib such a condition would in all probability escape attention. Diagnosis. — Pain and crepitus are the principal signs. Pain on pressure over the seat of suspected fracture, which in degree is out of all proportion to the pain of a bruise ; pain on ordinary or deep inspiration which can seldom be localized with any degree of accuracy by the patient. Crep- itus and mobility can frequently be elicited by direct palpation, but their absence in no wise negatives the ex- istence of fracture. Crepitus may occasionally be de- tected by auscultation, if the patient can be induced to take a deep inspiration. After twenty-four hours a local- ized traumatic pleurisy is usually developed, the friction of which is not likely to be mistaken for bony crepitus. A valuable sign of fracture is obtained in many cases by forcibly compressing the chest anteroposteriorly, a sharp impulse being given by one hand applied to the sternum while a counter-impulse is given by the other hand at the back. This manipulation will frequently produce pain at the seat of fracture. Finally, may be mentioned deform- ity, though as it is so seldom present it is probably the least valuable of the signs of fracture. That the ribs are so often fractured without any apparent displacement of the fragments, either overlapping or angular, depends, of course, upon their complete sheathing, periosteal, ten- dinous, and fascial. Their extreme elasticity in youth renders fracture relatively rare in young subjects as com- FRACTURES OF STERNUM AND RIBS. 1 79 pared with its frequency after middle life, and, for the same reason, they are more often the seat of incomplete fracture in the young than in the old. The most important complications met with in fractures of the ribs are (1) puncture of the lungs, producing pneumo- thorax, (2) hemorrhage from the lung or from an intercostal artery, and (3) rarely, injury to the heart. Puncture of the lung followed by pneumothorax was well illustrated by a case which came under my observation at the Pennsylvania Hospital. A boy, six years old, was brought to the hospital with an injury of the chest caused by the passage of a cart- wheel over it. He suffered much shock and great dyspnoea. Physical examination of the chest revealed complete pneu- mothorax of the left side. As no fracture of a rib could be discovered either by palpation or by skiagraph, the conclu- sion was reached that such a fracture had occurred beneath the scapula and was masked by it, and that the point of one fragment had penetrated the lung. His chest was aspir- ated twice for the removal of air, but, as the lung-wound had not closed, with only little relief. On each occasion intrathoracic pressure was so great that not only was the heart displaced markedly to the right side, but on removal of the needle cellular emphysema occurred so quickly that localized pressure at the point of puncture was required to prevent the emphysema becoming general. Later on, free incision evacuated a large quantity of blood-stained pus. The boy recovered ; but three months after the injury was again admitted to the hospital, into the medical ward, with pneumonia of the right side, of which he died. Post- l8o A CLINICAL TREATISE ON FRACTURES. mortem examination revealed green-stick fractures of the fifth and sixth ribs, not, as was supposed, beneath the scapula, but in the axillary line. Their character was such, however, that failure to detect them was clearly ac- counted for. In some cases puncture of the lungs by a broken fragment of a rib is fortunately not followed by pneumothorax, but by cellular emphysema. While the reason for this cannot be positively explained, it is probable that old pleuritic adhesions, obliterating the pleural cavity at the seat of fracture, allow the air to pass directly to it and into the areolar tissues. That perforation of the lung has occurred in every case of fracture of a rib accompanied by cellular emphysema is certain. Treatment. — As nearly complete fixation of the frag- ments as possible is the important element in the treatment, for, there being no displacement, reduction is very rarely required. As the principal cause of movement at the seat of fracture is that produced by respiration, to restrict this movement on the injured side is the object sought. This may best be done by strapping the chest. The area to be covered extends from the base of the chest to the axilla, and from a point three inches from the median line on the sound side in front, to a corresponding point behind. Two-inch straps are used, and should be applied thus : Anchor one end of a strap at the lowest point either behind or in front. The patient is directed to breathe out as fully as possible, mean- while steadying himself with the arm of the sound side. At the moment expiration is complete the strap is laid horizon- FRACTURES OF STERNUM AND RIBS. 151 tally with considerable force, its upper border dipping quite deeply into the skin, in order to prevent it from being puck- ered by the lower border of the next strap. The same ma- noeuvre is repeated for each successive strap, until about six are applied, overlapping one another one-half their width. The skin should always be shaved before the application of the straps. This dressing should be renewed whenever the straps become slack, and may be continued for three weeks ; after which the case seldom requires any attention. As this plan of treatment is very generally applicable to all cases of fracture of the ribs unaccompanied by any com- plication, it is the only one that need be mentioned. In cases complicated by puncture of the lung accompanied by cellular emphysema the latter is controlled and prevented from any tendency it may have to become general by the interposition beneath the straps at the point or points of fracture, of a compress, the size of an English walnut, of a piece of gauze rolled into a ball. In cases complicated with pneumothorax, strapping, while not contraindicated, may be useless because of the induced immobility of the chest by the pneumothorax on the side affected. Should the chest- wall incline to collapse from several fractures, strapping is contraindicated, as it would tend to diminish still further the intrathoracic area. Hemorrhage from an intercostal artery must indeed rarely be severe enough and persistent enough to require radical means for its arrest. If it should, how- ever, resection of the rib in order to reach the vessel on the cardiac side of the hemorrhage would become necessary. CHAPTER VI. FRACTURES OF THE SPINE. As the vertebral column may be described as an irregu- larly shaped hollow cylinder containing within its calibre the spinal cord, its walls pierced at numerous points for the passage of spinal nerves, any fracture which causes, through displacement of fragments, encroachment upon this calibre is liable to bruise, wound, or sever the cord or the nerves given off by it. Fracture of the spine is produced by direct impact, by force indirectly communicated, or by violent flexion. Any portion of a vertebra — the body, the laminse, or the processes — may be fractured; but the essential element of the lesion commonly spoken of as "fracture of the spine" implies a fracture which has caused injury to the cord or the spinal nerves. It will be seen, therefore, that as the spinous processes do not contribute to the formation of the bony tube, they may frequently be separated without giving rise to any general nervous symptoms ; but when it is remembered that the force required to fracture a spinous process is great and concentrated, it will be understood that it is of a kind well calculated to cause a greater or less degree of the condition, frequently occurring without fracture, known as spinal concussion. Paralysis following fracture of the spine is usually immediate and complete of 182 FRACTURES OF THE SPINE. 1 83 body and extremities, from a plane level with the seat of fracture downward. Deformity when it exists is apt to be anteroposterior, though not infrequently, where the plane of fracture through the body of a vertebra allows an overlapping which diminishes the thickness of that body, the only deformity discernible is a slight posterior angular displacement, producing prominence of a single spinous process. Such deformity is a traumatic reproduction of that existing in Pott's disease through the carious disin- tegration of bodies of vertebrae. If the fracture involve the body of a vertebra, preternatural mobility and crepitus are absent; but if both laminae are completely broken through, mobility of the spinous process belonging to the injured vertebra may at times be felt, and, occasionally, even crepitus. In cases in which no deformity, mobility, or crepitus is discoverable the existence of fracture cannot be demonstrated, but, should the paralysis show no tendency to prompt abatement, it may be fairly assumed. The per- sistence of paralysis, therefore, after an injury to the spine, while not conclusive, is strong evidence of fracture ; but if not corroborated by other signs of the latter must be accepted only with reserve. A woman was admitted to the Pennsylvania Hospital, after a fall from a third- story window, with complete paralysis below the neck, of trunk, upper and lower extremities. Careful examination of each cervical vertebra, failing to reveal deformity, mobility, or crepitus, excluded every local sign of fracture. Faint signs of improvement suggested that the spine was not fractured, but that the neck had been subjected to 1 84 A CLINICAL TREATISE ON FRACTURES. extreme flexion with more or less laceration of ligaments and contusion of the cord — a sprain of the cervical spine. The prognosis that the paralysis would be evanescent was verified, for she recovered in eight weeks. Another case illustrating paralysis without definite cord lesion was that of a colored woman who was admitted to the Pennsyl- vania Hospital with two gunshot injuries inflicted by a large calibred pistol. One ball traversed the elbow-joint ; the other penetrated the chest, and was removed from beneath the skin posteriorly, in a bone-battered condition, at the site of about the sixth dorsal vertebra. On admis- sion she had paralysis of the lower extremities, which within twenty-four hours was gone. In this case it was assumed that the cord had probably received only a severe concussion from the impulse of the ball in close proximity to it. Fractures of the spine occur most frequently in the dorsal region (Fig. 95); particularly is this true when they are produced by force communicated indirectly or by ex- treme flexion. That the spine yields here at its middle can be best understood if, for the moment, the spinal column is compared to a limber stick, and if the action of extreme flexion is regarded as identical in its effect with force indirectly applied through the pelvis or lower extrem- ities by a fall from a height upon the buttocks or feet. A walking-stick pressed upon breaks approximately at its middle, just as a walking-stick will break if thrust hard enough against the ground; any flexible structure bends before it breaks, and breaks at the middle of its bend. FRACTURES OF THE SPINE. 1 85 For this reason the common seat of fracture will be in the dorsal region whether the injury results from a crushing force which overflexes the spine or a fall which from momentum of superincumbent body-weight also overflexes it. Falls upon the head are, except hanging, the most Fig. 95. Skiagraph of fracture of the spine in the dorsal region. frequent cause of fractures of the cervical vertebrae. In this locality, too, the mechanism may perhaps most often be that of overflexion or overextension, though at times one of direct crushing strain. Fractures of the atlas and axis when resulting from falls upon the head are probably always caused by force of a crushing character. The common lesion resulting from hanging, however — fracture of the odontoid process of the axis, accompanied by dislo- 1 86 A CLINICAL TREATISE ON FRACTURES. cation of the atlas from the latter — is produced by over- extension. Fractures of the spine caused by force directly applied occur at the point of impact. The causes of such fract- ures are falls, blows, and gunshot injuries. Symptoms. — Fractures of the spine at different localities possess many signs in common, and yet they differ widely according to the nerve-functions disturbed or destroyed at and below the damaged point of the cord. There is paral- ysis, immediate and complete, of the trunk and extremi- ties, from a plane, often well defined, level with the seat of fracture; there is retention of urine, succeeded in a few hours by permanent incontinence, accompanied also by incontinence of the rectum ; there are disturbances of the vasomotor system affecting the bloodvessels and causing trophic changes in the integument which markedly predis- pose it to necrosis ; there may be temperature-changes, deviations from the normal, either above or below. Also there may be sensory phenomena, more or less marked, manifested by girdle-pains similar to those of locomotor ataxia, lancinating about the trunk; and various referred sensations over the paralyzed area, such as formication and flushes of heat and cold. Gastric crises may occur. Pria- pism is frequently observed. Accompanying these symp- toms, if the case does not tend to a rapidly fatal issue, there are gradual emaciation and general impairment of nutri- tion ; and, finally, the mental state may be placid and resigned, or nervous, restless, and emotional. Paralysis produced by fracture of the spine is usually FRACTURES OF THE SPINE. 1 87 complete of both motion and sensation, the line of de- marcation of the latter being frequently clearly denned. Its effect upon the soft tissues, is principally manifested by their tendency to become necrotic when subjected to pressure. In spite of every precaution to equalize the pressure, the integument over the sacrum, and even at the heels, breaks down and causes most intractable bedsores. The paralyzed extremities do not waste rapidly, as a rule; but present a doughy, flabby appearance. Owing to vaso- motor defect, cutaneous circulation may be somewhat con- gested, and give a flushed appearance and at times local increase of temperature to the surface. The bowels and bladder almost immediately become entirely incontinent, and their contents voided involuntarily. If the fracture occurs even as low down as the dorso- lumbar region, there is often, in addition to the symp- toms of general paralysis already enumerated, interference with respiration, due to the muscular relaxation of the abdominal parietes. Ascending the spine, the gravity of the injury increases as the function of the cord is cut off at a higher level, until the second dorsal vertebra is reached. A fracture occurring between this point and the third cervical vertebra (cervico-dorsal region) is likely, through involvement of the brachial plexus, long thoracic, or phrenic nerve, to embarrass respiration, or in the case of the latter fatally to arrest it. Fractures of the atlas and axis are usually immediately fatal through the almost inevitable injury to the medulla accompanying them. The above mentioned symptoms, occurring with greater 1 88 A CLINICAL TREATISE OX FRACTURES. or less severity, may be consistent with life, and tend to shorten it only as they torment and exhaust the patient. The prognosis regarding recovery is most unfavorable, while that regarding life is extremely uncertain. It may be generally stated, however, that many victims of fract- ure of the spine, having survived the acute effects of the injury, if their environment and nursing are of the best, survive two or more years. To what extent operation may be looked to to modify this gloomy prospect will be con- sidered in the treatment. Not always is the termination so unfavorable as this. Recovery with more or less per- fect restoration to health occasionally occurs after fracture with paralysis at any portion of the spine; and besides there may be mentioned a group of cases, occupying as it were a middle ground, which, although their paralysis lasts, recover their health, and in their upper extremities strength to such an extent that with certain artificial aids they can not only help themselves in many ways, but can even get about. A most generally useful appliance for these cases is the ordinary wheel-chair fitted with adjustable crutches. Fractures of the Spinous Processes. — Fracture of the spinous process of a vertebra is caused usually by direct violence; and while any vertebra may suffer, the upper dorsal and lower cervical, through the greater prominence of their spinous processes, are more likely to yield from the violence of a direct blow than are the processes of vertebrae lower down. They may well be described as the only fractures of a vertebra which can be clearlv demonstrated by palpa- FRACTURES OF THE SPINE. 1 89 tion, and the only fractures which are liable to occur with- out coincident injury to the cord or spinal nerves. Their importance is so slight as compared with other fractures of the spine that they hardly deserve to be classified as such. The symptoms to be observed are pain and tender- ness, contusion of the integument from impact of a more or less sharp body, with or without signs of concussion of the cord. On palpation the fractured process when dis- covered will be found freely movable, but not displaced. Slight crepitus may be felt if the process has been com- pletely detached. In a case of very serious depressed fracture of the skull which I had occasion to trephine at the Episcopal Hospital there was a fracture of the spinous process of the eleventh dorsal vertebra. It could be readily detected on palpation as abnormally mobile, though it was not at all displaced, and its existence offered no complication whatever to the patient's convalescence from the very serious head injury. As there is usually no appreciable displacement of a fract- ured process, no reduction is required ; and rest in bed to guard against any concomitant concussion of the cord from a crushing blow in such close proximity to it is all that is necessary. The union of such fractures may be by bone or fibrous tissue, but which is the more common result cannot, because of insufficient data, be stated. Fractures of the I/aminse.— A fracture involving one or both laminae of a vertebra can hardly occur without injury to the cord. If the laminae on both sides of the vertebra are broken, a degree of displacement of bone, I90 A CLINICAL TREATISE OX FRACTURES. as is shown in Fig. 96, must almost inevitably occur which, by encroachment upon the spinal canal, will bruise, compress, or sever the cord. If the displaced fragment spring immediately back into its normal position, whatever damage to the cord was done re- mains, but no continued pressure exists, and according to the extent of this damage Fracture of verte- will the cord recover or its functions be brai lammas. irreparably lost. Fracture of the laminae occurs most frequently in the cervical vertebrae, because of the peculiar arrangement of the spinous processes in this region, and because the neck is particularly vulner- able to the character of injuries most liable to cause their fracture. The fracture may be caused by either a blow on the top of the head, as in a fall, or by diving in shallow water, or from a blow on the forehead, as in passing beneath a bridge on horseback or on cartop. The effect of force applied bv either of these methods is to overextend this least supported part of the column. The spinous processes are so pressed upon at their tips that the laminae yield through the lever-like force exerted upon them by the latter. But this is by no means always the mechanism, as the neck may be bent in some other direction (forward or laterally), or may be thrust directly in the line of its axis, so that the force producing the fracture is a crushing one, or depends upon these two elements acting in com- bination with either the weight or with the resistance of the body. A lesion so profound may cause instant death FRACTURES OF THE SPINE. 1 9 1 if the displacement of fragments has been marked, or if the line of fracture have implicated the phrenic nerve. If death is not instantaneous, attention is drawn to the probable lesion by the sudden paralysis of the entire trunk and all the extremities. Shock, while present, may be only moderate and not of a degree proportionate to the immense gravity of the injury. Occurring at other points in the spine, fractures of the laminae are accompanied by no characteristic signs which can with any certainty be relied upon to distinguish them from fractures of the body alone, or in combination with them. None of the general symptoms vary; and locally, though it may be possible to detect mobility or deformity, which points to fracture of this portion of a vertebra, exploration by palpation is too much masked by the tissues imbedding the spine to permit of anything like a satisfactory demonstration. Operative exploration, therefore, as a step preliminary to operative procedure may be considered. Fractures of the Body of a Vertebra. — Fracture of the body of a vertebra is usually caused either by force com- municated through the length of the spine, as in falling from a height and alighting upon the feet or buttocks; or by a crushing force, as the falling of a bank of earth, which pro- duces excessive spinal flexion. The deformity resulting from such a fracture depends upon the sidelong displacement in the direction of obliquity of the plane of fracture, with conse- quent diminution in the thickness of the body of the vertebra involved. The element of sidelong or lateral displacement encroaches upon the spinal canal more or less according to its 192 A CLINICAL TREATISE ON FRACTURES. degree ; while the resulting diminution in the thickness of the body of the vertebra produces posterior angular deformity opposite the seat of fracture through the shortening of the anterior pillar of the column, exactly as the hump is pro- duced in Pott's disease by the carious disintegration and con- sequent loss of support of the body of the vertebra. The change in contour may consist, therefore, in undue promi- nence of the spinous process of the damaged vertebra. Should the fracture of the body involve the transverse proc- esses or their articulating surfaces, a tendency to rotary dislo- cation may appreciably alter the line of the spinous processes in a direction determined by the displacement ; while if the tendency be to partial anteroposterior dislocation the level of this line is affected. Lateral displacement deviates it slightly to one side or the other. The general symptoms vary, as in fractures of the laminae, according to the degree of displacement and encroachment upon the calibre of the canal, and the region of the spine involved. To sum up the general conditions regarding fractures of the vertebrae, it may be stated that there is the fracture of the spinous process, which may frequently be clearly demonstrated, but which produces no paralysis and requires no special treatment; there is the fracture through one or both laminae, which may at times give preternatural mobility of the corresponding spinous process, and which is almost invariably accompanied by paralysis; and there is the fracture through the body of the vertebra, which, by diminishing the thickness of the latter or by causing FRACTURES OF THE SPINE. 1 93 lateral or anteroposterior displacement, may produce angu- lar deformity or oblique deviation in the line of the spinous processes, accompanying which there is no preternatural mobility or crepitus. From a clinical point of view, how- ever, it is almost vain to dwell upon any symptoms except the paralysis, which can be clearly demonstrated as char- acteristic of fracture of any portion of a vertebra; for not only may the lesion involve different parts of one or more vertebrae, with or without comminution, but often the par- ticular fracture responsible for the paralysis exists without furnishing a single diagnostic sign. Fractures of the spine produced by indirect violence or forced flexion of its whole length occur more frequently in the lower dorsal region; while direct blows, of course, are likely to cause fracture at the point of impact. The higher up the spinal column the fracture occurs, assuming the extent of the injury to the cord to be equal, the more unfavorable is the prognosis. Treatment. — The treatment of fracture of the spine may very properly be divided into two distinct plans, pal- liative and operative. Under palliative treatment may be included gradual and continual extension, and forcible extension with attempts at times at forcible reduction of patent deformity. Gradual and continual extension may conveniently be employed by applying an extension appa- ratus (Buck's) to each leg. To these a weight of from eight to twelve pounds is added, while counter-extension is obtained either by inclining the bedstead by elevation of its foot four inches, or by carefully padded rings 13 194 A CLINICAL TREATISE OX FRACTURES. attached to its head, through which the arms are thrust to the axillae and supported as if on crutches. When the latter are used it is necessary to give the patient periods of rest from the fatigue which their incessant em- ployment causes. A quarter of an hour four or five times a day may be sufficient. Throughout the employment of such extension the greatest attention must be paid to every part of the integument involved in the paralyzed area, in order to avoid if possible the formation of bed- sores. The back, of course, is the most difficult part to keep sound. The bedding must be kept dry and clean, which is no easy task with paralyzed viscera. The crease of a sheet or of padding if allowed to remain a few hours may be the beginning of a sore. The integument over the sacrum and over the pelvis generally, receiving more pressure through the prominence of the bones beneath it, requires the greatest attention. Large ringed pads fre- quently changed and the integument carefully bathed many times a day with alcohol will probably give the best results. Any red point must immediately be relieved of all pressure until it pales again, for otherwise in twenty-four hours it will be a sore. I have frequently kept the back sound by changing the position of the patient once in three or four hours from the right side to the left side and then to the back, alternating in this way throughout the day. This change in decubitus is sometimes intolerable to the patient; but when it can be borne it is of great use. Equable dis- tribution of pressure may be obtained through a water- or air-mattress. At times it will be found to be most efficient FRACTURES OF THE SPINE. 195 in keeping the back sound. An objection to it, however, is that it may be relied upon too much to lessen the labor- ious task of frequent inspection, bathing, and changing of pads, etc., for this is necessary even with its use. If an extension apparatus is applied to the lower extremities, the pulleys at the foot of the bed must be elevated in order to convey the line of traction in a direction which will pre- vent undue pressure of the heels on the mattress. Fixation by a plaster jacket would seem to be indicated in cases characterized by unusual mobility at the seat of fracture. It should be applied during spinal extension. Forcible extension with at times an attempt at reduc- tion must invariably be performed under ansesthetization. Manual extension exerted by four assistants upon the lower extremities, with the usual sheet-hitches at the knee or ankle, will furnish as much force as can be prudently employed. Counter-extension upon the chest with a sheet looped from the back beneath the axillae and attached above should be supplemented, if there are enough assistants at hand, by manual support of the shoulders and arms, as the required counter-extension applied wholly to the chest is liable to interfere too much with respiration. At the word from the surgeon, the assistants apply their forcible exten- sion to the lower extremities, the surgeon meanwhile placing his fingers over the spine at the seat of injury in order to perceive any change in form which may result. It is evident that forcible extension applied in this way can only hope to effect permanent reduction by the frag- ments remaining restored of themselves, for if they slip 196 A CLINICAL TREATISE ON FRACTURES. immediately out of position nothing is accomplished. The manoeuvre of forcible extension, while it may do no good, runs small risk of doing any harm, except as applied to the fractures of the cervical vertebrae, where the danger of causing sudden death should be clearly explained to the patient and his friends, before it is undertaken. Operative treatment consists in exploring by incision and dissection the seat of fracture, and either removing with forceps any comminuted fragments of bone which may be found to be pressing upon the cord, penetrating its mem- brane or in any way encroaching upon the lumen of the fig. 97. Author's spinal ronguer forceps. spinal canal ; or performing formal laminectomy. After exposing the vertebra, should both laminae prove to be fractured, the arch may easily be removed by seizing and making traction upon the spinous process with heavy for- ceps and dividing with a scalpel its ligamentous and tendi- nous attachments. The removal of the arches of one or more vertebrae by laminectomy will at times give space and thereby relieve pressure upon the cord, which has been caused by displacement of fragments from a fracture even of the anterior portion of the column. The shock inci- dent to such an operation is not necessarily great, the FRACTURES OF THE SPINE. I 9 7 Fig. 98. principal danger likely to be encountered being the use of the anaesthetic required for its performance. This danger arises at times from the condition of continued shock often present, or from the prone position assumed when there is already embarrassment of respiration through paralysis of the abdominal muscles. The operation of itself is not very formidable. With the spinal ronguer forceps shown in Fig. 97, the six pairs of laminae were for the pur- pose of experiment divided and removed in ten minutes on the cadaver, as illustrated in Fig. 98. Having cleared away the muscular and tendinous attach- ments overlying the laminse, the forceps, in- sinuated at a joint, are made to cut from below upwards in a line situated midway between the bases of the transverse and spinous processes. After section of the lam- inae on both sides, the appropriate spinous process is seized with heavy toothed forceps and sufficient traction applied to make tense any remaining tendinous or ligamentous fibres which may require division with a specimen scalpel. On removal of the arch of one vertebra, the indications for the removal of the one immediately adjacent to it must be determined by the requirements of the conditions found. If the cord bulges and is observed to be at all nipped above or below, further space must be given and the arch of another ver- tebra excised. Hemorrhage is usually easily controlled. The question regarding the appropriate method of pro- experimental laminectomy. I98 A CLINICAL TREATISE OX FRACTURES. cedure which should be adopted in any recent fracture of the spine is a very grave one, and, unfortunately, cannot be answered as definitely and distinctly as its importance would demand. The whole subject of operation is as yet in a transition state, to be either indorsed or negatived with further experience. In favor of operation are : (a) the chance which it affords of removing a fragment of bone which has been so displaced that it presses upon the cord to an extent not to destroy it irreparably, but which if allowed to remain will inevitably do so; (b) the opportunity offered of relieving cord-pressure produced by encroachment of displaced fragments of bone anteriorly, by giving space posteriorly through laminectomy; (c) the relief, also by laminectomy, of pressure from hemorrhage ; (d) the hopelessness of obtaining, in almost every case, any amelioration of symptoms or an arrest of the direful conse- quences of the injury by any palliative measures. Against operation are: (a) the risk at times of using an anaesthetic, owing to the patient's general condition, or bad respiration ; (b) the complication of a deep wound situated in the worst possible place for proper management and in tissues which not only will show no disposition to heal, but will probably slough, and may cause septic infection that will, under the conditions, prove almost surely fatal ; and (c) the fact that operation, while adding these draw- backs to a case already most difficult of management, ac- complishes in the great majority of cases little, and often nothing. As it is extremely desirable that even scanty data gained by experience should be set forth as fully as FRACTURES OF THE SPINE. 1 99 possible, it may be stated that in any suspected case of fracture of the spine accompanied by paralysis, in which within forty-eight hours the paralysis shows a tendency to slight improvement, and in which no displacement in the line of the spinous processes can be detected, operation should at least be delayed. In cases where complete paralysis persists and deformity is observed, forcible extension under an anaesthetic, if the patient's general condition permits, may be applied. Should this fail to correct the displacement, operation, if ever to be performed, had best be done at once. If any lesson is to be learned from the operations which have been done, it is that delay of weeks or months has removed from the case the only chance it had of success, by allowing conditions which promptly removed would possibly have terminated in resolution, to cause, through persistent pressure, degen- eration of the cord. The very important questions of the earliest moment at which operation should be performed, if considered at all, and the latest period it may be hoped to be of benefit, depend upon the special peculiarities of every individual case, peculiarities which become manifest only upon exploration. The doubt sure to hang over every case allowed to remain unexplored is whether it may not be one which could be relieved by operation. If operation is to be performed, it should not be delayed unnecessarily — that is, beyond the requirements of the patient's general condi- tion, and after reasonable prospect of improvement and ultimate recovery of function in the cord has been aban- doned. If by forcible extension it is found possible to 200 A CLINICAL TREATISE ON FRACTURES. reduce the displacement, even incompletely, that much may be felt to have been accomplished, and the effect noted for a period of a week before deciding upon laminectomy. In reaching a decision whether or not to operate, a careful study of the behavior of the paralysis is a more useful guide than are the observations of its primary char- acter. Its behavior or progress, should it be, as already pointed out, towards abatement, furnishes definite proof of partial restoration of cord function, which could not occur with either complete destructive lesion or complete arrest of function occasioned by pressure of bone. Its character, partial or complete, denoted by the degree of anaesthesia and the preservation or obliteration of the superficial and deep reflexes, although indicating clearly enough the extent of arrest of cord function, does not reveal whether such arrest is produced by complete destruction of the cord, which is irremediable, or by pressure upon it of displaced fragments of bone, which may be relieved by their removal. Fractures of the sacrum and coccyx may be mentioned along with fractures of the spine. They are both very rare. Fractures of the sacrum are amenable to the same general management as are fractures of the vertebrae. Fracture of the coccyx can occur only after coossification of the bones composing it. Any deformity present may be reduced through the rectum. Perfect rest and the use of anodynes will best guard against the only serious consequence of the injury — coccydynia. CHAPTER VII. FRACTURES OF THE SKULL. The skull from a structural point of view is somewhat anomalous. So far as approximately spherical form is concerned, its double plating of compact substance with an intervening layer of diploic or cancellated material, its thickened protuberances at salient points, the interlocking by suture of the various bones composing it, all combine to give it the maximum resistance to external violence, and make it, for its weight, an ideal bone-case. Its struct- ural defect consists chiefly in the lack of uniformity of its thickness in different parts, which renders the weaker por- tions peculiarly vulnerable to certain vibratory forces. Its thickness varies in different races and individuals, and in like proportion does its resistance to applied forces. The surgical importance of fracture of the skull, as it depends principally upon the fact that the latter is the brain-case, subordinates the lesion to the more important injury which may be done to the brain, either directly by the fracture or incidentally by the force producing it. A displaced fragment of fractured skull may press upon, bruise, or wound the brain; but force applied to the skull also is capable, without causing any fracture, of bruising or lacerating the brain, or of producing hemorrhage which compresses it. In the former the broken fragment of bone 201 202 A CLINICAL TREATISE ON FRACTURES. is the direct vulnerating body, while in the latter the skull acts only as a transmitter of the violent impact directed upon it, and concussion, contusion, laceration, or hemor- rhage of the brain occurs, without fracture of the skull. While technically, therefore, fractures of the skull must be depressed fractures in order to possess surgical importance, all fractures which are accompanied by brain symptoms, and many which are not, may well be suspected of doing harm until the contrary is proved by exploration. The methods of conducting such exploration are now so free from risk and can be used so much more satisfactorily if they are resorted to at once, that delay is sel- Fig. 99. J dom advisable, or even justifiable, if proper technique and means are at hand. The structural form and physical constitution of the skull are such that a fracture of the external table may furnish little clue in regard to the existence of any abnormal con- Fracture of the external table dition of the internal table. Ac- of the skull. . companymg a fracture 01 the ex- ternal table produced by a hammer or sharp edge of metal or stone there may be decided depression of the external table with little or no disturbance of the internal table, as shown in Figs. 99 and 100 ; there may be a fracture of the internal table which corresponds in form and degree of depression with great accuracy to the fracture of the ex- ternal table, as shown in Fig. 101 ; or there may be an ex- FRACTURES OF THE SKULL. 203 tensive depressed (Fig. 102) or stellate fracture (Fig. 103) of the internal table, with a degree of depression of the external table so slight as easily to escape de- fig. 100. tection through the scalp. Fig. 103 is reproduced from a specimen which well illustrated this last condition. The case was one of depressed frac- ture of the skull anteriorly, which after trephining died. A post-mortem examination revealed a stellate frac- ture, Which is Shown in the lower Fracture of the external table portion of the figure, the presence of of the skulL which was the principal cause of death. So little depres- sion of the external table accompanied it that it could not have been discovered through the scalp if sought for; which it was not, because of the existence of the visi- ble lesion. An extensive radiating fracture is very liable after having done great damage to the brain or dura mater, and having caused in- tracranial hemorrhage bv wounding an artery or one of the cerebral Depressed fracture of the exter- • . -, , sinuses, to spring back again, more nal table accompanied by corresponding depression of or less completely, into position, thus the internal table. • -. i i i • i covering its tracks and leaving be- hind no trace of the damage it has wrought within. While the seat of such fracture is usually at the point of impact, it may be quite remote from it. If remote, the fossa most Fie 204 A CLINICAL TREATISE OX FRACTURES. adjacent to the point of impact on the vault of the cranium will frequently be the seat of such indirect fracture, con- stitutino- a fracture at the base of the skull. Fig. 102. Fig. 103. Fracture of the internal table of the skull with extensive depression. Stellate fracture of the skull. Fractures at the base of the skull, of which Fig. 104 is an example, may, however, be produced by direct vio- fig. 104. lence, as in a headlong fall, where the skull is brought to a stand- still and the spinal column, car- rying with it the momentum of the entire body, is thrust against the base, and is capable of severely comminuting it or even of being driven straight into the brain. Fig. 105 represents an extensive Fracture at the base of the skull, comminuted fracture of the base of the skull, produced by a headlong fall, which terminated fatally in a few days. Post-mortem examination revealed almost complete ankylosis of the cervical vertebrae, as shown in Fig. 106, a condition which doubtless contributed largely FRACTURES OF THE SKULL. 205 to the injury of the skull, as the column at this point, by its rigiditv, permitted no yielding of the neck, and was therefore driven with the force of a solid pillar. The base of the skull may also be fractured by compression of the head laterally, as when the head is run over by a heavy wagon. Fig. 105. Fig. 106. I Comminuted fracture of the base of the skull. Ankylosed cervical vertebrae in the case illustrated in Fisc. 10:;. Other forms of fracture of the base of the skull are punct- ured and gunshot fractures. Certain points, as the orbit and nasal cavity, offer little resistance to such an instrument as a foil without its tip or other light, delicate metal point. Many fractures of the vault of the skull, especially those produced by heavy blows and by falls, while their actual focus may be in the vault, involve the base by radiating lines of fracture ; when the symptoms of the one are masked by the other. Fractures of a parietal bone may extend to the base through frontal, temporal, or occipital bones ; but, as already stated, the base is more frequently fractured in that fossa most adjacent to the point of impact 206 A CLINICAL TREATISE OX FRACTURES. on the vault of the skull. In such cases, while the gross lesion is distinctly of the vault, symptoms of fracture of the base are also present. Fractures of the skull may best be considered under only two varieties, uncomplicated and complicated, as per- haps in no other way can the all-important distinction between a fracture which neither immediately nor remotely causes harm to the brain, and one which does so or is in danger of doing so, be so clearly emphasized. Once this dis- tinction is made, they may be described, as are fractures else- where, according to the special characteristics they possess ; thus they may be simple or compound. This, which in other bones is often the most important distinction, plays a very subordinate part in fractures of the skull. A simple fracture causing a mere fissure in any part of the vault of the cranium, accompanied by moderate and evanescent symp- toms of concussion of the brain, will almost inevitably escape detection, for no sign indicative of its existence can be felt through the scalp, and the brain symptoms present are not severe enough even to suggest the necessity of making an exploratory incision. Or a simple fracture may be of a character that will produce a degree of injury to the brain sufficient to cause almost immediate death, or a condition which if not immediately relieved will inevitably prove fatal. A compound fracture may consist of simply a slight chipping off of a small fragment of bone which does no harm and produces an injury which is of the most trifling importance. Such a condition is frequently found accompanying scalp-wounds, and often, were the compound FRACTURES OF THE SKULL. 2QJ element emphasized, it might from a medico-legal aspect be given very undue prominence. On the other hand, the severest lesions of fracture may be present with it, just as they may be with the simple fracture. The simple or com- pound element, therefore, in fracture of the skull is often an insignificant one. The latter, by making explora- tion of the skull possible without the use of an anaesthetic, rather simplifies than complicates the management of the case. In the same way linear, comminuted, stellate, and impacted are terms which, while useful for description, have little bearing upon the severity of the fracture. A minute linear fracture may have little importance, or it may be the wound of entrance of a penknife-blade which, thrust through the skull into the brain, and hav- ing broken off just below the surface of the bone, has left no trace behind. A comminuted fracture, too, may be important or not, depending wholly upon other conditions present ; and an impacted fracture may or may not add in some way to the complexity of the case. A depressed fract- ure does possess special characteristics, to which reference will presently be made. It is usually comminuted and more or less impacted ; while a stellate fracture is necessarily comminuted, and is likely to be more or less incomplete. The real importance in a general classification of fractures of the skull is to distinguish those which involve no injury to the brain, either at the time of their occurrence or at a later period, from those which have, either by wounding the brain or its membranes, or by lessening the intra- cranial capacity, produced those disturbances of the func- 208 A CLINICAL TREATISE ON FRACTURES. tions of the brain which are commonly called cerebral symptoms. As cerebral symptoms are caused by so many morbid conditions other than fracture, and as their origin, classifi- cation, localization, and management constitute a subject which must be treated fully, if treated at all, the description of the various fractures of the skull will be rendered clearer and simpler if the cerebral disturbances caused by them or associated with them are not specifically described, but only generally mentioned as the occasion requires. The conditions demanding surgical interference in fracture of the skull are much more frequently those which are local than those which are general. If there is a wound leading to the seat of fracture, the existence of the latter being immedi- ately revealed, its proper management may often be definitely determined upon without regard to the presence or absence of cerebral symptoms. In the same way the probability of fracture may be suggested by nothing more than the exist- ence of a boggy spot in the scalp. While the presence of cerebral symptoms accompanying such a local condition would point yet more strongly to the probability of there being a fracture and to the necessity for exploration, the absence of such symptoms would in no wise negative the existence of fracture. It must be mentioned, however, in qualification of this statement that there are a certain num- ber of fractures of the skull, especially those of limited area, in which localization is of inestimable value in indicating with extraordinary precision the site of the lesion. The lat- ter is in these cases usuallv hemorrhaofe caused bv fracture or FRACTURES OF THE SKULL. 200, cranial jar. While, as already stated, an intracranial lesion at any point may produce general symptoms identical in all respects with those due to fracture, when such symptoms are present, fracture being practically the only removable cause, it becomes a matter of the very first importance to prove or eliminate its presence. Cerebral localization is often of value in placing the lesion at some particular point ; but owing to the preponderance after fracture of symptoms produced by brain concussion or brain contusion, the aid it might render is not by any means as great as that afforded by it in the diagnosis of diseased conditions. If these symptoms are not so marked as to overwhelm completely those of localization, there may be observed occasionally faint twitching of the arm and leg on one side, indicating the involvement of the arm and leg centre on the opposite side of the brain as the probable focus of the lesion. In like manner other symp- toms may locate the lesion at a particular point in the skull, as indicated by cerebral topography. The frequency with which fracture of the skull is mistaken for various other conditions sufficiently indicates the necessity of carefully eliminating it by the most thorough exploration of the scalp in every case of coma or paralysis which cannot be clearly accounted for by surrounding circumstances. Such mistakes are most com- monly made by the ignorant, as when an unconscious in- dividual is placed in a cell at a station-house, thought to be a subject of alcoholic coma, when, albeit he may be satu- rated with spirits, he is found perhaps after death to have a fracture of the skull. But errors of this nature occasionally 14 2IO A CLINICAL TREATISE ON FRACTURES. occur in technical hands, sometimes unavoidably, but too frequently from carelessness. In every such case, there- fore, to which the surgeon is summoned, whether alcoholic intoxication, uraemia, or apoplexy be the apparent cause of the symptoms present, the possible presence of fracture should be borne in mind and sought for. If upon exami- nation any doubtful spot be discovered, the scalp should at this point be shaved, in order that the examination may benefit by inspection of the color of the skin and by the improved opportunity for palpation. If such a case recov- ers consciousness, he should be kept under careful obser- vation for a sufficient period to prove that his symptoms were toxic and not traumatic. Diagnosis. — The diagnosis of fracture of the vault of the skull is based on the evidence obtained by inspection and palpation, which in the absence of an external wound often furnish but meagre data, and on the presence of cere- bral symptoms, if they exist. When it is remembered that symptoms of every degree of concussion, of contusion, and of laceration of the brain may be present without fracture, and that symptoms related to one of these conditions are often present in conjunction with fracture, though probably not depending wholly upon it, it is evident that, without exploration, in many cases the question of existence of fracture will always remain in doubt. A depressed fracture of the skull requires surgical intervention, not only on ac- count of the damage it may have already inflicted upon the dura mater or brain, and may continue to inflict for the present by causing paralysis, hemorrhage, and a little later FRACTURES OF THE SKULL. 211 abscess, but also on account of the remote cerebral diseases (epilepsy, chronic meningitis, and dementia) which are not such uncommon sequelae that we can afford for a moment to ignore them. If with cerebral symptoms — and the term is intended as here used to denote disturbances of a more grave character — is combined a contusion extending over a considerable area, the central portion of which feels soft and boggy, incision will frequently reveal a fracture. Figure 107 illus- Fig. 107. trates a very extensive commi- nuted depressed fracture which occurred under these conditions, but which, as there was no wound of the scalp, it remained for the exploratory incision to reveal. Again, in certain cases which present symptoms of great compression of the brain occurring after a fall from a height where the head strikes Soft ground, and the impact is Diagram of simple fracture of the skull, showing the central area of depres- SO distributed Over a large SUr- sion and the radiating lines of fract- face of scalp as to cause no ap- ure - The fla P is indicated by the curved dotted line. preciable contusion at any one point, it may be extremely difficult to select a likely point for exploration, and perhaps even after one exploration has been made nothing more will have been learned than that there is no fracture, at least at the location explored. The following case well illustrates such a condition: A boy of 212 A CLINICAL TREATISE OX FRACTURES. twelve years was brought to the Episcopal Hospital in a state of complete coma and suffering general shock, having fallen from a height. Though he evidently had great com- pression of the brain, careful inspection and palpation of the scalp showed no contusion and no appreciable change in contour at any portion. Extravasation of blood into the orbits, both right and left, was so extensive that the eye- lids bulged out into the form of two half-spheres, dark blue in color. This one symptom pointed to fracture of the anterior part of the skull. A transverse incision carried across the vertex from temple to temple revealed depression of the whole frontal bone, the line of incision happening to have been so planned that it coincided almost throughout its course with the line of fracture; points of action for two levers were obtained by two small trephine- openings in either parietal bone and the frontal bone was readily elevated into position. The boy made a complete recovery. A depressed fracture of the skull may occasionally be detected by palpation through the scalp, but similar changes in subcutaneous contour to those felt in such fractures are much more frequently produced by indurated cellular tissue abruptly terminating in soft yielding depressions, caused bv adjacent portions being dense through oedema or yield- ing through effusion of blood. Little importance can there- fore be attached to irregularities present, even though they feel like bony irregularities. A fracture of the skull may occur at a point remote from that of the impact. This is, however, the exception, FRACTURES OF THE SKULL. 21 3 for the bone is much more likely to yield where it is struck ; and if the body inflicting the blow is of a shape to divide the integument the scalp wound present will usually lead directly to the fracture, and it will be possible to detect the latter by means of a probe if the wound is small, or with the finger if the wound be large enough to admit it. The symptoms of fracture at the base of the skull are few and often not very characteristic. Fracture of the anterior fossa causes epistaxis, loss of smell, and subcon- junctival ecchymosis. The blood may fill the orbits, and even cause false aneurism. In the absence of contusion of the eyes and of fracture of the nose these symptoms sug- gest the possibility of fracture of the base anteriorly. Symptoms indicating fracture of the middle cerebral fossa are bleeding from one or both ears, succeeded in a day or two by exudation of cerebrospinal fluid; there may be facial paralysis ; and intellection may be wholly unim- paired, or there may be delirium or coma. Few signs point with any certainty to fracture of the cerebellar fossa. There may be hemorrhage from the pharynx, or blood, being extravasated into the cellular tissue of the neck, may appear as an ecchymosis about the ear. Fracture of the base most frequently involves the middle fossa; and if, after a severe injury, a flow of cerebrospinal fluid follows bleeding from one or both ears, and the flow continues, the presence of fracture may be fairly assumed. Prognosis. — Fracture of the vault of the skull is not a very fatal injury, if the cases in which the damage done is so great as to cause immediate death are excluded. While 214 A CLINICAL TREATISE OX FRACTURES. it would appear almost useless to formulate any rules upou which to base an opinion regarding the outcome of a con- dition subject to such a wide range of variation in locality, extent, and severity, it may be stated that a large propor- tion of fractures of the skull which survive long enough to come under the care of the surgeon recover. It is encour- aging, too, to observe that of these cases there are com- paratively few in which the recovery is not complete and permanent. Fractures of the base are very fatal, though recovery occurs even after them. When it does so, there mav be at times an element of uncertainty reo-ardinsf the correctness of the diagnosis. Among the immediate causes of death from fracture of either vault or base are menin- gitis, cerebritis, pressure from hemorrhage, and cerebral abscess. The more remote conditions liable to give trouble are chronic meningitis, dementia, and epilepsy. Treatment of Fractures of the Skull. — From what has already been said, it is evident that in all simple fractures of the skull, diagnosis and treatment are corre- lated. Diagnosis is dependent in many cases wholly upon exploration, while the proper line of treatment becomes manifest only when a definite diagnosis is thus obtained. As the diagnosis of compound fractures, so far as their superficial character is concerned, is rendered immediately patent by the presence of the wound, this primary element in the management of the case — i. £., thorough exploration — does not obtain. The question, What local and general symptoms point with sufficient distinctness to the possible existence of fracture to warrant exploration, should be FRACTURES OF THE SKULL. 21 5 answered by enumerating not the gravest symptoms, because they speak for themselves, but the mildest: marked concussion which in twelve hours shows no improvement; contraction of one pupil more than the other; slight con- vulsive twitchings of an arm or a leg; irritability which is out of proportion to the degree of primary shock of con- cussion; the history of the injury indicating its character as one liable to cause fracture; and, finally, the presence at some point in the scalp of a spot which, though perhaps very small, is soft and boggy and is surrounded by an indu- rated border. Symptoms less than these seldom warrant exploration, for although a procedure of small surgical importance, it should not under certain conditions and surroundings be lightly undertaken, but should unhesitat- ingly be advised if sufficient evidence of fracture exists to prevent chagrin were it followed by a negative result. If, therefore, in a case of suspected fracture of the skull unac- companied by a wound of the scalp, it is decided to explore, preparation for such exploration should be as complete as the preparation necessary before trephining, and in all respects identical with it. A large area surrounding the proposed site of operation should be carefully shaved. Indeed, it is better, if prac- ticable, to have the entire scalp shaved. After the skin has been properly prepared, an incision down to the bone large enough to admit the entrance of the finger should be so planned that it shall include part of the edge of an oval or circular flap, which may afterwards be dissected up. Should the fracture prove extensive it may- be neces- 2l6 A CLINICAL TREATISE ON FRACTURES. sary to make two or even three flaps in order clearly to expose the field of operation. These may conveniently be kept out of the way by being turned back and pinned, as shown in Fig. 108, which represents a case of exten- Fig. 108. Extensive depressed fracture of the skull prepared for trephining, showing flaps pinned back out of the way. sive fracture with depression about to be trephined. The only general rule for the formation of such a flap is that its convexity shall look downwards in relation to the position of the head when the patient is in a state of recumbency. The flap is formed in this direction for pur- poses of drainage. Should the first incision reveal the existence of fracture with even slight localized depression, the skin-wound should be increased in size enough to allow careful inspection of the skull. The depression, if small, may be all included within the cut of a three-quarter inch trephine ; if extensive, elevation is accomplished with or without the use of a trephine. In applying the trephine over a limited point of depression where the latter is intended to remove a button which will include the full FRACTURES OF THE SKULL. 2\y extent of the depressed portion of bone, the centre-point of the instrument must be made to project far enough from the teeth to reach down to the deepest part of the depression, in order to centre the instrument until it engages. Should removal of the button reveal the existence of a stellate fracture of the internal table, the apex of the depression will in all probability be found to have been removed in the button; but very careful examination should be made around the periphery of the opening lest some spur of the internal table still exists at a point beyond. According as the radius of the fracture is found to be slight or extensive, any further depressed portion if impacted is removed with trephining-forceps or with a second applica- tion of the trephine at a point immediately adjacent to the first, the narrow neck of bone separating the two trephine- FlG. 109. Author's trephining-forceps. openings being excised with the trephining-forceps (Fig. 109). When, on exploration, the fracture is found to be comminuted and much depressed, a liberal flap, extending for one-third of a circle with a radius of two inches, may 2l8 A CLINICAL TREATISE ON FRACTURES. be dissected, or, as its under surface has iisually been com- pletely detached from the bone by the injury, simply lifted up, reflected over, and kept out of the way by long pins introduced through it and into the scalp in the manner just described. The field of operation should in no case be restricted, and flaps in other directions may have to be made in order to give ready access to new lines of fracture which are found during the operation. In comminuted depressed fractures a point of action for a lever may be made by removing some small fragment of bone, which, having been picked up with the corner of a chisel, may readily be detached, or such a point may be made in the sound bone surrounding the fracture with a one-half inch trephine. The latter should be so applied that two-thirds of its cut will occupy sound bone, the other one-third being free of its edge. A lever introduced into the opening thus made will readily act on the depressed bone, and will ele- vate it to its proper level, frequently carrying along with it other depressed fragments with which it is interlocked. The propriety of removing a depressed fragment or de- pressed fragments, or simply elevating them into position, depends (a) upon whether there is reason to suspect the presence of a fragment of the internal table which remains depressed after the external table has been restored, and (b) upon the probable existence of any injury to blood- vessels, dura mater, or brain produced by the fracture, and concealed by the fragment. In many cases of depressed fracture the element of indentation or punct- ure is evidently wanting. The depressed area of bone is FRACTURES OF THE SKULL. 2IO. composed of irregularly formed fragments, which present very much the appearance of a cracked egg-shell. In these the fracture of the internal table will, as a rule, be found to correspond with comparative accuracy to the lines of the fracture of the external table, and in most of such cases there is no stellation. The assumption is, therefore, suffi- cient to warrant not removing the fragments in order to inspect the internal table, particularly if the depressed area is extensive and the removal of all the fragments contribut- ing to it would leave a large gap in the skull. As hemor- rhage accompanies injury to an artery (middle meningeal), to a cerebral sinus, and usually to the dura mater or brain, evidences of it must be carefully sought for. Hemorrhage beneath the scalp, though usually resulting from an injury to a scalp-vessel, may proceed from beneath the skull, leak- ing through the lines of fracture. When from the latter source these lines are usually to be found filled with clot — a strong indication that the hemorrhage is intracranial. In such cases the present requirements outweigh the dis- advantage of a large gap in the skull, and it becomes necessary to ascertain immediately the cause of the hemor- rhage. Removing one fragment of depressed bone will readily demonstrate the presence of a clot beneath; and if it is found to be extensive and its locality suggests the probability of lesion of an artery or sinus, other fragments should also be at once removed. At this stage one of two conditions will usually present itself: (i) the removal of the bone-pressure from the wounded vessel will allow of free hemorrhage, which may, fortunately, be sufficiently exposed 220 A CLINICAL TREATISE OX FRACTURE'S. to be controlled by one method or another ; or (2) the clot being removed from the prepared area, the hemorrhage is found to have proceeded from a point at which it cannot be readily arrested without further clearing the field by the removal of sound bone. Removal of the exposed clot, if this is the case, will seldom cause further hemorrhage, and the alternative of trusting to there being no recurrence of hemorrhage may be justifiable, particularly if the best surgical technique is not at hand. If it is decided to search for the bleeding point and secure it, a three-quarter inch trephine should be applied and a disk removed at a point which will leave the bridge of bone to be removed by Fig. iio. Author's lever and fulcrum. trephining forceps not wider than half an inch. On removal of this bridge of bone a new field of one and a quarter inches will be obtained, which will in all probability clearly expose the bleeding vessel. As the point selected thus to apply the trephine will most frequently be over either the course of the middle meningeal artery, great longitudinal sinus, or lateral sinus, great care must be exercised in removing the disk of bone so clearly and neatly that no new lesion is caused to the frail structure beneath by the instrument cutting too far. When through the removal of a large portion of bone FRACTURES OF THE SKULL. 221 an extensive gap leaves no point upon which to rest a lever to elevate depressed fragments still remaining, the gap may be conveniently spanned at any point by the fulcrum shown in Fig. no, upon which the lever acts. These instruments are very useful for this purpose. The fulcrum being roughed on its lower surface engages firmly, while the lever is looped so near its tip that its action is powerful and under perfect control. The manner in which these instruments are used is shown in Fig. in. As already mentioned, sources of Fig. hi. Showing the action of lever and fulcrum in spanning wide gaps in the skull. serious hemorrhage occurring after fracture of the skull are either one of the cerebral sinuses or the middle menin- geal artery. Hemorrhage from the longitudinal or lateral sinus usually requires to be controlled after the fragment of bone which has punctured it is removed. Although the 222 A CLINICAL TREATISE ON FRACTURES. hemorrhage is profuse, it need not cause alarm, as the slightest weight of a finger easily controls it. There need be, therefore, no haste. A very delicate, curved needle threaded with silk or fine catgut should be prepared, and the attempt made to approximate the edges of the sinus wound by the introduction of a suture at two points. Closure in this way, however, can seldom be successfully done. The sinus' wall is so inelastic that the suture may pull through before approximation is sufficiently perfect to stop the bleeding. In the cases that I have met of wound of the longitudinal and lateral sinuses hemorrhage was per- manently controlled by the use of simply a small gauze compress, removed at the end of three or four days. In one or two instances such a compress was used after failure to control the hemorrhage by suture. When the middle menin- geal artery is torn, hemorrhage from it is not infrequently found on trephining to have ceased spontaneously. Should the vessel continue to bleed, or start afresh to do so on removal of the clot, a very delicate suture of catgut or silk may be passed around it just below the wounded point; or the hemorrhage may be controlled, as from a sinus, by a small compress of gauze. The latter can frequently be insinuated just beneath the edge of sound bone, there to remain four or five days, when it can be pulled out by its free extremity, which has been carried to some convenient point in the scalp-wound. The management of tears of the dura mater varies according to their character and extent. Clean tears should always be sutured, preferably with fine catgut; but nice FRACTURES OF THE SKULL. 22$ approximation of contused, ragged tears by suture is impracticable. Specially careful sterilization of the latter and of the whole wound is the best safeguard against fungus cerebri. This mischievous complication, while yet liable to happen, has happily been very much lessened in fre- quency by clean surgery. Various methods have been employed to protect the brain from future injury after the removal by trephining of an extensive area of bone. Certain it is that unless a very considerable portion of skull is removed little pro- tection is necessary, for not only is the vulnerable point usually much depressed below the level of the surrounding osseous wall, but the scar tissue covering it well resists all ordinary impacts. When it is desired to make the attempt to close a hiatus with new bone, the following method I have found very satisfactory: the dura mater is protected by a thin layer of connective tissue which has been shaved off from the under surface of the flap of a size and shape to fit the gap. Upon this is spread a layer of chopped bone prepared from some of the fragments which have been removed. The bone should be reduced to particles the size of coffee grounds by ronguer forceps, and should be kept warm and sterile until used. The layer of chopped bone is kept in place by the scalp flap. This method I have employed in a number of cases without drawback, and in those which I have been able to follow long enough have found, without exception, good bony restoration. The return of the button intact, or of removed fragments, I have never attempted. The 224 A CLINICAL TREATISE ON FRACTURES. scalp-wound may be approximated by catgut sutures, and it is desirable to insert a few strands of drainage-catgut leading out from the trephined point, and, if the flap is large, from its angles. The retention of a liberal gauze pad by a recurrent bandage completes the dressing of the wound. The patient's general management is in many cases simple. Small doses of calomel, along with absolute quiet and freedom from all excitement, best lessen the ten- dency to cerebritis. Little or no food for the first day, fol- lowed by a liquid diet until all risk of inflammatory reac- tion has passed, should be used. The dressing should be changed on the following day should much oozing have occurred ; but if it appears dry and clean it may be allowed to remain on for five days or more. In cases that progress favorably little treatment is required. The accompanying symptoms of concussion usually present subside in forty- eight hours. The patient's face assumes a comfortable, natural expression; he is free from irritability and restless- ness, and seldom complains, even of headache. In such cases the operative cure is rapid, and cerebral sequelae are not to be apprehended. Indeed, as far as we have data relating to the liability to the several remote consequences of fracture of the skull, they appear to be rare or fre- quent in direct proportion to the lightness or severity of the symptoms immediately following the injury. There is reason to believe that a very large proportion of trephined fractures of the skull, accompanied by nothing worse than slight concussion of the brain, recover perfectly and perma- nently; and that the beginning of those changes, menin- FRACTURES OF THE SKULL. 225 geal or cerebral, which finally develop epilepsy, insanity, or some other nervous disease, dates from and is caused by the inflammatory reaction immediately following the injury which produces the series of symptoms clearly indicative of its presence. Thus in a case of an extensive compound fracture of the skull (Fig. 112) I had occasion to trephine Fig. 112. Compound depressed fracture of the skull accompanied by wound of the longi- tudinal sinus. the injury was caused by the man being hurled from the top of a freight car going at speed, by the parting of his brake-lever. The brain was severely contused and the longitudinal sinus torn. The symptoms of cerebritis were so marked, as evidenced by a semiconscious delirium, that for forty-eight hours he required the constant restraint of two attendants. His mental condition from the first return of consciousness, at the end of two days, was characterized by perfect imbecility. The restlessness had disappeared, 15 226 A CLINICAL TREATISE OX FRACTURES. and he would lie upon his right side, staring vacantly around him. He paid no attention to what was said to him, and indeed showed no recognition of anything, except when winked at he would always wink in return. At the beginning: of the second week intellection began to improve, when it was found that his memory was entirely gone. He had forgotten his age, how many children he had, and their names. This symptom persisted long after his mental condition was otherwise restored, eight weeks after the accident still being unable to remember all of the stations on the railroad where he was employed. He had no headache at any time, and seldom complained even of discomfort at the seat of injury. Here then we have the historv of great violence causing almost fatal brain injury, severe cerebritis, and recovery with a single mental deficiency. When a depressed fracture of the skull is accompanied by cerebral symptoms, the immediate relief of these by trephining need hardly be expected, for when it is remembered that such symptoms are not usually produced by the depressed fragments of bone alone, but are provoked by the jar, contusion, or laceration of the brain coincident with the fracture, or by pressure of a blood-clot, it will be seen that elevation of fragments of bone, apart from removing one positive cause of compression, may only produce its good effects hours later, by giving free outlet to effused blood and serum, and space for inflammatory cedema of contused cerebral tissue. Efforts to lessen inflammatory reaction, when present, should be directed generally by depletion and counter- FRACTURES OF THE SKULL. 227 irritation, and locally by perfect drainage and careful atten- tion to the wound, and the application of an ice-cap to the head. Bromide of potassium may often be given quite freely to control restlessness or delirium. Depletion is best practised by the use of small doses of calomel, and occasion- ally, should the patient's strength permit, an active purge. Mustard poultices to the thighs and blistering collodion to the back of the neck sometimes seem to be of use. CHAPTER VIII FRACTURES OF BONES OF THE FACE. FRACTURES OF THE NOSE. Fracture of the nasal bones is caused by direct impact in front or at the side; and though often only one bone is broken, the fracture, which is apt to be transverse, may involve both. The deformity resulting from such fracture, whether one bone or both be broken, is usually lateral; though, particularly in cases in which the injury has extended to the perpendicular plate of the ethmoid bone, the deformity may be depressed in character, which causes flattening of the nose. In such cases, if only the perpen- dicular plate of the ethmoid bone is fractured, no serious symptoms are to be apprehended; but if the injury has extended to the cribriform plate a portion of the base of the skull is liable to be implicated, with its attendant risks. If the line of fracture of the nasal bone encroaches upon the lachrymal duct, occlusion of the latter, followed by abscess or fistula, occasionally results. Sometimes the force causing the fracture acts in such a manner as to split the nose away from the face. If the force has been sufficient to fracture the cribriform plate of the ethmoid, some degree of concussion of the brain is likely to occur. The profuse bleeding which accompanies fracture of the nose seldom requires attention, for it usually ceases spontaneously. If 228 FRACTURES OF BOXES OF THE FACE. 229 it should not, it may be necessary to plug the nose. A very rare complication of fracture of the nose is emphy- sema into adjacent cellular tissue, extending into the eve- lids. The contusion of the integument causes such quick and marked swelling that the presence of fracture is in many cases masked, and can only be revealed by a careful examination. This accounts for the unsightly distortions of the nose which follow when either the fracture has been altogether unrecognized or the displacement incident to it incompletely restored. Some deformity follows after the separation even of the nasal cartilages, and it is, therefore, proper when these alone are involved, for the surgeon to explain clearly the nature of the injury, for the least irreg- ularity observed after recovery will always be attributed by the patient and his friends to a " broken nose." As the community, therefore, draws no fine distinction between cartilaginous separation and fracture of the bone, the sur- geon should state the conditions found in the most une- quivocal way. If the distortion is lateral, it may usually be corrected by external manipulations, simply remodelling the fragments into position. If elevation is required, such manipulations may be combined with pressure from within by some delicate though rigid instrument introduced into the nostril. Once replaced, the fragment rarely shows any disposition to fall out; but as union of the nasal bones takes place with extraordinary rapidity, no effort should be spared to accomplish everything necessary in the way of adjustment during the first week, for it is at this time that the receding swelling furnishes improved opportunity to 23O A CLINICAL TREATISE OX FRACTURES. note carefully the slightest remaining defect, while yet it may be corrected. So important to the individual is it that his nose should be restored as nearly as possible to its former contour, that the surgeon may well be guided dur- ing this process of remodelling by the patient's friends and the patient himself, through the aid of a mirror. At the end of a fortnight no correction, except by the exercise of undue force, is possible. Treatment. — The greater number of cases of fracture of the nose require no retaining appliance. If the fragments are comminuted and show disposition to fall to one side, sufficient support to retain them in position can usually be obtained by the application of a small compress applied to that side of the nose requiring pressure, and retained in position by a narrow strip of adhesive plaster carried from cheek to cheek, with the degree of firmness found neces- sary. In performing reduction advantage may be taken of the local anaesthetic effects of cocaine. All retaining appli- ances introduced into the nostril or nostrils should, if possible, be avoided, for they are extremely uncomfortable to the patient and are seldom required except in cases in which the septum has been fractured in such a way as to cause collapse of the nose. FRACTURES OF THE UPPER JAW. Fracture of the upper jaw is caused by direct violence of a severe degree. The body or the nasal or the alveolar process may be involved. Fractures extending through the nasal process may or may not implicate the lachrymal canal. FRACTURES OF BOXES OF THE FACE. 23 1 The infra-orbital nerve may be injured by a fracture near the orbital plate. The fracture not infrequently involves also the sphenoid, nasal, or malar bones; and in general crushes of the face the upper jaw may be completely detached from the skull. In all fractures involving the alveolar process the teeth of the lower jaw will usually be found to give sufficient support without the employment of splints of gutta-percha or the like, which have occasionally been used. Frag- ments which are depressed should be elevated if they can be reached through the mouth. FRACTURES OF THE MALAR BONE. Fractures of the malar bone as single injuries are uncom- mon, for, although its position is exposed, its structure is so compact that it either resists violent impacts or transmits their force to an adjacent bone. They may be simply fissures, or they may extend into the antrum, constituting depressed fractures. Such a fracture is reduced, if simple and much depressed, by the employment of a screw-eleva- tor inserted through a small incision made in the cheek. A line of fracture in the malar bone may include in its course and injure the infra-orbital branch of the fifth pair of nerves, producing loss of sensation of portions of the face, as the alse of the nose, gums, and teeth of the upper jaw. The treatment, after reduction of any displaced frag- ments, is to keep them in proper position by compresses applied with adhesive strips, and to relieve the severe 232 A CLINICAL TREATISE OX FRACTURES. accompanying contusion of the cheek by cold evaporating lotions. FRACTURE OF THE ZYGOMA. The zygoma, a strong arch in construction, is seldom broken except by some concentrated force applied directly to it. The temporal portion is more apt to suffer, as it is lighter and more exposed than the malar. A fragment may press upon the masseter or temporal muscles, causing pain on movement of the jaw. If markedly depressed, it may be necessary to elevate the fragment with a loop of wire passed beneath it through a small incision in the skin. Application of Barton's bandage to restrict the movements of the lower jaw is the simple treatment required for the fracture. FRACTURES OF THE LOWER JAW. While any portion of the lower jaw is liable to fracture — body, ramus, coronoid process, or condyloid process — that portion of the body from its middle forward to its sym- physis is much the most frequent seat of fracture. The condyloid process may be fractured in its neck by force com- municated through the length of the bone from the chin; but fracture of the coronoid process is extremely rare. The ramus, though more commonly broken than either of these processes, is far less frequently fractured than the body. Double fractures of the body of the jaw are not uncom- mon. Fractures of the body are almost invariably com- pound through their communication with the mouth. Symptoms of fracture of the lower jaw after a severe blow applied directly in front or at its side are pain on the FRACTURES OF BONES OF THE FACE. 233 slightest movement, and profuse salivation, with more or less loss of the natural contour of the lower portion of the face. If no pronounced deformity exists externally, inspec- tion of the mouth will usually show an abrupt break in the line of the teeth at a point corresponding to the seat of fracture. Crepitus can, as a rule, be easily elicited. Ante- rior to the insertion of the masseter near the dental fora- men, the anterior fragment may be drawn inwards by the action of the digastric muscle, while the internal pterygoid and deep masseter tend to act more or less upon the pos- terior fragment. The deformity from fracture at any por- tion of the body is variable, and often not very great. Should the fracture involve the alveolar process only, obviously no change in exterior contour of the jaw occurs. Fracture of the condyloid process through its neck causes great pain on movement of the jaw and crepitus can usually be elicited. Treatment of Fracture of the Lower Jaw. — There are two distinct methods of treatment which may be used alone or in combination : (a) the external method, which, of course, includes every form of dressing and splint applied to the face ; and (b) the internal method, which consists in retaining the fragments in apposition by various devices employed in the mouth. As the teeth of the upper and lower jaws when fairly intact meet with nice precision, they will usually be found in a well-formed jaw to give the required opposing resistance to the pressure of an external dressing. It will, as a rule, be found that when a fracture in any portion of the body of the jaw is properly reduced the teeth will fit accurately. In accomplishing this reduc- 234 A CLINICAL TREATISE ON FRACTURES. tion, therefore, the patient's sensations will frequently be found of assistance. Such reduction is effected by simply grasping the fragments with the fingers and thumbs and coaxing them into proper position. This done, the lower jaw is closed and the chin supported, during the applica- tion of a Barton bandage. As the action of the Barton bandage is symmetrical, elevating and receding the jaw equally on both sides, it will occasionally be found that a more unilateral support given by the oblique bandage of the face will better correct a tendency to recurrence of the deformity. Again, if the anterior chin-turn of Barton's bandage, by causing overlapping of fractured fragments, is found to induce too much recession of the chin, a Gibson bandage, without the third ellipse, is available. With one or other of these dressings almost every case of fracture of the jaw can be satisfactorily managed, but no rule can be made regarding the particular fracture to which each is applicable, as the advantage of either in any individual case can best be determined by experiment. As salivation is profuse, any dressing becomes quickly saturated, and should therefore be frequently removed during the early part of the treatment, the skin of the face carefully bathed with alcohol, the hair of the head brushed and combed, and a new bandage applied. On account of the salivary overflow and the fact that the mouth, imperfectly cleansed, inclines to become foul, any permanent leather or muslin sling or splint, of which many have been devised, is very undesirable. In order to prevent putrefaction resulting, partly from retained food-products and partly from suppura- FRACTURES OF BONES OF THE FACE. 235 tion at the seat of fracture, the mouth should be thoroughly rinsed out after each meal with a potassium chlorate solution, peroxide of hydrogen freely atomized into it and flushed out with plain water. Should the dressings applied fail to retain the fragments in proper position, either because the teeth are imperfect or because the fragments are refractory, coaptation may be facilitated by some internal method. An interdental splint may be made of gutta-percha softened in hot water and modelled into the form of a horseshoe. On insertion in the mouth the teeth of the lower jaw are brought up firmly, in order to mould it into form. Such a splint had best be prepared by a dentist, if used at all. It is extremely uncomfortable, and must rarely be required. The two teeth adjacent to the fracture may be conjoined by a silver wire; or, if the fracture involve one alveolus, the tooth loosened thereby may have to be extracted and the adjoining teeth wired together. During the first two weeks of treatment the patient should be nourished almost wholly with liquid food ; milk, soups, and soft-boiled eggs being among the most useful articles of diet. Union firm enough not to require support usually occurs between the fourteenth and twentieth days, but no effort should be made at mastica- tion, until the end of four weeks. Delayed union and ununited fracture of the lower jaw are very rare. Barton's bandage when used for fracture of the lower jaw should be applied as follows: Place the initial extremity of the roller behind the ear on the sound side; carry the roller beneath the occiput to a corresponding point behind the 236 A CLINICAL TREATISE ON FRACTURES. ear on the injured side; thence to the vertex, and down the sound side of the face to the chin; up on the injured side to the vertex, intersecting the former turn directly in the median line, and back to the starting-point. Not until then is the bandage fixed. The fingers holding the initial extremity are now released, and the roller may be conven- iently passed from one hand to the other. The roller passes from here to the occiput, and along the injured side of the jaw to the chin, and back to the occiput; from the occiput to the vertex. Each of these turns is repeated in a similar manner twice, when the bandage is terminated at the vertex. Every intersection requires a pin. Gibson's bandage is applied in the following manner : Fix the roller by vertical turns around the face. The direction it takes in starting ' is determined by the location of the fracture, the roller always ascending on the injured side. After making three of these vertical turns a right-angled reverse is made at the temple, on whichever side is more conven- ient, and the bandage carried back to the occiput. Three horizontal turns are then made around the vault of the cranium, and on reaching the occiput the third time the chin-turns are begun. These are made by carrying the roller beneath the ear, along the side of the jaw to the front of the chin, and back to the occiput. Three of these turns are made. On reaching the occiput the third time the bandage is completed by a right-angled reverse at this point, whence it is carried over the top of the head to the forehead in the median line. A pin is introduced at the reverse over the occiput, and at each FRACTURES OF BOXES OF THE FACE. 237 intersection. It will be seen to consist of three sets of circular turns. FRACTURES OF THE HYOID BONE. The hyoid bone is occasionally fractured from constric- tion, as in hanging or throttling, and even by direct im- pact, as from a fall or a blow upon the throat. There is pain, increased by deglutition or articulation, but respiration may be so embarrassed that every symptom of fracture is masked by the alarming dypncea, which threatens instan- taneous suffocation. Immediate tracheotomy may therefore be necessary to save life before an attempt is made either to examine into the nature of the injury or to reduce any dis- placement which may be found to exist. Tracheotomy may also be indicated as a precautionary measure to guard against the imminent danger of inflammatory oedema suddenly ex- tending to the glottis. The management of the fracture, which is of secondary importance, consists in correcting any displacement of the fragments with a finger introduced into the pharynx, and in keeping the head at rest in a state of moderate flexion. For the first few days, or while local irritation and muscular spasm continue, no food should be given by the mouth, nu- tritious enemata being onlv used. CHAPTER IX. COMPOUND FRACTURES. The compound element of a fracture — i. e., the presence of an external wound communicating with the seat of fract- ure — while it always tends to increase the gravity of the injury, does so now, with the present perfection of surgical technique, far less than formerly. A larger proportion of compound fractures are susceptible of conversion into sim- ple fractures with thorough asepsis; and those which do suppurate, suppurate so slightly and are so free from infec- tion that, while the course of the injury is somewhat retarded by the compound element, its termination is seldom jeopardized. For convenience of description, the wound communicat- ing with the seat of fracture may be called the compound wound. The compound wound is produced (a) externally bv the bodv causing the fracture or (b) by one of the frag- ments of the fractured bone being driven through the integument, (a) When the compound wound is produced bv external violence its presence may depend wholly upon so casual an incident as the absence of protection afforded bv clothing, as in the passage of a wagon-wheel over a limb which is bare. The force exerted is no greater than if clothing had intervened, and the wound is made by the harsh pressure of the integument between metal and bone. 238 COMPOUND FRACTURES. 239 In like manner, of two wagons of equal weight, the one provided with steel, the other with rubber tires, the former may in passing over a limb cause a compound, the latter a simple fracture. Compound fracture caused in this way results also from railroad, machinery, and all other injuries in which the compound element is produced directly by the vulnerating body. Such may therefore well be called a direct compound fracture, not only because of the man- ner of its production, but also because in it the wound is usually situated immediately over the seat of fracture and gives direct communication between the latter and the exterior, {b) If, on the other hand, the compound wound is made by a fragment of bone (usually the upper) being thrust through the skin, investigation of the cause will show it to have been indirect violence, and the compound wound will likely be more or less remote from the seat of fracture. It may, therefore, be appropriately described as an indirect compotmd fracture. Its presence indicates that the force causing the fracture had not ceased with the production of the latter, but had gone on thrusting the broken fragment out through the skin, wounding in its course the intervening tissues to its point of emergence. It is, therefore, the continuance of the breaking force, after the bone has yielded, which renders damage to blood- vessels, nerves, and muscles more liable to occur in com- pound fractures so produced than in simple. In the same way, voluntary or involuntary muscular contraction or care- less handling may convert a simple, into a compound fracture, by forcing the upper fragment of the bone through 24O A CLINICAL TREATISE ON FRACTURES. the integument. When this happens the cause is identical with that producing compound fracture by the continu- ance of the force after the bone has yielded. The char- acter of the fracture, whether transverse or oblique, and the form of the penetrating fragment, whether sharp and pointed or smooth and blunt, will determine the extent and nature of the wound produced. As fractures caused by indirect violence incline to be oblique, and as force thus indirectly applied is of a kind most liable to thrust a fragment of bone through the skin, the fragment exposed is frequently the more or less slender extremity of an oblique fracture. Compound fractures are frequently more difficult to re- duce and to keep reduced than simple fractures, for three reasons : (1) The fractured ends of the bone may be com- minuted or bruised by the crushing force, as of a car-wheel, which has produced the injury, and has so distorted the surfaces that they cannot be refitted to one another. (2) In fractures caused by indirect violence the surrounding tissues may be so generally torn that they cannot give even the partial support to the broken fragments they would do under less extreme conditions. Such complete tearing of periosteum, tendinous, and muscular tissue, is more fre- quently observed in indirect compound fractures, because in them, through the continuance of the force after the bone has yielded, one fragment is thrust far beyond the other and extruded through the skin. (3) Proper reduction may be prevented by the interposition between the fragments dur- ing their wide separation of some portion of muscle or of a tendon. The button-holing of the skin by the protruding COMPOUND FRACTURES. 24 1 fragment rarely offers any great impediment to its reduction. The three conditions just mentioned existing separately or in combination constitute the difficulties most frequently met with, and to them is often added muscular spasm from severe traumatic irritation. Once reduced, it may be found impossible to retain the fragments in position because of their battered extremities, or of the interposition of some tissue between them. While, therefore, efforts at reduction of simple fractures rarely fail, compound fractures of cer- tain bones are often difficult to adjust without the aid of some mechanical device having more direct action than can be obtained by the employment of splints or apparatus. Apart from the bone lesion, compound fractures are fol- lowed by more or less suppuration, the degree of which depends (1) upon the extent of damage done the soft parts by the injury, (2) the completeness of the surgical procedure in preventing infection, (3) the presence or absence at the seat of fracture of any material acting as an irritant, and (4) the perfection of the immobility of the fractured frag- ments obtained. 1. Pulpefied soft tissue, having been completely devital- ized by the injury, necessarily becomes necrotic, and must be detached from the living by a process which involves suppuration. Properly supervised, this process may be conducted without risk of the infection of the living tissue by the dead. At times dead tissue may be reduced by such an agent as plaster-of-Paris to a desiccated, mummified con- dition and the ulcerative process thereby minimized. 16 242 A CLINICAL TREATISE ON FRACTURES. Fig. 113. 2. The importance of surgical cleanliness in preventing infection and consequent suppuration can best be emphasized by a brief retrospect of the clinical history of compound fractures in the preaseptic period. Fig. 113 shows the results of a septic osteitis of the tibia and fibula following compound fract- ure, and strikingly illustrates the dis- astrous course which unhappily too often followed the injury. As no sterilization was thought of, septic suppuration in almost every case fol- lowed. As the true principles of mM drainage were not understood, pus burrowed. Following the routes of least resistance, it found its way be- ( I : , neath the superficial fascia in all c .. . ... ^^ „ directions, to the seat of fracture, and Septic osteitis accompanying ' ' compound fracture of the { n \_ Q the medullary cavity of the bone. tibia and fibula. . ,,.,., Being septic, it decomposed healthy tissue by contact, and so increased its own bulk. Com- pound fractures discharged pus so copiously that Barton utilized the bibulous properties of bran to absorb it, and for nearly forty years the bran dressing was almost exclu- sively employed in certain localities. The advantages claimed for it were that when thoroughly saturated with pus it swelled somewhat and gave good support to the limb, that it prevented the pus overflowing into the bed clothes, and that the dressing was quickly changed by COMPOUXD FRACTURES. 243 letting fall the sides of the fracture-box, scooping up the soaked portion of bran with both hands and pouring in fresh from a bucket. The only reduction attempted was that by manipulation and the adjustment of splints, for the dangers of operation were known to be so great that it was rarely undertaken, and refractory fragments there- fore remained often very imperfectly coaptated. The lesson therefore tausfht is that no detail of cleanliness or drainage, no detail of reduction or coaptation, nor of fixation, can be slighted without risk of trouble. 3. The presence at the seat of fracture of any material acting as an irritant, either because it is a focus for infec- tion or is a foreign body, promotes suppuration until it is discharged, or, remaining at the seat of fracture, ma}" indefi- nitely prolong the process. The former is often produced bv foreign matter which gained access to the wound at the time of the injury. The latter, though occasionally a real foreign body, is more frequently a comminuted fragment of bone which, having been detached, has become necrotic and acts as such. 4. The perfection of immobility attained at the seat of fracture markedly influences the degree of suppuration. The importance of complete fixation, therefore, in compound fractures adds this to the other advantages obtained by it. Complications. — General conditions which, by adding gravity to a compound fracture, may well be considered as complications, relate to the age and health of the patient, and to what is to be his surgical environment during the course of treatment. 244 A CLIXICAL TREATISE OX ERACTURES. Thus a vouthful individual of sound and vigorous health and temperate habits receiving a compound fracture is promptlv removed to a suitable place for treatment. Whether his injury be slight or grave, it is at least attended by no general complication of any sort. Any deviation constitutes a drawback, and may prove sufficiently serious to change radically the whole aspect of the case, and, later, the treatment it requires. Thus, the hope of saving a limb may be wholly negatived on account of the advanced age of the patient or the presence of visceral disease. The great importance of prompt and suitable management is well illustrated by the unfortunate necessity in war of amputating many compound fractures in order to diminish the risk to life in preparing for a long journey, because a case of amputation can be subjected to greater hardships in travelling by land or sea, consistently with life, than can a suppurating compound fracture. Specific and local complications are : ( i) Comminution. Comminution of the bone adds to the gravity of compound fracture in many respects. It usually indicates that greater force has produced the injury than that required to cause a single line of fracture. It leaves fragments of bone which are liable to become necrotic (Fig. 114). Also such fracture, if it suppurates, requires more care to keep properly drained and cleansed, and, owing to its great mobility, complete fixa- tion of the fragments is more difficult to obtain. (2) Joint- involvement always increases the severity of a compound fracture. It does so at once by embarrassing reduction, by increasing the tendency to suppuration, and by opening up COMPOUND FRACTURES. 245 a dangerous pocket for infection ; and it does so, finally, by causing rigidity of the joint involved. (3) The tearing of an arterial trunk often decides adversely the fate of the limb in many compound fractures which would otherwise yield successfully to conservative means. Such a compli- cation as applied to the femoral or brachial artery almost inevitably turns the scale, but this is by no means true Fig. 114. Compound fracture of the femur with comminution and subsequent necrosis of the large middle fragment. when only one artery is wounded in portions of the limb which are supplied by more than one trunk. (4) Injury to a nerve, while it renders the prognosis of ultimate restoration of function of the limb sometimes doubtful, does not add materially to the difficulties to be met with during treatment, especially if it be only wounded, not sev- ered. (5) Injury to the soft parts, either extensive laceration of the integument which denudes a considerable portion 246 A CLINICAL TREATISE ON FRACTURES. of the limb, particularly if girdling it, on the one hand, or perhaps only minute puncture of the skin, accompanied by severe bruising or pulpefaction of the muscles, effectually disposes of any opportunity for conservatism. Should ampu- tation be advised and refused, it remains for the surgeon to decide in each individual case whether he should simply cleanse the wound, provide for suitable drainage, and retain the limb at rest with an appropriate splint, or whether he should operate upon the damaged bone. With- out discussing the numerous aspects of this subject, it may be stated in general terms that it is probably desirable in certain cases of compound fracture regarded as hopeless, in which amputation has been refused, to anaesthetize the patient and do what would be done were it hoped or intended to have saved the limb. The degree of shock after compound fracture varies very much, and though, as a rule, it is in proportion to the gravity of the injury and the loss of blood, yet it often depends largely upon the individual lack of resistance of the patient. While it is usually possible to discriminate between temporary emotional shock and the severe consti- tutional shock accompanying a grave injury, the psychical element will often be observed to retard reaction. Tetanus. — Formerly not infrequent among the fatal consequences of compound fracture, tetanus has happily, through aseptic methods, become rare. It followed, and even under these improved methods may occasionally fol- low, compound fractures, either those usually considered insignificant, as of the bones of the hand and foot, or those COMPOUND FRACTURES. 247 which are grave. Its occurrence is more to be feared if there has been much comminution of bone accompanied by great laceration or crushing of the soft parts. As dirt— that is, either city dirt or country dirt— is liable to contain tetanus bacilli, and as dirt has often gained access to the most intricate recesses of the bone, soft tissues, or a joint, the possible risk of tetanus is one of the complications to be borne in mind when conducting the sterilizing process before the application of the first dressing. If the com- pound fracture has been caused by the passage of a wheel over the part, dirt is ground into the wound and often into the bone; or, if a bone be fractured by a fall and the upper fragment is thrust through the skin into the ground, the fractured fragment may be filled with dirt, which can be completely removed only by the most careful cleansing, combined, if necessary, with scraping or cutting. Should tetanus ensue, the operative procedures offering a chance of recovery are stretching of the nerve-trunk supplying the part, or, if the injury involves a finger or toe, amputation. Fat-embolism is an extremely grave, but fortunately rare, complication of compound fracture. It is due to small particles of liquid fat from the bone-marrow entering the venous circulation, and usually does not manifest itself until three or four days subsequent to the fracture of the bone. The symptoms develop with considerable sudden- ness, the most prominent being disturbance of respiration and of the heart's action. There is usually great dyspnoea, and the respiration becomes Cheyne-Stokes in character. The temperature is elevated, fat-globules are liable to appear 248 A CLINICAL TREATISE ON FRACTURES. in the urine, and occasionally there is paralysis of various groups of muscles. The treatment of such a condition is entirely symptomatic, chiefly consisting in the rigorous use of rapidly acting and powerful cardiac and respiratory stimulants. Amputation of the fractured limb has been advocated in order to prevent the danger of further forma- tion of emboli, but, in the presence of cardiac and respira- tory disturbances, it could not be undertaken. Gangrene following compound fracture results from deficiency in the blood-supply produced by injury of a principal arterial trunk or by the mechanical interference with circulation of overdistended and engorged tissues. Either is capable of causing gangrene, though they may act in combination as when even moderate tension succeeds ligation of the posterior tibial artery in a compound fracture of the leg. The collateral circulation, which would quickly and surely be established after simple ligation, is prevented by tissue tension, and gangrene results. In a subject with diabetes or atheroma very slight tissue tension will, after compound fracture, cause gangrene. Treatment. — Compound fracture belongs to the class of injuries which cannot receive too prompt surgical atten- tion. If seen as an emergency, it is better to cover the wound with a clean handkerchief or napkin than to con- duct any imperfect efforts at washing or irrigating it, for such measures done hastily may frequently do more harm than good, as they fail to render the depths of the wound sterile and are very likely to convey infection into it. In order to keep the fragments of bone as quiet as possible, COMPOUND FRACTURES. 249 an extemporized splint may be applied. When the patient has reached his destination — that is, the hospital or house at which he is to be treated — preparations should be quickly but methodically made for the first, the all-important dressing. If any indications exist that the wound will have to be enlarged, that the fragments of bone will be at all refrac- tory in yielding to adjustment, that they may require con- trolling, sawing, or suturing, that a bloodvessel will have to be tied, or, finally, if the patient is already suffering much pain or agitation, an anaesthetic should, without hesi- tation, be administered. With instruments and appliances appropriate for wound-dressing, bone-joining, and amputa- tion made ready, the temporary dressing, if one has been employed, is removed and the skin shaved over a liberal area about the wound. The latter is freely irrigated with a 1 : 2000 solution of corrosive sublimate and the adjacent skin sterilized. Not until then is a systematic exploration made of the damage done and a decision reached of the steps necessary to be taken. As the compound wound may vary in size from a minute puncture to an extensive lacera- tion, the question whether to allow it to remain as it is or to enlarge it sufficiently to admit the entrance of a finger must rest wholly upon the conditions observed. Should there be little tendency to displacement of fragments, and the tissue beneath feel comparatively soft and relaxed, if the skin is pale and pliable, and little or no blood oozes from the wound, it should not be opened. Indeed, under circumstances in which it may fairly be assumed that the 250 A CLINICAL TREATISE ON FRACTURES. minute puncture was made by the pointed summit of a fragment which, having penetrated the integument, was in- stantly withdrawn, even irrigation may be undesirable, and such a wound may be dressed with dry sterile gauze. Seal- ing it with tincture of benzoin or collodion, while still practised, would seem to have no advantage over dry gauze dressing in favoring its early closure, and the conversion thereby of the compound into a simple fracture. The prog- ress of such cases, whether occurring in the upper or lower extremity often varies but little from that of a simple fract- ure. There may be no suppuration, and the wound when the dressing is removed at the end of five days or a week is found to be closed ; or, superficial suppuration of integ- ument may continue for a fortnight or three weeks with- out any communication whatever with the seat of fracture. In either case the fracture unites in all respects as does a simple fracture. The compound element having existed but a brief period complicates the management of the case no more than would a wound of the integument which never did communicate with the seat of fracture. Such a wound, like a severe abrasion or a splint-sore, would be troublesome only in requiring the removal of the dressing more frequently than necessary for the management of the fracture. The appropriate splint or dressing for such a compound fracture is identical with that for the fracture, had it been simple. On the other hand, if accompanying a minute wound there be marked displacement or comminution of the frag- ments, tension of the limb, or bogginess beneath the COMPOUND FRACTURES. 25 I integument, if the skin be red, turgid, and tense, or there is blood oozing from the wound or a clot plugging it, the wound should be enlarged. An incision large enough to admit a finger for exploration should at first be made, and afterwards enlarged as the requirements demand. Should the tissue beneath be found filled with blood, the wound of an arterial trunk will be suspected, and its exist- ence will be at once proved or not by feeling for the pulsa- tion of the vessel involved, whether the posterior tibial, dorsalis pedis, radial, or ulnar. Should the vessel be found not to pulsate at the distal point examined, it must be immediately searched for in the wound and ligated. As injury to an artery is almost always caused by a fragment of the broken bone, the lesion in it will usually be found pretty close to the point of one fragment or the other. If, on the contrarv, it be determined that the bleedine arises from numerous small vessels, the clots should be turned out and perhaps some one or two points secured. Blood-clots enveloping the fractured fragments have been allowed to remain in order to facilitate, as demonstrated by Schede, early union, provided there is good reason to believe that such clots are aseptic. Cross-tears or lacera- tions of the muscles may properly be sutured; or if detached from their origin and drawn down into coiled masses lying in the wound, they should be excised, as the exten- sive dissection required to suture them to their points of origin — perhaps two-thirds of the length of the limb — could not properly be undertaken. After thorough irriga- tion, a drainage-tube should be introduced, either as a 252 A CLINICAL TREATISE OX FRACTURES. single tube emerging from the wound, which has been sutured about it, or a double tube entering at one angle of the wound and emerging at the other, or a through- and-through tube introduced into the wound and carried through a counter-opening at the opposite side. The extent of drainage is provided for according to the conditions found and the prospect of slight or free suppuration ensu- ing. A dry gauze dressing retained by a gauze bandage, and a splint or apparatus appropriate for the management of the fracture is applied. A very useful fixed apparatus for compound fractures of the tibia is found in the plaster-of-Paris dressing, with a trap-door cut into it over the seat of fracture, which permits access to the wound if necessary. Such an arrangement is best applied as follows : A half-inch band of lead tape, of a length equal to the circumference required for the trap, is formed into a loop or ring by closing the ends together with a bit of rubber plaster. This is applied to the limb, and, modelled into an ellipse, circle, or square, is held in posi- tion by the initial flannel bandage, which also retains the wound-dressing. The plaster-of-Paris dressing is then ap- plied, and after it has set the outline of the lead wall, being distinctly apparent, is cut down upon with a penknife, ex- cept at one point which is to act as a hinge, and the lead band removed, as shown in Fig. 115. Beneath the everted, flange-like edge of the opening absorbent cotton should be inserted in order to prevent the leakage of discharge between the plaster dressing and the skin. The trap thus formed is afterwards kept in place by a bandage. Should COMPOUND FRACTURES. 253 the opening exceed in width one-third the circumference of the limb, the dressing may be reinforced by strips of tin laid at its back during the application of the plaster bandages. The removal of such a dressing may be facilitated by preliminary steps taken at the time of its application. A strip of lead tape placed upon the limb next to the skin may be cut down upon with a penknife, immediately the plaster has set, and a clean cut made through its whole Fig. 115. Fenestrated plaster-of- Paris dressing for compound fracture of the leg, showing the trap-door opened. length, after which the lead tape is withdrawn. Or, better, a vertebrated brass chain, so constructed that when it is placed iipon a part prior to the application of a fixed dress- ing it will, on withdrawal, as soon as the plaster has set, leave behind it in the latter a hollow longitudinal ridge. This may be readily divided by a knife or plaster shears at any time it is desired to remove the dressing. An improve- ment on this affair is an India-rubber strip of the form, on cross-section, of an inverted T, which is used in a similar manner. The progress of many cases of compound fracture, whether direct or indirect, is often unexpectedly favorable. 254 A CLIXICAL TREATISE OX FRACTURES. At the end of five or six days the escape of bloody serum diminishes, and in two weeks the scanty suppuration follow- ing will have almost ceased. When deep discharge no longer flows from the drainage-tubes thev should be removed and Fig. 116. Apparatus for using continuous irrigation. the granulating surfaces dressed with a little gauze until they have healed. Occasionally continuous irrigation from such an apparatus as is shown in Fig. 116, with some mild antiseptic solution, COMPOUND FRACTURES. 255 especially in compound fractures of the upper extremity, accompanied by violent cellulitis, will relieve pain and ten- sion, and perhaps will limit sloughing. If the soft parts have been damaged so much that a portion of tissue adjacent to the fracture becomes necrotic, thorough and frequent irrigation with peroxide of hydrogen, followed by solution of corrosive sublimate, may, by allow- ing the slough to separate without causing infection, prevent bone suppuration. Should the conditions, however, not be so favorable, deep and more copious discharge of pus, accompanied by continued crepitus of the fragments on motion, will clearly indicate that the seat of fracture is implicated in the suppurative process. In such cases more or less necrosis is to be looked for. Absolute fixation of the fragments, always important, then becomes imperative. I have seen the formation of pus from a compound fracture reduced in the space of forty-eight hours to perhaps one- twentieth by the substitution of an appliance which gave perfect fixation for one which had not. This detail cannot be too strongly impressed, for the cessation of suppuration is essential to union of the fragments, while its continuance not only delays repair, but often by causing osteitis, dissect- ing abscess, and occasionally osteomyelitis, may prove the first cause for the ultimate sacrifice of the limb. When a compound fracture implicates a joint, as the elbow, wrist, knee, or ankle, three courses are open for its management : drainage, and partial or formal excision. Simple drainage is applicable to many cases in which there is no comminution of bone nor great contusion of the 256 A CLINICAL TREATISE ON FRACTURES. adjacent soft parts. It must, however, be carefully super- vised, and, on the faintest indication of its insufficiency, im- proved. Partial excision, which includes in its wide scope the removal of any portion of a joint, from a small frag- ment of the articular surface of one bone to almost the entire joint, is available where there is considerable com- minution of the articular surface of one bone, without very serious damage to the soft parts. If its subsequent treat- ment is carefully conducted and the case progresses favor- ably, this procedure may be followed by excellent restoration of function. Formal excision is rarely practised, for if the joint has been so disorganized, as by a crush, that it is destroyed, conservatism is usually impracticable. A third group of compound fractures, either because they cannot be satisfactorily reduced, or, after reduction, will not remain in proper position, are called refractory. As the tibia is by far the most common seat of refractory compound fracture, upon it has been expended more ingenuity than upon any other bone in the skeleton. And since every detail appropriate to its management applies almost unmodified to the femur, humerus, radius, and the ulna, it may well be the bone selected upon which to demonstrate the various means at our disposal for the correction and management of such fractures. One of the methods in most general use for the purpose of securing apposition of the fragments is that of wiring them to one another. After thoroughly cleansing the wound, removing tissues which are torn in such a way as to have lost their vitality, loose fragments of bone, clots, etc., COMPOUND FRACTURES. 257 under the most thorough antiseptic precautions, the ends of the fragments are perforated with a bone-drill, and secured in close approximation by silver wire passed through the open- ings thus made and twisted. In addition to the partial fixa- tion obtained by such suturing, considerable inflammatory reaction is produced, causing a hyperplasia in the osseous tissue. After such procedure, if the wound has not been too large, and has been capable of being rendered aseptic, the integument mav be sutured and the wound closed. The usual antiseptic dressing of sterile gauze is then applied, and the limb placed in some splint which will secure immobility of the part ; for it is evident that wiring, thus employed, leaves a flail-like joint which, while it prevents the frag- ments from overlapping, is not firm. Other methods looking to better fixation are the scarf joint of Volkmann secured by pegs ; the adjustment of a metal plate to which the fragments are attached by dowels or screws ; and the use of metal screws or ivory pegs in various ways to best secure coaptation and immobility. The fault apparent in them all is the want of precision in pre- paring the fragments, and in adjusting them after prepara- tion. In order to present this subject systematically the several methods, particularly one which has been elaborated somewhat by me, will be described as : Bone-joi7iing. — The term joining is selected on account of its technical significance in the arts as applied to wood or metal. Two essential elements are necessary to a wood or metal joint : (a) the nice fitting of the ends to be joined, and (d) the fastening of them by some uniting medium, as 17 258 A CLIXICAL TREATISE OX FRACTURES. glue, dowels, bolts, or screws. The preparation of the ends so that they shall fit together in an even joint is called a scarf, and, according to its shape, a square or bevelled scarf. The line of an oblique fracture is a surgical illustration of a bevelled scarf. A square scarf must be cut with a saw; but unless the depth of the scarf in each end of bone is equal Fig. ii; Fig. 118. Drill-clamp. Rack. the resulting joint will not be firm. An imperfect joint may be made firm by two screws or pegs ; but as the depth of the scarf required to give space for the insertion of two screws or pegs would too much shorten the bone, a method will presently be described by which a firm joint can be obtained by the use of a single screw, in cases in which COMPOUND FRACTURES. 259 the fracture is too nearly transverse to secure the fragments in the line of their fracture. For cases in which it is desired to join the ends of bone, I have devised the fol- lowing method: As the ends of a bone cannot be sawn or drilled with any precision unless they are held much more firmly than is possible by manual support, the mechanical device shown in Fig. 118 was designed for this purpose. It consists of a framework, or rack, into the arm of which can be inserted two separate clamps ; the first (in place), a simple C-shaped one, in which the bone is firmly held by a Fig. 119. •Tibia after section to make scarf-joint (experimental). pointed binding-screw preparatary to being sawn; and the second, a fenestrated clamp (Fig. 117), which will hold the sawn or fractured fragments together in firm and accurate apposition for drilling. The apparatus is kept steady by the hands of an assistant. It is applicable for bone-joining by any method, whether used for compound fracture, ununited fracture, or faulty union after fracture, and is equally ad- 260 A CLINICAL TREATISE ON FRACTURES. justable to all the long bones ; for the principles upon which it operates are simply to hold firmly, and as much like a vise as the conditions will allow, first, the fragment of bone to be sawn, and, second, the two fragments to be drilled. With a saw to which a gauge is attached, which may Fig. 120. Fig. 121. Fig. 122. Fig. 123. Ivory screw. Reamer. Screw-tap. be set at a half, five- eighths, or three-quar- ters of an inch, a square scarf is cut of corresponding depth in the lower fragment, which is held firm in the rack by the C clamp. Reversing the gauge to the opposite side of the saw, a similar scarf is cut in the upper fragment, as shown in Fig. 119. The joint thus prepared by scarfing the two ends is adjusted and held firmly together by the drill clamp (Fig. 117), which is substituted in the rack for the C clamp. The drill (Fig. 120) is applied above and made to bore through both fragments. With the reamer (Fig. 121) the drill-hole in the lower fragment (which is above) is enlarged and the Drill. COMPOUND FRACTURES. 26 1 screw-tap (Fig. 122) made to cut a thread in the upper fragment (which is beneath). The ivory screw (Fig. 123) is then set up with the wrench used for the tap. On removal of the clamp a firm, strong joint remains, which readily supports the weight of the portion of the limb below it, as shown in Fig. 124. The same operation demon- Fig. 124. Tibia united by single screw (experimental). strated on the femur, to which it would seem specially applicable for ununited fracture, is represented in Figs. 125 and 126. The following requirements are therefore met by this method : accurate sections, made possible with a gauged saw and when the work is firmly held ; shallow scarfs to min- imize the resulting shortening of the limb ; and fastening of the scarfed joint by a single screw, as so little space is required for it. The ivory or bone bolts should be sterilized by prolonged boiling, before the thread is cut in them and afterwards resterilized by immersion in a sublimate solution, as boiling distorts the thread of the screw. While the practice of surgeons differs regarding the classes of compound fractures which require some operation in order to secure coaptation and fixation of their fragments by mechanical means, probably all agree that in most cases 262 A CLINICAL TREATISE OX FRACTURES. in which the deformity is sufficiently refractory, both in resisting reduction and retention after reduction, operation is entirely justifiable. Certain it is that when compound fractures — and this statement applies more to the tibia than to any other bone — require free incision for purposes of cleansing and removal of the debris, whether of extraneous matter or of comminuted bone and crushed soft tissue, they had far better be given the advantage of nice coaptation and perfect fixation. Skilfully done, no increased element Fig. 12;. Femur after section for scarf joint (experimental 1. of risk is added to the case, and the danger of infection is lessened by the greatly reduced tendencv to suppuration always observed after accurate adjustment and complete fixation. Depraved Union after Fracture. — Since the manage- ment of refractory fractures as just described is often equally applicable for the correction of deformities result- ing from the faulty union of fractures, the latter may properly be referred to here. By this term is understood a degree of deformity after union is complete which so COMPOUND FRACTURES. 263 interferes with the natural function of the part as seriously to impair or destroy its usefulness. Occurring in the shaft of a bone the deformity may be angular or it may consist of overlapping or rotation. Whatever its principal char- acter, correction, if complete consolidation has taken place, can only be effected by osteotomy combined at times with some method of bone-joining. If simple osteotomy is to be performed, it should be done just as for correction of Fig. 126. Femur united by single screw (experimental). deformity from any other bone defect; but if it is intended to join the fragments after division the section should be made with a saw instead of a chisel, and so planned, according to the nature of the deformity, that it can be best utilized in forming the desired joint. Thus if the frag- ments have united with marked overlapping, a very oblique or even longitudinal section will best utilize their length; while, if angularity is the prominent element, accompanied perhaps with rotation, cross-section may best prepare them for reunion. Faulty union after fracture which affects the appearance 264 A CLINICAL TREATISE ON FRACTURES. but not the function of a part is, of course, most frequently observed after fracture of the bones of the face, particularly the nose and lower jaw. If union in such cases has become too firm to yield to the application of moderate force, section with the chisel may be resorted to, but not without the clearest understanding of the risks it may involve, and only if the degree of deformity is so marked as to justify such radical means for its correction. The general management of any compound fracture in which, owing either to the form of the bone or to the character of the fracture, the elements of displacement and mobility are wanting, is very much simplified. With no deformity, or deformity which once corrected remains re- duced, and with none of the requirements of fixation to prevent motion at the seat of fracture, the treatment is narrowed down to the thorough sterilization of the bone and soft parts, the removal of foreign matter and loose fragments of bone from the wound, provision for free drain- age, and the application of the appropriate gauze dressing to the part. INDEX. Acetabulum, fractures of, 171. Age, influence of, on frequency of fract- ures, 9 Allis's sign in fractured femur, 155 Ambulatory treatment of fractures, 131 Astragalus, fractures of, 112 treatment, 113 B. Barker's operation for fractured patella, 144 Barton's bandage for fracture of the jaw, 235 bran dressing for compound fractures, 242 Bond's splint, 39 Bone-joining after compound fracture, 257 Buck's extension apparatus, 162 C. Calcaneum, fractures of, III treatment, 112 Carpus, fractures of, 23 Causes of fractures, 9 age, influence of, 9 diathetic disease, 10 direct force, 10 experimental production, 12 force required to produce, II indirect force, 10 muscular force, 10 predisposing, 9 tensile strain, 13 Clavicle, fractures of, 98 causes, 98 deformity resulting from, 99 Desault dressing, 102 diagnosis, 100 treatment, 101 Coccyx, fractures of, 200 Coccydynia, 200 Colles's fracture, 34 diagnosis, 38 reduction, 38 treatment, 39 Comminuted fractures, 16 Complicated fractures, 16 Compound fractures, 16, 238 bone-joining, 257 causes, 239 complications, 243 depraved union after, 262 difficulty in reduction, 240 irrigation in treatment of, 254 operative treatment, 256 plaster-of- Paris dressing, 252 refractory, 256 suppuration after, 241 treatment, 248, 256 wiring of fragments, 256 D. Delayed union, 20 treatment, 21 Depraved union after compound fracture, 262 Desault dressing for fractured clavicle, 102 Diathetic disease in relation to fractures, 10 E. Experiments in the force required to pro- duce fractures, 12 Face, fractures of the bones of, 228 Fat-embolism after compound fracture, 247 Femur, fractures of, 147 Allis's sign, 155 experimental production, 13 265 266 INDEX. Femur, fractures of, Nelaton's sign, 154 of the lower extremity, 156 causes, 157 diagnosis, 158 treatment, 167 varieties, 156 of the shaft, 148 causes, 148 diagnosis, 150 treatment, 162 varieties, 148 of the upper extremity, 152 causes, 153 diagnosis, 153 treatment, 165 varieties, 152 treatment, general considerations, 160 Fibula, fractures of, 118 accompanying fracture of tibia, 122 deformity, 126 diagnosis, 121 Pott's fracture, 119 treatment, 124 Fissured fracture, 16 Fixation of fragments, 23 Force required to produce fracture, ex- perimental estimation of, 12 varieties, II Forearm, fractures of both bones, 61 diagnosis, 65 treatment, 65 G. Gangrene following compound fracture, 248 Gibson's bandage, 236 Green-stick fracture, 24 Gunshot fractures, 19 H. Humerus, fractures of, 67 experimental estimation of force re- quired to fracture, 13 of the lower end, 68 causes, 69 diagnosis, 70 Humerus, fractures of the lower end, treatment, 72 varieties, 68 of the shaft, 77 causes, 77 diagnosis, 79 treatment, 80 varieties, 78 of the upper extremity, 83 anatomical neck, 86 causes, 84 diagnosis, 84 epiphyseal separation, 88 non-union after, 92 surgical neck, 85 treatment, 88 tuberosities, 88 varieties, 83 Hyoid bone, fracture of, 237 I. Ilium, fractures of, 169 Indian puzzle apparatus for fractured patella, 141 Irrigation apparatus for compound fract- ures, 254 Ischium, fractures of, 170 J- Jaws, fractures of (see Maxilla), 230, 232 L. Leg, fractures of (see also Tibia and Fibula), 114 both bones, 122 treatment, 124 Lever and fulcrum for use in fracture of skull, 220 Lower jaw, fractures of (see Maxilla), 232 Liston's long splint for fractured femur, 164 M. Malar bone, fractures of, 231 Malgaigne's hooks, 140 Maxilla, fractures of, superior, 230 inferior, 232 IXDEX. 267 Measure of force required to produce fractures, II Metacarpus, fractures of, 28 treatment, 32 Metatarsus, fractures of, 107 treatment, 109 Multiple fractures, 16 Muscular force, fracture by, 10 N. Nose, fracture of, 228 O. Operation for ununited fracture, 22 Os calcis, fractures of, III Patella, fractures of, 131 Barker's operation, 144 causes, 132 diagnosis, 135 experimental production, 13, 132 Indian puzzle apparatus, 141 non-operative treatment, 139 operative treatment, 138, 144 Stimson's operation, 145 subcutaneous operation for, 144 treatment, 137 varieties, 134 Pelvis, fractures of, 169 acetabulum, 171 ilium, 169 ischium, 171 pubis, 170 treatment, 172 Phalanges, fractures of, fingers, 25 toes, 106 Plaster-of- Paris dressing for leg fractures 126 jacket in fractures of the spine, 195 Pott's fracture, 1 18 Predisposing causes of fracture, 9 Pubis, fractures of, 170 Punctured fractures, 16 R. Radius, fractures of, ^ Bond splint, 39 Colles's fracture, 34 diagnosis, 38, 45 lower extremity, 33, shaft, 44 silver-fork deformity, 34 treatment, 39, 46, 51 upper extremity, 49 Reduction of fractures, 23 Refractory fractures, 23 Ribs, fractures of, 176 complications, 179 diagnosis, 178 treatment, 180 Riehle testing-machines, 12 Rongeur forceps (spinal), 196 S. Sacrum, fractures of, 200 Scapula, fractures of, 94 acromion process, 96 body, 94 coracoid process, 95 treatment, 97 Scarf-joint for ununited fractures, 259 Simple fractures, 15 Skull, fractures of, 201 base, 204 cerebral symptoms, 208 diagnosis, 210 lever and fulcrum to elevate frag- ments, 220 prognosis, 213 sequelse, 224 treatment, 214 varieties, 206 Smith's anterior splint for fractured femur, 164 Spine, fractures of, 182 bodies of vertebrse, 191 causes, 184 coccyx, 200 diagnosis, 183 laminae, 189 268 IXDEX. Spine, fractures of, non-operative treat- ment, 193 operative treatment, 196 sacrum, 200 spinous processes. 1S8 symptoms, 186 Sternum, fractures of, 174 diagnosis, 175 treatment, 175 Tarsus, fractures of, 109 astragalus, 1 1 2 diagnosis. Ill os calcis. 1 1 1 treatment, 112 Tenotomy of tendo Achillis in fractures of leg, 127 Tetanus after compound fractures, 246 Tibia, fractures of, 114 accompanying fracture of fibula, 122 diagnosis, 1 16 lower extremity, 1 14 shaft, 114 treatment, 124 upper extremity. 117 Trephining forceps for fracture of skull, 217 U. Ulna, fractures of, 51 coronoid process, 58 diagnosis, 51, 54, 55, 58 olecranon process, 55 shaft, 52 styloid process, 51 treatment, 52, 55, 56, 59 Ununited fracture, 20 treatment, 21 Upper jaw, fractures of [see Maxilla), 23c Varieties of fracture, 16 Velpeau bandage. 97 Vertebrae, fractures of, 182 bodies, 1 91 causes, 184 coccyx, 200 laminae, 189 non-operative treatment, 193 operative treatment, 196 sacrum, 200 spinous processes, iSS symptoms, 186 treatment, 193 Z. Zygoma, fractures of, 232 D£C3G X5^vo\ >\X\ COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 101 H77C.1 A clinical treatise on fractures. 2002103400 Br ■ I® m IB! m : ■ ■ ■ ■::< mi ■■■:■■'.'■:■ ' I - ':■ 1UIMJ