DUPLICATE HX00018961 m. 0?y m ■^mmik Mi^^^. ^' WOOD'S MEDICAL HAND ATLASES. (tnlumbta Hntnrnittg in tl}t (Citij of N^rn f nrk Messrs. Wm. Wood & Co. Have the pleasure of announcing a series of Atl-icpc nnnn vcinniic hrcinrhp>c x^f medical and beauty, and ything here- d in colors impressions the proper ' the largest raphers in have been utiful plates highest ar- e publishers :h has never for cheap- nature of linent medi- supervision The vol- ir more full- sing several descriptive e subject to re uniformly inches in size, and reference, plate is always convenience of JFrom ti?p 5itbrari| nf (EtlurrlitU (Earmalt M, i. ^rparntr^ by ti}t Extrrnr (Club of Nnu ^nrk aDout live by seven and a half most convenient for ready use The descriptive matter for each printed on the page f^icing it, for study. For the subjects covered by the volumes nov^r offered to the profession, see inside of back cover. >u4r ATLAS OF TRAUMATIC FRACTURES AND LUXATIONS WITH A BRIEF TREATISE BY H. HELFERICH, M.D., PROFESSOR AT THE UNIVERSITY OF GREIFSWALD. WITH ONE HUNDRED AND SIXTY-SIX ILLUSTRA- TIONS AFTER ORIGINAL DRAWINGS BY DR. JOS. TRUMPP. NEW YORK: WILLIAM WOOD AND COMPANY. 1896. PREFACE. This Atlas and Treatise are intended to aid stu- dents entering upon that important field of surgery which embraces fractures and luxations, and to be a useful book of reference to physicians in their prac- tice. I have endeavored to furnish a work of prac- tical utility, and at the same time to facilitate the comprehension of the questions arising, especially as regards anatomical details. The first instigation came from the publishers, whose proposition I gladly accepted. On the one hand, I was pleased to utilize in this connection the specimens and drawings which I had accumulated in the course of years ; on the other hand, it appeared to me desirable to aid the more general spread of useful knowledge in a department where much harm *\$s^ can be done, and which, at present in particular, is of M^- great importance to every practitioner by reason of . y novel social arrangements. /^ I would lay special stress upon the fact that this fj book is by no means intended to take the place of studies at the clinic or in special courses, but is to form a supplement to the demonstrations and expla- X nations of the instructor. With very few exceptions, the Atlas presents only original drawings from specimens, many of them r-* O •, +0 w-isi iii iV PREFACE. recently prepared. I have striven to utilize the si')ace at my disposal to the best advantage and to furnish illustrations both theoretically and practically charac- teristic and instructive. In these endeavors I have been well seconded by Dr. J. Trumpp, who undertook the artistic part of the work and made the original drawings. Many specimens illustrating important injuries were artificially produced, and prepared in the man- ner I have been accustomed to for years in connec- tion with the operative course on the cadaver. Some figures show specimens observed by me while as- sistant to Dr. Thiersch at the Leipsic, Munich, and Greifswald clinics; others were kindl}" placed at my disposal by Professor Bollinger and by my colleague, Professor Grawitz, from the pathologico-anatomical collections in Munich and Greifswald. As the explanations printed opposite the plates did not appear to me sufficient, the Treatise was pre- pared, which is printed in separate divisions to ac- company each section of the Atlas. The lesions of frequent occurrence and of practical importance are treated in detail ; the rare injuries are explained very briefly. It is hoped that the book will be of some use. H. Helferich, M.D. Greifswald, October, 1894. CONTENTS. I. Fractures. General Remarks on their Production, Symptoms (Displacement), and Treatment. Plates 1-6. General Remarks on Fractures, . S3anptoms of a Recent Fracture, . Examination of the Fracture, Course and Reparative Process of Fractures, Untoward Accidents in Fractures, Treatment of Fractures, General Remarks on Luxations (Dislocations), II. Fractures of the Skull. Plates 7-13. Fractures of the Skull, .... III. Fractures and Luxations of the Lower Maxilla, the Thorax, and the Spinal Column. Plates 13-18 Fractures of the Bones of the Face, Luxations of the Lower Maxilla, . Fractures of the Spinal Column, . Luxations of the Spinal Column, . Fractures of the Ribs, . Fractures of the Sternum, IV. Fractures and Luxations of the Upper Extremity Plates 19-44. Fractures and Luxations of the Upper Extremity, 1. Fractures of the Clavicle, Luxations of the Clavicle, 2. Scapula 3. Shoulder-Joint, a. Forward Luxations of the Humerus, (1) Extension with Arm Slightly Ab ducted, 1 5 8 9 13 16 23 29 37 39 40 44 45 47 49 49 53 55 56 57 61 VI CONTENTS. PAGE (2) Kocher's Method of Rotation, . 01 h. Downward Luxations of the Humerus. 64 c. Backward Luxations of the Humerii?. 04 4. Ann, ••..... 64 A. Fractures at the Upper End, . .04 a. Fracture of the Anatomical Neck, . 04 b. Fracture at the Surgical Neck, . . 05 c. Fracture of the Tuberosity, . 07 d. Traumatic Separation of the Epiphy- sis, 07 B. Fracturesof the Diaphysis of the Humerus, 09 C. Fractures at the Lower End of the Hu- merus, 70 a. Supracondylar and T-Fractures, 72 h. Fractures of the Condyles, . . .73 c. Oblique Fractures of the Articular End, 73 n. El bow -Joint, 74 a. Posterior Luxation of the Forearm, . 75 b. Lateral Luxation of the Forearm, 77 c. Anterior Luxation of the Forearm, . 79 d. Divergent Luxation of the Forearm, . 79 e. Isolated Luxation of the Ulna, , . 79 /. Isolated Luxation of the Radius, . 80 0. Forearm, ........ 82 A. Fracture of both Forearm Bones, . 82 B. Fractures of the Ulna, . .85 a. Fracture of tlie Olecranon, . .85 b. Fracture of the Coronoid Proce.ss, 87 c. Fracture of the Ulna in the Upper Third, with Luxation of the Capitulum of the Radius 88 d. Fracture of the Diaphysis of the Ulna, 89 e. Fracture of the Styloid Process of the Ulna 90 C. Fractures of the Radius, .... 90 (I. Fracture of the Capitulum of the Ra- dius 90 CONTENTS. Vll h. Fracture of the Diaphysis of the Ra- dius, 91 c. Fracture of the Lower Diaphysis of the Radius, ....... 92 D. Luxation in the Lower Radio- Ulnar Joint, 97 7. Wrist-Joint, 98 8. Hand and Fingers, 98 A. Fractures, 98 B. Luxations, 99 V. Fractures and Luxations of the Lower Extremity. Plates 45-64. 1. Pelvis, 103 2. Hip-Joint, 106 A. Backward Luxation (L. postica s. retro- cotyloidea), 107 B. Forward Luxation (L. antica s. prsecoty- loidea), Ill C. Rare Luxations at the Hip-Joint, . . 113 3. Thigh, 113 A. Fractures at the Upper End of the Femur, 113 a. Fracture of the Neck of the Femur, . 113 h. Isolated Fracture of tlie Great Tro- chanter, 118 B. Fractures of the Diaphysis of the Femur, 119 C. Fractures at the Lower End of the Femur, 122 4. Knee-Joint, 123 A. Luxations at the Knee-Joint, . . . 123 B. Luxations of the Patella, . . . .124 C. Fractures of the Patella, . . . .126 5. Leg, 129 A. Fracture of Both Bones in the Region of the Diaphysis, 129 B. Isolated Fracture of the Tibia, . . .131 a. Fracture of the Tibia at its Upper End, 131 b. Traumatic Separation of the Epiphysis, 132 c. Separation of tlie Tuberosity of the Tibia, 132 d. Fracture of the Shaft of the Tibia, . 133 Vlll CONTENTS. PAGE C. Isolated Fracture of the Fibula, . . 133 D, Fractures at the Lower End of Both Bones, 134 a. Typical Fracture of the Ankle, . . 134 b. Other Fractures of the Ankle, . . 138 c. Separation of the Epiphyses at the Lower End of the Leg Bones, . .138 d. Supramalleolar Fracture of Both Leg Bones 138 6. Ankle-Joint, 139 a. Luxations at the Astragalo- Crural Joint, 139 h. Luxations at the Astragalo-Tarsal Joint, ....... 139 c. Isolated Luxation of the Astragalus, . 140 7. Foot, . . 140 A. Fi-acture of the Tarsal Bones, . . .140 a. Fracture of the Astragalus, . . 140 b. Fracture of the Calcaneus, . . . 141 c. Fracture of the Remaining Bones, . 141 B. Luxations, 142 a. Luxation of the Tarsal Bones, . .142 b. Luxation of the Metatarsal Bones, . 142 c. Luxation of the Toes, .... 142 LIST OF ILLUSTRATIONS. Plate 1. — Infractions (Greenstick Fractures). Fig. 1 a and h. Tibia and fibula of the left leg with in- fractions. Fig. 2. Artificial infraction of the fibula. Plate 2. — Fractures by Torsion. Fig. 1. Fracture by torsion of the shaft of the femur in its upper half. Fig. 2. Artificial fracture by torsion of the femur. Plate 3. — Forms of Fracture by Traction and Compression. Comminution by Machinery. Fig. 1. Pronounced fracture by traction. The carpal ex- tremity of the radius and ulna of an adult. Fig. 2, Upper end of the humerus with united fracture by compression. Fig. 3. Comminution of the bones of the forearm at the carpal extremity by powerful machinery. Plate 4. — Gunshot Fractures, Fig. 1. Femur with extensive splintered fracture caused by a gunshot wound by the German army rifle, model No, 88, at a distance of 600 metres. Fig, 2 a and 5, Gunshot perforation of the humerus at its upper end, produced by the army rifle, model No. 88, at a distance of 1,500 metres. Plate 5. — Displacement of the Fragments. Figs. 1 and 2. United fracture of the femur with displace- ment. Plate 6. — Reparative Process in Fractures, Formation of Callus. Fig. 1. Section of a humerus with multiple fractures and extensive callus formation on the shaft. Fig. 2. Section of a humerus with angular union. ix X LIST OF ILLUSTRATIONS. Fig. 3. Fracture of rib without displacement, with abun- dant external callus. Fig. 4. Fracture of the tibia united with displacement. Plate 7.— Gunshot Wound of the Skull at 200 Metres. Fig. 1. Wound of entrance. Fig. 2. Wound of exit. Plate 8. — Fractures of the Vault of the Cranium. Fig. 1. Gunshot wound, from without and from within (artificial) . Fig. 2. Slight gunshot injury (artificial). Fig. 3. Old fracture of the vault of the cranium, united with depression of the fragments and thickening of the bone at the point of fracture. Fig. 4. Vault of the cranium with fissure in the left parietal bone and diastasis of the right half of the lambdoidal suture. Plate 9. —Fracture of the Skull with Rupture of the Menin- geal Arter}'. Fig. 1. View of the line of fracture. Fig. 2. View of the site of the effusion of blood. Plate 10.— Fracture by Compression of the Base of the Skull. Fig. 1. Transverse fracture of the base of the skull. Fig. 2. Longitudinal fracture by compression of the base of the skull. Plate 11.— Fracture of the Base of the Skull by the Ix)wer Maxilla and the Vertebra. Fig. 1. Sagittal section through the base of the skull and the left maxillary articulation (normal). Fig. 2. Fracture of tlie base of the skull by the pressure of the on-crowding spinal colunm. Plate 12.— Fracture of the Base of the Skull by Injury in the Nasal Region. Figs. 1 and 2. Section and anterior view of a skull in which a fracture of the base of the skull has resulted from pressure upon the region of the nose and upper maxilla. Plate 13.— Forward Luxation of the Lower Maxilla. Fig. 1. Bilateral luxation of the lower maxilla artificially produced on the cadaver and dis.sected. LIST OP ILLUSTRATIONS. XI Figs. 2 and 3. Articulation of the lower maxilla in the normal state. Plate 14. Fractures of the Lower Maxilla. Fig. 1. Recent fracture in the body of the lower maxilla. Fig. 2 a and h. Fracture of the articular process of tlie lower maxilla. Fig. 3. Oblique fracture through the body of the lower maxilla and both articular processes. Figs. 4 and 4 a. Hammond s wire splint for fractures of the lower maxilla. Plate 15. — Fractures of the Ribs and the Sternum. Fig. 1. Four ribs showing old united fractures on three of them. Fig. 2. Fracture of the sternum. Fig. 3. Diastasis between manubrium and body of the sternum united with displacement. Plate 16. — Luxation of the Cervical Vertebrae. Fig. 1 a and 6. Unilateral luxation of the cervical ver- tebrae. Fig. 2 a and h. Bilateral luxation (by flexion) of the cer- vical vertebrae. Plate 17. —Fracture of the Cervical Spine. Fracture of the cervical spine involving the sixth and seventh vertebrae. Plate 18. — Fractures of the Vertebrae. Traumatic Kyphosis. Fig. 1. Fracture of the fifth cervical vertebra. Fig. 2. Fracture of a spinous process. Fig. 3. Angular kyphosis by fracture of vertebrae. Fig. 4. Plaster jacket in the same injury. Plate 19. — Subcoracoid Luxation of the Humerus, Exterior View. Plate 20. — The Same after Exposure of the Muscles. Plate 21. — The Same after Exposure of the Head of the Humerus. Plate 22. — The Same, Reduction. Fig. 1. Adduction of the arm. Fig. 2, Outward rotation of the arm. Fig. 3. Forward elevation of the arm. Fig. 4. Inward rotation of the arm. xii LIST OF ILLUSTRATIONS. Plate 23. — Old Subcoracoid Luxation; Formation of anew Socket on the Scapula and Abrasion of the Head of the Humerus. Fig. 1. Humerus and scapula in luxation, anterior view. Fig. 2. The same bones after removal and rotation of the humerus 180^. Plate 24. — Fractures of the Scapula. Fig. 1. Fracture of the neck of the scapula. Fig. 2. The same, with two lines of fracture. Fig. 3. Fractures of the scapula united by callus. Plate 25. — Luxations of the Clavicle. Fig. 1. Upward luxation of the acromial end of the clav- icle. Fig. 2. Position of the acromion in the same injury. Fig. 3. Forward luxation of the sternal end of the clavicle. Plate 26. — Fracture of the Clavicle, with Typical Displace- ment of the Fragments and Typically Altered Position of the Arm. Plate 27. — Traumatic Separation of the Epiphysis at the Upper End of the Humerus. Fig. 1. The actual injury. Fig. 2. Consecutivedisturbancesof growth in consequence of the injury. Plate 28. — Fractures at the Upper End of the Humerus. Fig. 1. Course of the epiphyseal line on the section of the normal bone. Fig. 2. Separation of the epiphysis at the upper end of the humerus, posterolateral view. Fig. 3. Lines of fracture drawn in the anatomical and the surgical neck of the humerus. Fig. 4. Old fracture of the upper part of the shaft of the humerus united with marked displacement. Plate 29.— Fractures in the Middle of the Humerus. Fig. 1. Anatomical preparation to show the position of the radial nerve witli reference to the bone. Figs. 2 and 3. United fractures of the shaft of the hume- rus with some dis])lacement of the fragments. Plate 30. —Fractures at tlie Lower End of the Humerus. Fig. 1 a and h. Partial separation of the lower epiphysis of the humerus. LIST OF ILLUSTRATIONS. Xlll Fig. 3. Longitudinal fracture of the humerus extending into the elbow-joint. Fig. 3. Separation of the erainentia capitata and the ex- ternal condyle. Fig. 4. Typical transverse fracture of the humerus. Plate 31. — Fractures at the Lower End of the Humerus and at the Capitulura of the Radius. Figs. 1 and 2 show the epiphyseal line at the lower end of the humerus. Bone preparations. Fig. 3. Fracture at the lower end of the humerus above the condyles, with typical displacement. Fig. 4 a and b. Old, united fracture of the capitulum of the radius. Plate 32. — Deformity of the Arm after Articular Fracture at the Lower End of the Humerus. Figs. 1 and 2, Old oblique fracture at the lower end of the humerus, with formation of a cubitus valgus (bone preparation) . Fig. 2, The same condition during life. Plate 33. — Outward Luxation of the Forearm, with Separa- tion of the Internal Condyle. Plate 34. — Backward Luxation of the Forearm. Plate 35.— Reduction of Posterior Luxation of the Forearm by Hyperextension and Traction. Plate 36. — Isolated Luxation of the Capitulum of the Radius in Fracture of the Ulna in the Upper Third, with Marked Displacement of the Fragments. Fig. 1. The more minute anatomical details in an artificial preparation. Plate 37. — Fracture of the Olecranon and the Coronoid Pro- cess. Fig. 1. Fracture of the olecranon. Fig. 2. Old bone preparation of a fracture of the olecranon. Fig. 3. Separation of the coronoid process. Plate 38. — Fractures in the Middle of the Forearm. Fig. 1. Unfavorable position of the fragments in fracture of the forearm. Fig. 2. Similar unfavorable angular position ; the radius • in a state of bony union. XIV LIST OF ILLUSTRATIONS. Fig. 3. Nearthrosis between radius and ulna at the point of fracture. Plate 39. — Fracture of the Radius. Lower Epiphyseal Line of the Forearm Bones. Fig. 1. Isolated fracture of the radius above its middle and the effect of the biceps on the position of the upper fragment. Fig. 2. Epiphyseal lines at the lower end of the radius and ulna, after a dry preparation. Plate 40. — Typical Fracture of the Lower Epiphysis of the Radius. Fig. 1 a. Normal forearm. Fig. 1 h. Forearm in typical fracture of the radius. Fig, 2. Fracture of the radius, separation of a portion of the articular surface. Fig. 3. — Transverse fracture of both forearm bones. Plate 41. — Typical Fracture of the Lower Epiphysis of the Radius. Fig. 1. Typical fracture of the lower epiphysis of the radius, lateral view. Fig. 2. — Longitudinal section through the forearm in this fracture. Plate 42. — Replacement and Dressing of the Typical Fracture of the Radius. Fig. 1. Replacement of the typical epiphyseal fracture of the radius. Fig. 2. Application of a Beely's plaster-of -Paris splint after replacement is effected. Fig, 3. — Illustration of the dressing devised by Professor Roser, Plate 43.— Typical Luxation of the Thumb. Plate 44. — Incorrect and Correct Mode 'of Reduction in the Typical Luxation of the Thumb. Fig. 1, Incorrect mode of reduction in the typical luxa- tion of the thumb. Fig. 2. Correct mode of reduction in the same injury. Plate 45. — Fractures of the Pelvis. Bertini's Ligament. Fig. 1. Lines of fracture in the anterior circumference of the pelvis. LIST OF ILLUSTRATIONS. XV Fig. 2, Pelvic fracture through the acetabulum in a boy aged 14. Fig. 3. Ileo-femoral or Bertini's ligament. Plate 46. — Luxation of the Femur. Fig. 1. Backward luxation of the femur. Fig. 2. Forward luxation of the femur. Plate 47. — Backward Luxation of the Femur, Anatomical Preparation. Pla-TE 48. — Forward Luxation of the Femur, Anatomical Preparation. Plate 49. — Extra capsular Fractures of the Neck of the Femur. Fig. 1 a and b. Extracapsular fracture of the neck of the femur, with impaction of the fragment (bone prepa- ration) . Fig. 2 a and b. United extracapsular fracture of the neck of the femur. Plate 50. — Intracapsular Fractures of the Neck of the Femur. Plate 51.— Typical Displacement in Fracture of the Shaft of the Femur. Fig. 1. Badly united fracture of the femur. Fig. 2. Action of the muscles upon the upper fragment of the femur. Plate 52. — Typical Displacement of the Fragments in Supra- condylar Fracture of the Femur. Plate 53. — Different Fractures of the Femur. Fig. 1. Very acute-angled oblique fracture in the upper half of the femur. Fig. 2. Oblique fracture below the middle of the femur. Fig. 3. Old fracture of the femur, united with marked displacement. Fig. 4. Oblique fracture through the lower articular end of the femur. Plate 54. —Vertical Extension in Fractures of the Femur in Children. Plate 55. — Fracture of the Patella. Fig. 1. Isolated fracture of the patella. Fig. 2. The ligamentous, tense tissue adjoining the patella on both sides is severed with the latter. Plate 56.— Fracture and Luxation of the Patella. XYl LIST OF ILLUSTRATIONS. Fig. 1. Old fracture of the patella, united by a broad ligamentous mass. Fig. 2. Fragments united by a short, broad ligamentous mass. Fig. 3, Fragments united by a very long, thin ligament- ous mass. Fig. 4. Outward luxation of the left patella. Plate 57. — Fractures in and about the Knee- Joint. Fig. 1. Normal course of the epiphyseal lines. Fig. 2. United stellar fracture of the patella. Fig. 3 a and h. Fracture by compression of the tibia at its upper end. Plate 58. — Fractures of the Leg Bones United with Deform- ity. Figs. 1 and 3. Typical deformities which must be abso- lutely avoided. Plate 59. — Figs. 1 and 3. Fracture of the tibia with luxation of the capitulum of the fibula. Plate 60. — Fractures of the Leg Bones. Fig. 1. Fracture of the Leg Bones United with Marked Displacement of the Fragments. Fig. 3. Fracture of the leg bones united with slight dis- placement of the fragments. Fig. 3. Supramalleolar fracture of both leg bones united with marked displacement. Fig. 4. Recent fracture by torsion at the lower end of the tibia. Plate 61.— Typical Malleolar Fracture. Plate 62. —Typical IMalleolar Fracture. Plate 63. — Fractures of the Ankle with Displacement of the Fragments. Fig. 1. Traumatic pes valgus. Fig. 2. Bilateral, typical fracture of the ankle with back- ward subluxation of the foot. Fig. 3. Epiphyseal lines of the tibia and fibula. Plate 64. — Luxation of the Foot in the Astragalo-Crural Articulation. Fig. 1. Backwnrd luxation. Fig. 3. Forward luxation. I. FRACTURES. GENERAL REMARKS OiX THEIR CAUSATION, SYMPTOMS (DISPLACEMEiXTj, AXD TREATME^^T. Explanation of Plate 1. Infractions (Green-Stick Fractures). Fig. 1 a and b. — Tibia and fibula of the left leg of a boysLged 14 (William Kohn), who was severely injured on November 21st, 1889, Idj being caught be- tween the cam wheels of a threshing-machine. Both ])ones are drawn as seen from the outside. On the specimen the fracture of the fibula is about three fingers' breadth higher than that of the tibia. At the point of fracture both bones are bent backward so as to produce a salient angle at the anterior side and a depressed angle at the posterior side. Both bones exhibit a marked infraction (green-stick frac- ture) . It may be seen plainh^ that the bending causes first a separation of the parts on the convex side, and then a detachment of a wedge-shaped fragment on the concave side; this wedge is not fully separated on either bone. (Author's collection.) Fig. 2. — Artificially produced infraction of the fibula. The specimen is taken from the leg of a cadaver, which was fractured by means of Rizzoli's osteoclast. The same etfect is produced by other osteoclasts or by breaking a thin bone over the edge of a table. In every instance the base of the wedge, whether completely or incompletely detached, or per- haps sometimes merely marked by fissures, corre- sponds to the concave side of the bent bone. (Author's collection.) Fig.l' FJg.1' Fy2 Lith.Anst v.F.Reichholci.Munchen . FigJ Fifj 2 Lith Anst V F Reichhold.Miinchen Explanation of Plate 2. Fractures by Torsion. Fig. 1. — Fracture by torsion of the shaft of the femur in its upper half ; specimen derived from a woman aged 88 (Anna Kainz). The left femur is seen from in front, and the pronounced spiral direc- tion of the line of fracture is evident. The fracture was caused by rotation of the bod}^ while the foot was fixed. Personal observation at the surgical policlinic in Munich. (1884, No. 4,359.) Fig. 2. — Artificially produced fracture by torsion of the femur. The spiral line is seen ascend- ing from below upward to the right ; a fissure starts from this spiral, passes almost vertically downward, and its inferior limit again joins the lowest portion of the spiral line. Since near the upper end of the spiral line another vertical fissure passes downward and meets the spiral line again at a lower point, an approximately rhombic fragment is detached, which is a characteristic feature in a large number of frac- tures by torsion. The short sides of this rhombic fragment are segments of the spiral line of fracture ; the long vertical sides comprise about one-fourth of the circumference of the femur. Fracture by torsion can be artificially produced on the cadaver by thorough fixation of the limb, vigor- ous torsion, and a sharp blow with a hammer at the point where the fracture is desired. (Author's collec- tion.) Explanation of Plate 3. Forms of Fracture by Traction and Compres- sion. Comminution by Machinery. Fig. 1. — Pronounced fracture by traction. The carpal extremity of the radius and ulna of an adult J both stj'loid processes are torn off in a jagged line. This separation is obvioush" the result of a sudden traction transmitted through the lateral liga- ments, in the present instance caused by injury to the hand in a machine. The separation of the styloid process of the ulna is incomplete. (Personal observa- tion.) Fig. 2. — Upper end of the humerus with united fracture by compression. The head of the humerus and the upper end of the shaft are markedly displaced, but still united by abundant callus. The latter, with its velvety, partly porous structure, can be prettj- well recognized in the illustration. The fragment of the head likewise is not normal, but is traversed by fissures at the anatomical neck and within the tubercle, which contribute to the deformity and at the same time exhibit the effect of compression. The upper end of the shaft is displaced forward and inward, and also shifted upward. The fragments are lixed by a spongy mass of callus; the joint was immovable. (Author's collection.) Fig. 3. — Comminution of the bones of the f(rre- arm at their carpal extremity by powerful ma- chinery. The patient (Harloff), a man aged 50, was injured on December 21st, 1H91, while tending an engine; he stumbled, and his left arm was caught in the drum. As the soft parts were extensively con- tused the forearm was immediately amputated. The healing of the wound and of a compound fracture of the upper arm which was present at the same time was perfect. (Author's collection.) Ei^l Ei^.2 Fig 3 LiHi Anst.v F Reichhold.Munchen Lith Anst V r RpirhhnW Muncben Explanation of Plate 4. Gunshot Fractures. Fig. 1. — Femur with extensive splintered frac- ture caused by a gunshot wound by the German army rifle, model No. 88, at a distance of 600 metres. The drawing shows the posterior surface of the femur with the wound of exit and a large number of replaced fragments. At the anterior sur- face of the femur is the somewhat smaller wound of entrance. Such a comminution of the bone with the associated injury of the soft parts would be an indication for amputation. (Author's collection.) Fig. 2 a and b. — Gunshot perforation of the hu- merus at its upper end, produced by the army rifle, model No. 88, at a distance of 1,500 metres. On the fresh specimen the soft parts, periosteum, and bone showed a smooth perforation. The bullet represented at b had entered at the anterior surface of the humerus, made the perforation shown, and was lodged behind under the skin (Fig. 2 b). On the macerated specimen there is a fissure be- ginning at the point of impact, extending upward and outward through the tubercle, and passing al- most completely around the anatomical neck. The wound of exit at the posterior side of the humerus is slightly larger than that of entrance, but still of a rounded form. (Author's collection.) Explanation of Plate 5. Displacement of the Fragments. Figs. 1 and 2 show different views of the same specimen of a united fracture of the femur. It is a good object for demonstrating the forms of displace- ment, all of which are combined in this one specimen. The fragments are : a. Displaced laterally so that their ends do not meet but overlap completely, i.e., dislocatio ad latus. b. These laterally shifted fragments are displaced side by side in a longitudinal direction so that the entire bone is materially shortened, i.e., dislocatio ad longitudinem ciun contractions. c. The fragments, however, are not so juxtaposed that their longitudinal axes are parallel, but the axis of one fragment is at an angle to that of the other — the fragments are united at an angle, i.e., dislocatio ad axin. d. Finally, during this multiple displacement, one of the fragments has also rotated on its longitudinal axis. Fig. 1 shows the upper fragment exactly from in front; the lower one therefore is markedly turned inward, i.e., dislocatio ad peripheriam. Fi^.1 Fig 2 Lith.Anst.v.F.Reichhold.Miinchen. <§ ^w «Nf Si re ^B ;5 ::^ 2 ^ n § ^ ^S-2 f=fe^a.B =^ cr^-, rj ? s» ^ 2. S^^cfQ r ^ ^ '^ ^"S ^'-^^ £. :i- ^ ® 2 3 ^^^s so|^s ^::i's^-g.g2^8s 8 fe) O CD ^ tJ r/^ ^ it: «^^ w^ H ti H-i "~^ (-N O i-h, • ?^^^=^i;^o'^^2'Ti^i^^'-Jc:l!-^2 tz^ 02.^^ So ^--o" -^ CD CD 1 r— I • 1 CD I ® i-ts*-".^. ct- i General Remarks on Fractures. In the discussion of fractures we must distinguish above all those due to an extraneous force (traumatic fractures) from such as occur independently of an extraneous force or from so slight a cause as would not suffice to break a healthy bone (spontaneous fractures) . Spontaneous fractures are the result of fragility of the bone, due as a rule to tumors (sarcomata, meta° static carcinomata, echinococcus cysts, etc.), and to inflammatory diseases of the bone (osteomyelitic ne- crosis not supported by an appropriate box splint, bone abscess, tuberculous caries, syphilis, rickets, osteomalacia, etc.). The following explanations do not appl}^ to such spontaneous fractures. The observations here given refer to traumatic fractures of healthy bones. We distinguish compound fractures and simple or subcutaneous fractures. A compound fracture is one associated with an injury of the skin and soft parts at the point of fracture. As a rule such a complica- tion exposes the seat of the fracture and subjects it to the danger of infection from without ; even a slight lesion of the skin and soft parts which does not reach as far as the seat of fracture is included in the term. In these cases the antiseptic or aseptic treatment of the wound must always be carried out strictly in ac- cordance with surgical rules. In this way alone are 1 2 FRACTURES AND LUXATIONS. we justified in expecting a favorable course of such open fractures which in former times were fraught with dangers. In other respects the treatment of these fractures follows the same principles applying to the simple variety, and aims at a firm knitting of the broken bone, with the least possible displacement. It is a matter of frequent experience that this task is much more difficult in compound fractures, and that often we have to be satisfied with results which are not absolutely perfect. According to the degree of separation of the bone at the seat of the injury we distinguish complete and incomplete fractures. The latter include fissures which traverse the bone without altering its external form, and infraction or green-stick fracture, which is observed most frequently on the bent leg bones of rachitic children, but occurs also in the tubular bones of adults and in flat bones. In complete fractures the lines of separation may pass in very different directions; hence we distin- guish transverse, oblique, longitudinal, and spiral fractures. When small particles are completel}' de- tached at the point of fracture, whether or not they are still connected with the periosteum, the fracture is called comminuted ; but when a larger portion is broken off at the seat of the injury we may designate it a separation of a fragment or splinter. It is a matter of some importance whether the frac- ture is direct or indirect. This term is used to desig- nate the seat of the fracture with reference to the force causing the injury. When the fracture occurs at the point of injur}', as for instance in parrying a blow with the forearm (parrying fracture of the GENERAL REMARKS ON FRACTURES. 6 ulna), it is a direct fracture. But when a fracture of the clavicle occurs in a child from a fall on the hand, it is an indirect fracture. Inasmuch as in a direct fracture the marks of the effective force (con- tusion and consequent ecchj^mosis) appear at the seat of the fracture, such injuries as a rule are considered to be more serious than indirect fractures. A very essential point, morever, is the occurrence of various form of fracture at different ages. It is obvious that the middle adult age furnishes the larg- est number of fractures, for at this period the heavi- est labor is performed and the liability to the dangers and accidents connected with it is greatest. In order to calculate correctly the statistical proportion the number of the population at the various ages must be taken into consideration. We then find that fractures are most frequent between 30 and 40 years (15.4^), and that they are more frequent in advanced age than in childhood; the minimum is found in children up to the age of 10 years. The occurrence of fractures in advanced age is in part the result of an increased fragility due to a senile atrophy of the osseous tissue (diminution of the organic substance in the bone). In early age the presence of the carti- laginous symphysis between diaphyses and epiphyses plays an important part ; often enough there is not a true fracture of the tubular bones, but a traumatic separation of the epiphysis, such as occurs spontane- ously in inflammatory processes, especially in acute osteomyelitis and also in syphilis. In considering the mechanism of the production of fractures, the description is to be based upon the study of specimens obtained by accident and those 4 FRACTURES AXD LUXATIONS. artificially produced on the cadaver. The results thus secured agree with each other; most forms of fracture can be artificially produced without diffi- culty. Infraction (green-stick fracture) results from flex- ion of a bone beyond the limits of its elasticity. In the same way as a stick is broken across the knee and parts first on the convex side, so does a long tubu- lar bone bent in like manner. This happens in vari- ous ways. The form of the green-stick fracture is quite characteristic; see Plate 1. An incomplete development of these lines of fracture produces trans- verse and oblique fractures. We might perhaps distinguish a special form of infraction caused by lateral pressure ujDon the end of a bone otherwise fixed ; for instance, fracture of the fibula in the typical malleolar fracture by pressure of the astragalus. In part this is certainly a process of flexion. Fracture by torsion results from twisting. This is possible when one end of the bone is fixed and the rest of that part of the body is twisted. This pro- duces a spiral fracture which can also be effected arti- ficially; see Plate 2. When the bone is twisted to the right the resulting spiral turns toward the right. Torsion causes many oblique and longitudinal frac- tures. Fracture by compression is due to a crushing force acting on a bone. This force may be exerted in the longitudinal direction of a tubular bone, in which case there result characteristic infractions at the can- cellous end of the bone, as well as complete fracture with impaction of the fragments into each other (for GEKERAL REMARKS ON" FRACTURES. O instance, at the upper end of the humerus, tibia, etc., crushing- of the calcaneus by a fall upon the feet. See Plate 3, Fig. 2). To the same class be- longs also the detachment by contusion of small marginal portions from the articular ends. Fracture by traction results from the sudden pull of muscles or ligaments in forcible movement of a joint (distorsion) . Among characteristic instances are cases of fracture of the patella, olecranon, malle- olus, the lower epiphysis of the radius, etc. See Plate 3, Fig. 1. Gunshot fracture is due to a gunshot injury of a bone. The specimens illustrated on Plate 4 show the extensive splintering in close proximity and the characteristic gunshot perforation at a great distance of the object. A knowledge of these relations is also practically of great value, occasionally, for the forensic physi- cian. It is obvious that not rarely combinations of the various mechanical effects may be observed in the living patient. Powerful forces (injury by ma- chinery) sometimes produce complete comminution of bones. SYMPTOMS OF A RECENT FRACTURE. On inquiring for the symptoms of a fracture pain is mentioned with remarkable frequency — the most unimportant symptom, which moreover would be valueless for differentiating a fracture from a severe contusion were it not that it is sometimes possible to localize this pain at a narrowly circumscribed spot or line of the bone, while in contusion pain on pres- sure is more frequently felt over a larger surface. 6 FRACTURES AND LUXATIONS. The characteristic feature of a fracture is the soki- tion of continuity of the bone. This and its mechan- ical sequeli© form the most important symptoms of a fracture. 1. The abnormal mobility is the chief symptom, which is more or less pronounced and marked in most cases. It is absent in incomplete fractures, i.e.^ fis- sures and infractions, and in imj^acted fractures. In the latter variety the smaller and firmer portion of a bone is wedged into the cancellous part and so fixed mechanically that the two pieces again form a single bone. This occurs particularly in fractures of the neck of the femur, though it is met with also at other articular ends and different tubular bones. In other cases, as in fractures of short bones, the ribs, etc., abnormal mobility cannot alwaj'S be demonstrated. 2. Crepitation, the sensation of friction (possibly also an audible friction sound), on displacing the broken ends on each other, results from rubbing the recently fractured surfaces together. Crepitation is conditional on the presence of abnormal mobility; for where the latter is absent, where the fractured surfaces cannot be displaced on each other, no crepi- tation can result. This symptom, therefore, cannot be perceived in fissures, infractions, and impacted fractures. In other cases, in which the abnormal mobility is not clearly demonstrable, some sort of crepitation can still at times be noticed with appropri- ate attempts at displacement. In other cases, however, the abnormal mobility is characteristically present, often even very markedly, and still crepitation is absent. This is the case when the fragments are so displaced that they are no longer GENERAL REMARKS ON FRACTURES. 7 in contact {dislocatio ad longitftdinem), both wlien they are separated from each other (diastasis), as occurs, for instance, with the fragments of the pa- tella, and when they overlap considerably, with pro^ nounced shortening of the entire bone. Crepitation is absent, moreover, when soft parts are situated between the movable fractured extremi- ties, that is, when there is an interposition of soft parts, chiefl}^ portions of fasciae and muscles. This ensues when the sharp fractured extremities are widely displaced and penetrate into the surrounding soft parts, and during reduction are not com.pletely freed. The interposed tissue in that case acts as a cushion which prevents the contact of the fractured ends. 3. A third very important symptom is deformity which can generally be seen and felt. This symp- tom is absent oidy in the case of fissures and of those rare complete fractures in which there is no displace- ment of the broken ends. The deformity is the result of the displacement of the broken ends. In order to characterize this, it has long been customary to dis- tinguish different forms of displacement (see Plate 5), namely : a. Angular displacement of the fragments (dislo- catio ad axin) ; h. Lateral displacement (dislocatio ad latus) ; c. Longitudinal displacement (dislocatio ad, lon- gitudinem). In the latter case Ave must distinguish whether the fragments are drawn apart (diastasis, • dislocatio ad longitudinem cum distractione) , as occurs in fractures of the olecranon and patella, or whether they override each other with consequent 8 FRACTURES AND LUXATIONS. shortening of the entire bone (dislocatio ad longitu- dinem cum contractione), as is frequently observed in tubular bones. Diastasis occurs only when the bony framework of the limb is intact, and merely some prominences are subject to a certain muscular trac- tion (patella, olecranon, trochanter, etc.); d. •i)isplacement by torsion of the fragments or fragment around its longitudinal axis {dislocatio ad perij^heriam), slight degrees of which are not rarely seen. It occurs in a marked form in fractures of the neck of the femur, and in fractures of the shaft of the femur and radius, in which the peripheral portion of the bone undergoes such displacement when the patient is put to bed. Further symptoms of a recent fracture are effusion of blood at the point of injury, the above-mentioned pain, and disturbance of function. The latter two are subjective symptoms dependent upon the individ- uality of the patient, and therefore are not decisive. THE EXAMINATION OF A FRACTURE should be gentle and rapid. Frequently inspection will establish the fact, so that manual examination of the fragments is required only to settle certain questions. In every case the examination should clearly determine the nature of the fracture, the form and position of the fragments. To this end anaesthesia is often necessary, especially in fractures involving a joint. Whoever in doubtful cases resorts to anaes- thesia (chloroform, ether, ethyl bromide) by prefer- ence, of course with all due caution, will have no cause to regret it: the more accurate and correct GEN"ERAL KEMARKS OK FRACTURES. 9 appreciation of the conditions will result in a shorter duration of treatment, and besides an exact reduction can be effected at the same time. An important auxiliary in the examination is men- suration. Since the broken bones are nearly always shortened, the demonstration of a difference in length is of value. This is not meant to imply that a tape measure should be at once applied ; on the contrary, the correct way is to make a careful inspection from a proper distance of the injured limb in comparison with the sound one, both being in symmetrical posi- tion. After judicious exercise in the clinic and later in practice slight differences can often be better appre- ciated with the eye than with the tape measure. Still mensuration should likewise be practised. COURSE AND REPARATIVE PROCESS OF FRACTURES. A fracture is followed by a swelling of the sur- rounding soft parts, which is due partly to the effused blood, partly to the infiltration of the tissues. The swelling is greater in proportion to the severity of the injury and to the length of time elapsed between the latter and the replacement of the fragments and suitable position of the limb. These conditions of course are not without influ- ence upon the system in general. At the seat of fracture are comminuted bone marrow and other tis- sue elements, together with the effused blood. This is the reason that rise of temperature, i.e., fever, occurs soon after the injury in healthy persons with recent subcutaneous fractures. This fact may be ex- plained by the absorption of small necrosed tissue 10 FRACTURES AND LUXATIONS. elements at the seat of fracture, but might be more correctly ascribed to the action of the blood ferment which is absorbed from the extravasation. That fever results from the absorption of blood ferment has been established by experiment. Smaller or larger amounts of fat enter the circula- tion from the crushed bone marrow (for fat embolism xiicle infra), which is partly excreted by the kidneys. Therefore in some cases of fracture fat is found in the urine, sometimes associated with albumin and casts. At the seat of the injury the tumor caused by the effused blood and a kind of inflammatory swelling (oedema) persists for some days; but under correct treatment it subsides markedly as a rule by the end of the first week. The effusioji of blood then mani- fests itself on the skin by its well-known color changes and the tension diminishes. When the swelling is very great the skin at the seat of the fracture is sometimes raised in serous blisters; these do not dis- turb the normal course when the treatment is correct and no additional complications occur, but the}' call for careful disinfection of the skin and an aseptic dressing. At the point of fracture there is formed, or discov- ered after the subsidence of the swelling, a rounded fusiform tumor which at an early period is of carti- laginous hardness, the ends of which gradually merge into the normal outlines of the bone. This is the so- called callus. As the latter becomes firmer the ab- normal mobility of the fractured part diminishes. Finally the broken ends are truly fixed by the callus: the fracture is consolidated. GENERAL REMARKS ON FRACTURES. 11 It is a noteworthj^ fact that this course forms the rule. Under normal conditions, both in new-born children and in most advanced age, the fracture is consolidated by means of callus. The bulk of its substance is a product of the periosteum. As the latter is irregularly torn at the point of fracture, small portions of it being possibly displaced into the neighborhood of the fracture, a periosteal prolifera- tion occurs at these places, which is of the nature of a periostitis ossificans. The medulla of the bone at the same time is not altogether passive ; it likewise exhibits some degree of callus formation (medullary callus). If we picture to ourselves this callus forma- tion on a fracture without marked displacement of the fragments, the external or periosteal callus resem- bles a mass of mortar laid all around the broken ends, the internal or medullary callus occludes the medullary cavity at the point of fracture, and the two masses are united by the so-called intermediary callus formed sparsely by the bone itself. When the fragments are considerably displaced the callus formation of course is much more abundant; in such cases the broken ends are at times, as it were, plastered together by a large mass of callus. The callus is most scanty in the fractures occurring in children, in which the periosteum has remained in- tact so that it forms a closed sheath around the frac- ture and prevents displacement of the fragments. While callus formation was formerly divided into temporary and definitive (Dupuytren), nowadays we use these terms only in so far as after the healing of a fracture in the ordinary sense further changes take place for a long time, by which the anatomical rela- 12 FRACTURES AND LFXATIONS. tions of the seat of the fracture acquire a more defin- itive character. In other words, after a fracture is firmh' consolidated the point of the injury does not continue unaltered for quite a long period. The cal- lus, at first plentiful and spongj^, hecomes sparser and firmer, gradually assuming the character of com- pact bone. Whatever is not required in a mechani- cal sense of the mass of callus and the fragments undergoes slow absorption; of these parts only so much remains as the bone needs for its mechanical function. The medullary canal likewise may be re- stored. These processes of absorption and ossification are effected very slowly. Plate 6 contains illustra- tions showing the external callus, the occlusion of the medullary cavity by internal callus, also callus tissue of a spongy and compact character, and the absorption of old compact bone substance. UNTOWARD ACCIDENTS IN FRACTURES. Mention has been made above of fat embolism. While the absorption of small quantities of fat in fractures is very frequent and as a rule harmless, the absorption of larger amounts of fat may be ver}' dan- gerous and even fatal. The fat is derived from the comminution of the bone marrow, sometimes perhaps also from the damaged panniculus adiposus at the seat of the fracture. The fat, which is liquid at the temperature of the body, may pass directly into the ruptured veins of the bone and thus into the circula- tion ; in part it may also come to be absorbed and carried along by way of the lymph channels. The fat then enters the blood current and leads to fat em- GENERAL REMARKS ON FRACTURES. 13 holism in the pulmonary capillaries. Whatever fat passes through the pulmonary capillaries enters the arterial circulation, where it may cause embolism in the various organs (general fat embolism). In fatal cases extensive fat embolism has been demonstrated in the lungs, in the central nervous system, or in the capillaries of the major circulation. The treatment should be directed toward strengthening the activity of the heart by stimulants so as to favor the excretion of the fat by the kidneys. Venous thrombosis and embolism in subcutaneous fractures are rare but grave accidents. Cases have been reported in which, in the course of a healing fracture, death occurred suddenly with symptoms of asphyxia ; the autopsy showed embolism of the pul- monary artery due to venous thrombosis in the region of the fracture. Other cases gave rise, in a similar manner, to embolic infarction of the lung, and in some cases which recovered the diagnosis of embo- lism of the pulmonary artery could also be made from the clinical symptoms. Venous thrombosis in the region of the fracture often causes an oedematous swelling of the injured extremity. This accident has been most frequently observed in fractures of the lower extremity (generally in the third week), at times in relatively mild cases, as for instance recently after fracture of the patella. Lesions of the blood-vessels are very rare ; they may cause profuse effusions of blood, and, when the arteries are involved (rupture of the anterior and pos- terior tibial arteries have been most frequently ob- served), aneurisms and gangrene. Gangrene due to too tight bandaging will be discussed hereafter. 14 FRACTURES AND LUXATIONS. Nerve lesions may result in various ways in cases of fracture : for instance, a nerve trunk, such as the radial and peroneal which rest upon the bone, may suffer simultaneous injury by the force which causes the direct fracture ; or a nerve trunk may be wounded by the displaced fractured ends (interposition) ; or else during the healing the nerve is compressed, sometimes almost surrounded, by the callus forma- tion. The symptoms of course depend upon the cause and the distribution of the injured nerve. Operative interference (liberation of the compressed nerve from the callus mass) is not objectionable and has repeatedly terminated in complete recovery. Delayed Callus Formation. — While callus forms sometimes in excess and, though rarely, produces true tumors (osteoma, enchondroma), its develop- ment is occasionally remarkably retarded. The cause of this delay can seldom be ascertained. Prac- tically it is important that in such cases careful ex- pectancy and the employment of appropriate measures will as a rule result in consolidation. Among these measures are, besides a suitable strengthening diet, walking about of the patient and suspension of the broken limbs in appropriate dressings. A favorable effect is often produced by establishing venous hyper- aemia at the seat of the fracture by the application of a moderately tight rubber tube (drainage tube) above the fracture, while the distal extremity of the limb is protected by bandaging. More vigorous measures are friction of the fragments against each other under anaesthesia or perhaps the insertion of nails into them in order to set up an irritation and a stronger reaction. GENEKAL REMARKS ON" FRACTURES. 15 Pseudartlirosis is the term applied to the false joint which may result when the fracture does not consolidate. Some remarks on this subject will be found under the head of treatment. Briefly it must be remembered that the formation of a false joint may be due to general or local causes. Chief among the general causes are syphilis, general debility, etc. At the seat of the fracture various factors may give rise to a pseudarthrosis, mainly extensive local con- tusion, such as occurs in serious direct fractures, especially the compound varieties. When the callus formation is permanently at a minimum the forma- tion of a false joint will be the natural consequence. In other cases callus formation may be normal and even excessive and yet a false joint may result, namely, when soft parts are interposed or when the fragments are so displaced that they no longer come into sufficient contact ; therefore this accident is more common with the humerus and femur than in limbs containing two bones. It is readily understood that defective immobilization of the fracture likewise favors the occurrence of a pseudarthrosis. In the treatment of a false joint the minor measures, such as friction of the fragments, the insertion of nails or ivory pins, are usually insufficient ; as a rule resection of the fractured ends, possibly followed by a bone suture, will be required. When there is a marked defect of bone at the seat of the fracture healing can be effected only by transplantation of bone between the fragments. 16 FKACTURES AXD LUXATIONS. TREATMENT OF FRACTURES. The treatment aims at recovery without displace- ment and with good function, that is, consolidation of the fracture with the fragments in good position, without injury to the adjoining parts, especially the neighboring joints. This aim nearly always requires, besides replacement of the fragments, an appropriate dressing which must put the fracture at rest, and therefore must include not only the broken bone but also the two neighboring joints. The dressings may consist of pillows, box splints, wire cradles, and more complicated apparatus; in case of necessity and for the first transportation the broken arm may be fast- ened to the thorax, the broken leg to the healthy one. As a rule use is made at present of circular harden- ing (particularly plaster of Paris) bandages, or of splints, or of extension by weights. There is no question that fractures may be treated in various ways, by the exclusive use of one or the other method, with excellent results, if the surgeon possesses some skill and experience ; but in order to avoid unfortunate sequelae it is desirable that he pro- ceed in general according to definite principles. In early times physicians sometimes inclosed the recent fracture in plaster of Paris on their first visit and left the dressing for weeks undisturbed until the fracture was supposed to be consolidated; this is wrong in principle, and recovery with more or less marked displacement is the necessary result. The first dressing of a fracture must be based on the fact that the place of the injury is increased in thickness GENERAL REMARKS ON" FRACTURES. 17 by the swelling of the soft parts, which is sometimes considerable ; in order to allow for this swelling, the first dressing must be well padded. Of course it should be correctly applied and include the neighbor- ing joints, but make allowance for the greater volume by loose material, such as wadding or the like. About the eighth day the first dressing should be changed; for then the swelling has certainly partly subsided, and the dressing, having become loose, is apt to permit displacement of the fragments. The new dressing is applied , after careful correction of the position and with slight padding. For the latter I prefer the wood felt supplied by the firm of Hart- mann in Heidenheim, as it is both soft and firm, and keeps the skin dry. This dressing likewise is not to be the final one; after about another week, or say two weeks after the injury, the second dressing must be changed. At this time the swelling has fully subsided and the seat of the fracture, though sur- rounded with callus, is still movable, so that a final correction of the position can be easily effected. This third dressing may in ordinary cases remain until complete consolidation has occurred. After that a light and removable protective dressing may be worn as long as required in each case; best a light splint or a water-glass and chalk dressing cut open. The dressing of the recently injured limb should not be a circular plaster bandage, unless special con- ditions obtain and the dressing can be inspected daily. A splint is much better for the first dressing. Disregard of this rule has caused much mischief. In some cases an excessively tight plaster-of-Paris dressing applied for the purpose of compressing the 18 FRACTURES AND LUXATIONS. fracture has led to ischsemic paralysis and contrac- ture, to gangrene at the seat of the fracture, or even to gangrene of the whole limb, and many a physician has in consequence got himself into trouble by being held responsible for the injury. All the cases of ischsemic paralysis and contracture (Volkmann) which I have seen were due to a plaster- of -Paris dressing applied to the recent fracture. In such a case the prolonged restriction of the blood supply to the muscle causes disintegration of its ele- ments, it loses its elasticity, and becomes fixed in its contracted position (contracture). The irritability of the respective nerve is intact ; that of the muscle, ac- cording to the gravity of the case, is more or less diminished, and at times absent. Among the splints for fractures flexible metal splints, or plaster splints (plaster-of-Paris and tow splints of Beely) especially prepared for each case (see Fig. 2, Plate 42), will be found particularly use- ful. .Of the former I prefer the w^ire splints devised by Dr. Cramer, of Wiesbaden, or padded strips of tin of different length, width, and thickness. By keeping these on hand, padded with wadding and covered with mull, suitable material is ahvays ready for fixing a broken limb in any position by means of two such splints and a few bandages. I know that many of my pupils have these splints in daily use; the}' are also employed at the Munich and Greifswald policlinics. Extension dressings for the permanent extension .by weights is correctly employed not only in frac- tures of the femur, but also in fractures of the upper extremity (for instance, of the neck of the humerus, Fig. 1.— Ischgemic Paralysis and Contracture of the Forearm Muscles in a Young Man, aged 17, the result of a fracture of the lower end of the humerus about ten years before. 20 FRACTURES AND LUXATIONS. of the elbow- joint), of the spine, etc. The technique for all these dressings, of course, must be acquired by practice, which is readily afforded in every surgical clinic. For the treatment of certain fractures other methods are also in use nowadays, which have given excellent results in the hands of some specialists, but it is doubtful whether the methods are suitable for the general practitioner. It is unquestionable that the principle of the suture of the fragments of a fractured patella gives superior results in the hands of the sur- gical specialist; it is admitted that the treatment of fractures of the lower extremities by ambulatory dressings is followed by good results; for the treat- ment of the typical fractures of the lower epiphysis of the radius it is even recommended to dispense with every dressing and to place the limb simply in a mitella; but for general medical practice these and similar methods are not suitable, in my opinion. After the consolidation of the fracture great im- portance attaches to the after-treatment, with a view to restore the function of the injured extremity. In this respect a gratifying change is to be noted in recent times, much more being done in order to secure good results. Even in connection with the later changes of the dressings we may institute care- ful massage and passive movements of the joints which have been included in the dressings and have become somewhat stiff. Both of these manipulations come into the foreground after the consolidation of the fracture; at the same time warm baths, jet baths, bandaging, and especially the employment of medico- mechanical apparatus, are of great value. GENEKAL llEMARKS ON FRACTURES. 21 Particular care is required in the treatment of fractures involving the joints, i.e., those fractures which implicate the articular process of a bone, and therefore give rise to severe lesions of the joint, whose capsule is filled with effused blood. In such cases the aim of the surgeon, the consolidation of the frac- ture and the preservation of a movable joint, is most difficult of attainment. The indication in these in- juries is to change the dressings frequently, during the first one or two weeks every two or three days, later every day. To favor the absorption of the effused blood, unless it has been removed by aspira- tion, we must resort to slightly compressive dress- ings, combined with massage whenever these are changed, and, in addition, passive movements, fix- ation of the extremity in various positions, early active movements, and the application of mechanical apparatus. To carry out such a treatment imposes much labor upon the surgeon, but the reward is a brilliant result when consolidation of the fracture with good mobility is secured. It might almost appear surprising that I finally discuss badly or, rather, unfavorably united fractures. In spite of every care it^ may happen to every surgeon that the result of his treatment will be unsatisfac- tory ; besides, the stupidity and intractability of the patients, or their treatment by quacks, furnish oppor- tunities often enough for treating fractures united with deformity. In all such cases improvement of the position should be attempted and forced without loss of time. This will require a refracture of the bone, perhaps by the aid of an osteoclast, followed by an improvement of the position by temporary 22 FRACTURES AND LUXATIONS. manual or permanent extension by heavy weights and pulleys, and finally the preservation of the favor- able position during the renewed consolidation. Such operative interference is urgently indicated in badly united articular fractures likewise. GENERAL REMARKS ON LUXATIONS. The normal mobility of joints has a limit of ex- cursion which in many cases is not absolute. Every joint is provided with some arrangement which checks the continuance of the motion beyond a cer- tain point. This check is effected in some joints by the form of the bone, in others by articular liga- ments, and in a few by the muscles ; accordingly we use the terms muscular, ligamentous, and bony checks of articular mobility. While the bony check is absolute, the muscular check varies with the elas- ticity and distensibility of the respective muscles. We need but recall the great mobility of the wrist- joint, for instance, in professional piano players and the movements of the so-called India-rubber men; such mobility can be attained only by practice and the lessening of the muscular check. Every joint has its limit of mobility, and when the motion is continued beyond this the articular appa- ratus suffers an injury, laceration of portions of the capsule or the ligaments, that is, a strain or sprain (distorsio). When this lesion of the articular ap- paratus is extensive it may result in a dislocation (luxatio), in which the articular extremity of one bone entirely severs its normal contact with the other and (with few exception;!;) passes more or less com- GENERAL REMARKS ON LUXATIONS. 23 pletely (Inxatio, subluxatio) through the ruptured capsule. As in the case of fractures so in luxations we dis- tinguish traumatic, pathological or so-called sponta- neous, and congenital forms. The latter ar.e due to true faults of development or to displacements which occurred in utero. Spontaneous luxations result only in severe alterations of the joints by pathological pro- cesses, especially by tuberculous caries or extreme stretching of the capsule and ligaments. Traumatic luxations, which are the only ones to be considered here, result from injuries affecting the joint directly or indirectly ; some luxations even are due to active muscular action in sudden violent movements. Luxations are naturally more frequent in men than in women, and in adults, to the onset of senile age, than in children. In children under ten years luxa- tions are extremely rare. It is noteworthy, too, that, according to Kronlein, among 100 luxations 92.2 affect the upper extremity, 5 the lower extremity, and 2.8 the trunk. Luxations by the direct action of a force are rare. In such cases the trauma acts upon the region of the joint, where it produces the luxation, as a fracture results in the bone from a direct force. In the occur- rence of indirect luxations there is an increase of the joint motion beyond the extreme limit of its physio- logical excursion, the action of the long lever of the shaft of the bone overcoming the normal check. The short lever (the condyle or the articular extremity which is luxated) then is crowded outward in a defi- nite direction, at the same time forming a fulcrum ^4 FRACTURES AND LUXATIONS. (the margin of the socket, capsule, ligament, or a neighboring bony projection), loses its contact with the opposite articular surface, and the luxation is accomplished. We always speak of a luxation of the peripheral portion of the skeleton, for instance, of a luxation of the humerus when the dislocation is at the shoulder- joint, and designate its direction by the course taken by the peripheral bone, for instance, pr^eglenoid lux- ation of the humerus when the head of that bone has slipped forward in front of the glenoid fossa. The symptoms of a recent luxation are as a rule very pronounced. The absence of the articular end at its normal position, its presence at an abnormal point, cause at least a ver}^ marked deformity, which may be hidden only by a profuse effusion of blood. The position of the dislocated limbs is nearly always quite characteristic, so much so that the diagnosis can frequently be made by simple inspection. In addition the position in the several forms of luxation is as a rule typical, because it is determined by the influence of certain portions of the capsules and liga- ments which are preserved in the regular forms of luxation. The dislocated limb is elasticall}' fixed in this position, that is to say, it may be forced by ex- ternal pressure and traction to the normal limit of its excursion, which has been restricted by the luxation, but when released the limb springs back into the old pathological position. The last-mentioned symptom is the most important for the differential diagnosis between luxations and fractures, for in the latter this elastic fixation is absent. Other important points in luxations are the GBKERAL REMARKS ON" LUXATIONS. 25 absence of the normal bony prominence, the possi- bility of x>alpating the articular end in an abnormal position, and the changed direction of the longitudi- nal axis of the bone. Mensuration is valuable at times, since in some forms of luxation there is no shortening but a lengthening of the limb. As in fractures so in luxations incidental injuries may be present, such as lesions of nerves and blood- vessels, extensive laceration of the soft parts sur- rounding the joint, ^en v^ounds of the overlying integument w^hich give the luxation an open, com- pound character. In that event the treatment must be carried out on strictly aseptic principles. The diagnosis is sometimes rendered very difficult when the dislocation is complicated with a fracture. As a rule this rare complication is due to the fact that the extraneous force continues to act upon the luxated bone, thus causing a fracture of its dislocated end. The treatment of course aims at the reduction of the dislocation. This was formerly done in a very forcible manner by powerful traction, with the aid of three or four assistants or the use of block and tackle, which sometimes did much damage (laceration of large vascular and nerve trunks, fractures, etc.) ; but nowadays reduction is offected in a physiological manner without force, as a rule under anaesthesia. The rule, that the surgeon must effect reduction by making the luxated condyle return by the same way in which it reached its abnormal position, is in the main correct. The manipulations should not be arbi- trary, but should be based on an accurate knowledge and observation of the position of the condyle, the rupture of the capsule, and the surrounding soft 26 ■ FRACTURES AND LUXATIONS. parts. " The anatom}^ of the hixation determines pre-eminently our modern procedure" (Kroclein). While these conditions will be considered at greater length in the special section devoted to this subject, a description of the further procedures after reduction will be appropriate here. Under normal conditions, with a suitable dressing which enforces rest, the laceration of the capsule is repaired, the effused blood is absorbed, and the irritation of the joint (sliglit synovitis) subsides in a week or two. As soon as possible, even before the end of this period, massage and careful passive movements may and should be begun. If these set up fresh pain and symptoms of articular irritation thej' may be suspended or contin- ued very gently. Beginning with the third week more extensive movements and active exercises, the use of apparatus, etc., are indicated; finally full restoration of function must be secured. By habitual luxation we mean the frequent recur- rence of the dislocation, often in consequence of the most insignificant injury. Such patients know their condition very well and commonl}' apply to the sur- geon with the correct diagnosis; some of them are able to reduce their luxation themselves. The cause of these habitual luxations is generall}' a marked lesion of the joint which has left an abnormall}" wi- dened attachment of the capsule. The treatment rec- ommended is more prolonged immobilization, the injection of alcohol for the purpose of effecting a cer- tain shrinking of the tissues, etc. ; in very severe cases resection has been performed. Perhaps arthrotomy and partial extirpation of the capsule might be attempted. GENERAL REMARKS ON LUXATIONS. 27 Under certain circumstances a luxation may be irreducible ; it may happen that replacement fails in spite of the most careful attempts under anaesthesia. The cause may be the small size of the laceration of the capsule, but usually it depends upon the inter- position of adjoining soft parts ; that the reduction may be very difficult or impossible when complicated with a fracture of the margin of the socket will be readily understood. In all such cases the luxation should be reduced at an early date by operative inter- ference; the reduction must be forced by opening the joint as far as may be necessary. When a dislocation has not been reduced the con- dition presented is that of an old luxation, often enough associated with the formation of a new joint, a nearthrosis. Careful examination and the local condition will decide what steps are to be taken in these cases. When the function of the nearthrosis is quite good, as may happen in rare instances, it may be left undisturbed, and the efforts of the surgeon will be directed toward increasing the mobility of the new joint by appropriate exercises, etc. In other cases the only alternatives are resection or arthrot- omy with a view to replace the luxated condyle into the old socket. The latter should be the normal pro- cedure, because such cases of non -reduced luxation will come ever more frequently under treatment, and because the result of reduction is generally far better than that of resection. But it is desirable that re- duction be forced as early as possible. i-H o o •r-t 0(3 I— • >< ffl O o Q H CO o O O (D C^ ^ O 03 -+J o goo goo -*-3 CO Q ^5z; PJ 'T3 ^ CC o -+J O 9r cc "^ cp tJD af fl. ^ C C O) S r— o fl c5o;^ O T-l 2 O) r-j •r-s 72 0) «4-l o s^ 13 o 0) S ?H (-H O ;-. p rS bC CD 02 ^ fl « g «2 g J ^ r-^ ^^ ^ ? 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