IPO I"! Scu 3 /9oa Hiirarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatmentoffractOOscud u ■=; = 1) 3 .5 S •£ O 5° THE TREATMENT OF FRACTURES BY CHARLES LOCKE SCUDDER, M.D. ASSISTANT IX CLINICAL AND OPERATIVE SURGERY, HARVARD UNIVERSITY MEDICAL SCHOOL SURGEON TO THE OUT-PATIENT DEPARTMENT, MASSACHUSETTS GENERAL HOSPITAL ITbirt) lEMtion, ITborouobl^ IRevise^ TRUitb 645 11 [lustrations PHILADELPHIA AND LONDON W. B. SAUNDERS & COMPANY 1902 ^1) l^f l<\0 Copyright, igoo, bj' W. B. Saunders Copyright, igoi, by W. B. Saunders & Company Copyright, 1902, by W. B. Saunders & Company Registered at Stationers' Hall, London, England TO ARTHUR TRACY CABOT, A.M., M.D. PREFACE TO THE THIRD EDITION In this edition several new but not uncommon fractures are described. A chapter on gunshot fractures of the long bones is added. A careful review of the reports of surgeons in the field during recent wars, together with the ver}^ great assistance afforded by Mr. ]\Iakins' valuable systematic contribution to gunshot fracttues — "Surgical Experiences in South Africa," — has made it possible to present concisely important facts regarding fractures of bone produced by the small-caliber bullet. Through the courtesy of Mr. Makins and his publishers I am able to illus- trate this chapter with satisfactory- plates. The general text of the book has been carefully reviewed. A carefully prepared index is added. I wish to thank Drs. Putnam, AValton, Bullard, and Paul for reviewing the chapters upon fractures of the Skull and Spine. Photographs are introduced in place of many of the drawings. The uses of plaster-of- Paris as a splint material are more fully illustrated. The kindness and liberality of the publishers have again en- abled me to enhance the value of the book through freedom of illustration. Charles L. Scudder Boston, Mass., August, igo2 PREFACE TO THE FIRST EDITION The general employment of anesthesia in the examination and the initial treatment of fractures, especially of those near or involving joints, has made diagnosis more accurate and treat- ment more intelligent. The application of the Rontgen ray to the diagnosis of fracture of bone has already contributed much toward an accurate interpretation of the physical signs of frac- ture. This greater certainty in diagnosis has suggested more direct and simpler methods of treatment. Antisepsis has opened to operative surgers' a vers' profitable field in the treatment of fractures. The final results after the open incision of closed fractures emphasize the fact that anesthesia, antisepsis, and the Rontgen ray are making the knowledge of fractures more exact, and their treatment less complicated. The attention of the stu- dent is diverted from theories and apparatus to the actual condi- tions that exist in the fractured bone, and he is encouraged to determine for himself how to meet the conditions found in each individual case of fracture. This book is intended to serve as a guide to the practitioner and student in the treatment of fractures of bone. In the follow- ing pages many of the details in the treatment of fractures are described. So far as possible these details are illustrated. A few vers" unusual fractures are omitted. Mechanical simplicit}^ is advocated. An exact knowledge of anatomy combined with accurate observation is recognized as the proper basis for the diagnosis and treatment of fractures. The expressions "closed" and "open" fracture are used in place of "simple" and "com- pound" fracture. "Closed" and "open" express definite condi- tions, referring to the freedom from, or liability to, bacterial infec- tion. The old expressions are misleading despite their long usage. Theories of treatment are not discussed. Types of 12 PREFACE dressings for special fractures are described. Many illustrative clinical cases are omitted purposely. The tracings of tlie Rontgen rays, which have been ver}^ generally used to illustrate the sites and the displacements of fractures, have been the subject of careful study. Each tracing represents the combined interpretation of the plate made by skilled observers who were in every instance familiar with the clinical aspects of the case. The writings of many who have contributed their experience to the literature of fractures have been consulted. Those to whom I feel indebted for suggestions are mentioned in the section on Bibliography. References to literature are not made in the text. I take this opportunity to extend my thanks to the members of the Surgical Staff of the Massachusetts General Hospital for their courtesy in permitting me to study cases of fracture of the lower extremity in the wards of the hospital, and to Professor Thomas Dwight for the use of valuable anatomical material. I also thank Dr. F. J. Cotton for an untiring interest in the pro- duction of most of the drawings, and in the search for fracture literature. The half-tones are made from photographs taken under the direct superintendence of the author. Due credit for illustrations not original is given next the legend. I wish to thank Mr. Walter Dodd for his courtesy and interest connected with the production of the Rontgen-ray plates, and Dr. H. P. Mosher for kind assistance. The chapter on the Rontgen ray is written by Dr. E. A. Codman. Charles T. Scudder 189 Beacon Street, Boston, Mass. April, igoo TABLE OF CONTENTS CHAPTER I ^''^^ Fractures op the Skull ^' Fractures of the Vault 24 Fractures of the Base 26 Treatment ^'^ Later Results of Fracture of the Skull 38 CHAPTER II Fractures of the Nasal Bones 44 The Nasal Septum 47 "treatment 49 Fractures of the Malar Bone 52 Treatment ^^ Fracture of the Superior Maxilla 56 Treatment 57 Fractures of the Inferior Maxilla 59 Treatment ^^ CHAPTER III Fractures of the Vertebr.^ 72 Treatment ^^ CHAPTER IV Fractures of the Ribs ^4 CHAPTER V Fractures of the Sternum 1^^ CHAPTER VI Fractures of the Pelvis ^^2 Treatment ^^5 Rupture of the Urethra ^0' Rupture of the Urinary Bladder 1^8 CHAPTER VII Fractures of the Clavicle ^ ^^ Treatment in Adults ^ ^^ Treatment in Children ^ ^ ' Operative Treatment -^20 i^ 14 TABLE OP CONTENTS CHAPTER VIII PAGE Fractures op the Scapula 12 1 Treatment 123 CHAPTER IX Fractures of the Humerus 125 Fractures of the Upper End of the Humerus 125 Diagnosis 129 Treatment 140 Fracture of the Upper End of the Humerus with a Dislocation of the Upper Fragment 145 Fractures of the Shaft of the Humerus 147 Fractures of the Shaft with Little Displacement 151 Fractures of the Shaft with Considerable Displacement 156 Fractures of the Shaft in the New-born 158 The Musculospiral Nerve in Fracture of the Humerus 159 Malignant Disease Associated with Fracture of Bone 162 Fractures of the Elbow 162 Diagnosis ■. 169 Treatment 181 CHAPTER X Fractures of the Bones op the Forearm 192 Fractures of Both Radius and Ulna 192 Treatment 201 Nonunion of Fractures 212 Fractures of the Olecranon 214 Treatment 217 Tetanus 223 Colles' Fracture 223 Diagnosis 23 1 Treatment 236 CHAPTER XI Fractures of the Carpus, Metacarpus, and Phalanges 246 Fractures of the Carpus 246 Fractures of the Metacarpus 249 Fractures of the Phalanges 257 Open Fractures of the Phalanges 259 CHAPTER XII Fractures of the Femur 260 Fracture of the Hip or Neck of the Femur 260 Treatment 269 Operative Treatment . 277 Fracture of the Neck of the Femur in Childhood 277 TABLE OF CONTENTS 15 l>AGli Fracture of the Sliajt oj the I'cmur 280 Treatment ^^^ Subtrochanteric Fracture of the Femur 299 Supracondyloid Fracture of the Femur 300 Ambulatory Treatment of Fracture of the Thigh 303 Fracture of the Thigh in Childhood 309 Separation of the Lower Epiphysis of the Femur 314 Treatment -^^^ Traumatic Gangrene ^- ' 321 Septicemia Malignant Edema ~^- ^ Fat Embolism ^ -CHAPTER XIII Fractures of the Patella 324 Treatment ^^^ Open Fracture of the Patella 338 Operation in Recent Closed Fractures of the Patella 342 CHAPTER XIV Fractures of the Leg ^■^" Treatment ^^^ Fractures with Little or No Displacement 357 Fractures with Considerable Immediate SweUing 3o9 Fractures Difficult to Hold Reduced. . , 37^0 Treatment of Open Fractures of the Leg 3/4 Thrombosis and Embolism 383 Pott's Fracture Treatment ^^^ Open Pott's Fracture -^"^^ CHAPTER XV Fr.\ctures of the Boxes of the Foot -^OO Fracture of the Astragalus ^^^ Open Fracture of the Astragalus and Os Calcis 404 Fracture of the Metatarsal Bones 405 Fracture of the Phalanges CHAPTER XVI Anatomical Facts Regarding the Epiphyses 407 CHAPTER XVII Gunshot Fractures of Bone 413 Treatment 1 6 TABLE OF CONTENTS CHAPTER XVIII PAGE The Rontgen Ray and Its Relation to Fractures 425 By E. a. Codman, M.D. CHAPTER XIX The Employment of Plaster-of-Paris ■ 441 CHAPTER XX The Ambulatory Treatment of Fractures 462 BIBEIOGRAPHY 471 INDEX 475 THE Treatment of Fractures CHAPTER I FRACTURES OF THE SKULL It is unwise to consider the treatment of fracture of the skull apart from a more or less systematic review of traumatic lesion of the brain. The skull is the brain's protection. In cases of fracture of the skull the injur\' to the brain is of paramount importance. The immediate damage to the brain may be caused by direct pressure of bony fragments, b}" pressure due to hemorrhage from torn vessels within the skull, by bruising of the brain itself, or by cere- bral edema. Great interest attaches to serious head-injuries, not only because the brain may be damaged, but more especially be- cause the lesions are often obscured by an intact scalp. A proper determination of the conditions existing after a given head- accident necessitates careful observation of symptoms, com- bined wdth good judgment in interpreting the signs present. Concussion and Contusion of the Brain. — A concussion and a contusion of the brain associated with minute bruising of brain- tissue wall exist after all serious injuries to the skull. The symptoms of concussion are varied according to the sever- ity of the injury. Following slight concussion, the individual is stunned by the accident ; there is simple vertigo, possibly mental confusion lasting but a short time. xVfter severe concussion there will follow a momentary loss of consciousness, or there may be unconsciousness of longer duration. Vomiting may occur. Head- 2 17 1 8 FRACTURES OF THE SKULL ache will probably be present. Following a still more severe con- cussion, the patient will be profoundl}' unconscious for a long period. The sphincters may be relaxed; hence involuntary micturition and defecation will occur when the bladder and rec- tum become overdistended. Retention of urine and feces is the sign immediately after the injury. Incontinence is the evidence of overdistention of the viscus in these cases. The pulse will become feeble and slow along with the general systemic depression. The pupils still react to light. The temperature will be subnormal. It is impossible clinically to distinguish between concussion and contusion of the brain. The pathological differences are more or less artificial. Laceration of the Brain. — If there is laceration of the brain, the symptoms of concussion will be present to a marked degree, and will be characterized by immediate, pronounced, and long- continued unconsciousness. After recovery from the initial shock of the accident fever will be present, which may rise to 103° or 104° F. Concu ssion alone is neve r as sociate d with feverishness. Early fever is a sign of laceration. Mental irritability and rest- lessness will mark returning consciousness. If the motor areas of the brain are involved, signs of irritation will appear — namely, muscular twitchings and spasms according to the motor centers imphcated. Compression of the Brain. — Slight hemorrhages do not cause symptoms of compression; neither do slight depressions of the cranial bones. Before symptoms of compression appear, the cranial contents must be impinged upon to a very considerable ex- tent. If the compression is sudden and limited, there is an irri- tation of the parts involved, which is manifested by restlessness and delirium and by twitching of certain groups of muscles; the pulse is hard and j iow; If the compression is gradual, whether it be localized or diffused, the brain accommodates itself for some time to the new conditions;, the appearance of the symptoms of local pressure is delayed, although they may be relatively sudden in their onset. Following the muscular spasms and twitchings due to the sudden onset of pressure there may appear symptoms of paresis and paralysis. Loss of power in the face or arm or leg indicates a lesion about the fissure of Rolando, upon the opposite EXTRADURAL HGMORRHAGK 19 side. Loss of power, for example, in the right arm and right leg indicates that the brain lesion is about the fissure of Rolando upon the left side of the brain. TMhrre h pre ss ure u pon the third nerve at the base of the skuJL_dilatatjon_of the pupil upon the side opposite to the pressure will be noticed. This pupil \viir not react to TTghY. As the pressure of the hemorrhage increases, the symptoms will again become more general; convulsive movements of the limbs and body appear, and the drowsiness or stupor increases to profound unconsciousness; the pulse becomes rapid and small; and the respiration frequent, Fig. I. — Fracture of skull with middle meningeal hemorrhage. Compression of brain by blood. Fig. 2.— Fracture of skull with de- pressed fragments. Compression of brain bv bone. shallow, and sighing, or it passes into stertor and Cheyne-Stokes' breathing as the condition becomes immediately grave; the tem- perature rises high. Focal symptoms may exist from pressure by bone or blood-clot, apart from loss of consciousness. Extradural Hemorrhage (see Figs, i, 2).— A most important symptom of intracranial hemorrhage is the inter\-al of conscious- ness that exists from the time of the injun,' to the onset of uncon- sciousness. This period of consciousness ma}' be preceded by the temporary- or prolonged unconsciousness of concussion. Uncon- sciousness in cases of intracranial hemorrhage is due to an increase 20 FRACTURES OF THE SKULL of the intracranial pressure caused b}' the presence of free blood. An interval of consciousness exists in these instances in from one- half to two-thirds of all cases. In the cases of hemorrhage which occur without an interval of consciousness (unconsciousness com- ing on immediately upon the receipt of the injury) it must be that the injury is so severe that the unconsciousness caused by the con- cussion and laceration of the brain is continuous with the uncon- sciousness from hemorrhage. The unconsciousness of concussion is continued over into the coma of compression. The duration of the interval of consciousness may vary within very wide limits; it may be a few moments, it may be three months. fiujituTe on larger scale; jilaek bristle in lumett. of artery- Fig. 3. — Frontal section of skull. Middle meningeal hemorrhage. The dura bulges inward toward skull cavity (diagram). Fig. 4. — A case of rupture of middle men- ingeal artery. Preparation of dura viewed from outer side (Warren Museum). The sources of intracranial hemorrhage, whether from the mid- dle meningeal artery (see Fig. 3) or its branches (see Fig. 4), from the middle cerebral arteries, from the veins of the pia mater, from the sinuses of the brain, or from lacerated brain-tissue, can not be easily differentiated short of operative procedure. There is one condition which is not to be overlooked in connection with the question of hemorrhage — namely, the period of semiconsciousness which sometimes follows concussion and laceration, and gives rise to the suspicion of some more serious gross lesion. To illustrate : A young girl received a severe blow upon the head. A true period SUBARACHNOID SEROUS EXUDATION 2 1 of unconsciousness followed. There were no external evidences of hemorrhage. Convulsive movements, deviation of the eyes, and disturbance of the pupils were absent. The breathing was regular and of normal character. Notwithstanding the absence of other untoward symptoms, complete consciousness did not return for a number of days or even of weeks. In such a case, after a number of days the question naturally presents itself, Have we not to do with a hemorrhage, and should not trephining be considered? The absence of all symptoms excepting the un- consciousness should lead to the suspicion that we have to do with a mental state rather than with a gross lesion. Hysteroid semi- consciousness (Walton)' supervening upon a blow is not to be Fig. 5. — Splintering of inner table; cross-sections; diagrammatic: a. Usual form ot punctate fracture ; d, shows that a linear fracture may be much more extensive internally than externally. mistaken for the deepening unconsciousness which indicates hemorrhage. Subarachnoid Serous Exudation (Cerebral Edema). — A severe blow upon the head, with or without fracture of the skull, may result in a local bruising and in congestion and swelling of the brain-tissue, with serous exudation into the subarachnoid space, either with or without edema of the brain-substance. If this accumulation of fluid occurs over the motor area, localized symptoms, as if of hemorrhage, may appear. The lesion is usually self-limited, the resulting paralysis disappearing in the cqurse^of a_ few days. The careful observation of the onset and sequence 1 of the signs of compression is of the very greatest importance, for it is by a proper interpretation of these localizing symptoms that \ the surgeon is led to operate, and then is enabled to remove the ' compressing blood-clot or the depressed fragment of bone. 1 Fig. 6. — Case of compound depressed fracture of the frontal bone. Note extent of depression. Recovery (Harrington). Fig. 7.— Normal skull. Note relations of facial bones in connection witii figs. 16 and 18. 22 THE FRACTURE OF THE SKULL 23 THE FRACTURE OF THE SKULL WIkiIkt ihv wouiul of lliL' bone is compound or simple, open or closed, is of comparatively little importance, because of the xerx general recognition and employment of aseptic and antisep- tic methods. A knowledge of the nature of the fracture will heli) Fig. 8. — Depressed fracture of fron- tal bone from front, showing depres- sion of fragments (Warren Museum, specimen 7951). Fig. 9. — Same as figure 8; inner surface from below; shows excess of bone-formation. Fig. 10. — Depressed fracture of right frontal bone : a, Point toward vertex ; b, anterior corner ; c, lower outer end (War- ren Museum, 4721). Fig. II. — Same from within ; letters as in figure 10. Fracture shows depression without much new bone-formation (War- ren Museum, 4721). in determining the injurs- to the brain. If there is a perforating fracture, or if the fragments are comminuted or depressed, then it is highly probable that a tremendous or sharply localized force has been exerted upon the bone, and that, in consequence, the injury to the underlying brain is serious. It is a generally ac- cepted fact that the skull may be simply contused and the great 24 IfRACTURES OF THE SKULL lateral sinus ruptured, with resulting fatal hemorrhage. It is likewise true that the bone may present but a fissure, but if that fissure crosses the middle meningeal artery, or any of its branches, they may be torn across, and the consequent hemorrhage and associated intracranial pressure will prove disastrous unless checked by surgical interference. On the other hand, the bone in the frontal region may be greatly damaged, literally crushed, and yet no grave symptoms arise (see Fig. 6). The extent of the bone-lesion is, however, of the greatest im- portance. Fractures of the Vault of the Skull (see Fig. 8). — Fractures of the vault of the skull without involvement of the base are much more unusual than is generally supposed. fwcKthirds of all fractures of the Fig. 12. — No fract- ure of skull. Hemato- maof scalp, the depress- ed center and firm edge of which often simulate fracture. vault are associated with fracture of the base of the skull (see Figs. 8, 9, 10, 11). Evi- dences of fracture of the vault are determined by sight and touch. A wound in the scalp may disclose the fractured bone. Whether this is a mere fissure or a single or a commin- uted fracture, whether depressed or not below the general surface of the normal skull, can be determined only by careful inspection. A fissure of the bone may be difficult of recogni- tion. It must be remembered in this connec- tion that blood can not be wiped from a fissure, whereas from the normal suture lines it can readily be wiped away. Blood may be seen escaping through a fissure. Torn periosteum must not be confused with a fissure of the bone. A hematoma of the scalp may suggest a depressed fracture of the skull (see Fig. 12). The center of the blood-tumor is soft; the edges are edematous and hard. If the finger be pressed firmly into the soft center, an intact skull generally will be felt. The uniform edge of a hematoma is unlike the irregular jagged edge of a fracture. It is sometimes impossible to distinguish between a hematoma and a fracture of the skull. The symptoms of general disturbance are of course more marked and prolonged FRACTURE OF THE BASE OF THE SKULL Crista sialli. 25 AntfHor fossa. Foramen rotundum Anterior branch niidiUc ^meningeal artery. Foramen ovale. Foramen spinosum. Petrous portion tem- poral bone. Lateral sinus Cribriform plate, foramina for olfactory nerves. Optic foramen. Middle fossa. Foramen lacerum medium. Depression for Gasserian ganglion. — Meatus auditorius internus. Foramen lacerum posterius. Foramen magnum. Posterior fossa . V\%. i^.— Base of skull, from inside and above. crack. Fig. 14. — Punctate fracture entering posterior fossa. From the punctate de- pression a line of fracture extends down- ward and backward (Warren Museum, specimen 965). Fig. 15.— Inner view of figure 14, showing comminution of inner table of skull. 2 6 FRACTURES OF THE SKULL in the case of a fracture of the skull than when only a hema- toma is present. Fracture of the Base of the Skull (see Figs. 13, 14, 15). — It is not uncommon to discover that what in the vault appears to be a simple fissure continues down to and involves the base of the skull. Fractures of the base of the skull are usually regarded, and rightly so, as more serious than fractures of the vault. A greater trauma being necessary to cause the fracture, the cerebral dis- turbance is more pronounced and vital parts are endangered. These fractures of the base often open into cavities which it is im- possible to keep surgically clean — namely, the cavities of the naso- pharynx and the ear. The danger of septic infection, therefore, in such fractures is very great. About eighty-five per cent, of basic fractures originate in the vault — i. e. , are caused by an ex- tension of a linear fracture of the vault to the base. A few basic fractures are due to forces acting from below and thus causing a , , „ penetration of the base of the Fig. 16. — Fracture of base of skull ; ^ impaction of nasal and part of ethmoid skull by Othcr boueS. The facial bones, which project into the interior of , i c i • j_ j.i the cranium. Male, aged twenty-eight; DOUeS may be forCcd Up mtO the diagnosis, fracture of nose. Died of men- anterior foSSa (sCC Fig. I 6). The ingitis (after Helferich). articular process of the inferior maxillary bone may be pushed up through the glenoid fossa of the temporal bone (see Fig. 17) into the middle fossa by a blow upon the chin, particularly if the jaw is relaxed. The vertebral column may be forced up into the posterior fossa through a fracture of the occiput. Symptoms of Fracture of the Base. — Hemorrhage may take place from the ear, from the nose, from the mouth or be noticed under the conjunctiva. Occasionally blood is seen in all four situations. Hemorrhage may occur beneath the pharyngeal mucous membrane. Escape of cerebrospinal fluid from the ear and nose may be noticed. Brain-tissue sometimes escapes from the skull and is seen lying in the external auditory meatus or near a wound which communicates with the fracture of the skull. Injuries may occur to the third, fifth, seventh and eighth nerves. SYMPTOMS OK I-RACTURE OF THE BASE 27 Associated with these local signs may be the general signs of concussion or laceration of the brain. Posterior nares. Glenoid fossa. External pterygoid plate. Fig. 17.— Showing thinness of the roof of the glenoid fossa, which is occasionally broken by the condylar process of the inferior maxilla when a blow is received on the jaw. Frontal sinus. Sphenoidal sinus. Cribriform plate. Fig. iS.— Median section. Anterior portion of skull, showing thinness of the ethmoid plate, which alone separates the cavities of nose and skull. If the orbital plate of the frontal bone is broken, blood Avill gravitate into the orbit ; ecchymosis of the lids and subconjunc- 2 8 FRACTURES OF THE SKULL tival hemorrhage will appear. There may be greater tension of the eyeball upon the affected side, detected by palpating the globe through the closed lid. vSubconjunctival hemorrhage may appear from a fracture of the malar or superior maxillary bones. If the cribriform plate of the ethmoid is fractured, hemorrhage from the nose will occur (see Fig. i8). Impairment of the sense of smell may exist if the olfactory nerves become involved in the fracture. Blood may trickle from a fracture of the base into the pharynx, be swallowed, and later vomited. Epistaxis, of course, may be due to a blow upon the face without fracture of the base. If inspection discloses a broken nose or ecchymosis of the face or Fig. 19. — Fracture of the base of the skull, involving the middle and posterior fossae on the left (Warren Museum, 5106). the skin of the forehead, it is very probable that the minor acci- dent has occurred. Most fractures of the base involve the middle fossa. If the petrous portion of the temporal bone is fractured, several im- portant signs appear (see Fig. 19). If the tympanum is torn, hemorrhage from the external auditory meatus is sure to follow. If this hemorrhage is continuous, it is significant; if it is trifling and temporary, it is probably unimportant and may be local. Cerebral tissue may escape from the nose, thus establishing the seat of the lesion. Cerebrospinal fluid may likewise escape from the ear. Cerebral tissue may also appear at the external auditory meatus. Any of these signs is conclusive evidence that the base of the skull is fractured and that there is a lesion of the brain. Lesions of the facial (seventh) and auditory (eighth) nerves lying SYMPTOMS OK KRACTURK OF THE BASE. 29 within the bones oecur. Lesions are hkewise reported of the fifth nerve, because of its lying upon the fractured petrous portion of the temporal bone. Subconjunctival hemorrhage may appear, owing to the blood working its way forward through the sphenoi- dal fissure and the optic foramen. A prima rv profuse watery discharge from the nose or the ear is probably cerebrospinal fluid. Fig. 20. — The three fossae of the base of the skull. A watery discharge appearing late after such an injury is likely to be serum from a blood-clot. The optic nerve may be involved in the injury with resulting blindness. If the posterior fossa (see Fig. 20) is involved in the fracture, there may be hemorrhage into the phars'nx. Ecchymosis under the pharyngeal mucous membrane may^ be present wdthout actual rupture of the mucous membrane. A fullness may be detected 30 FRACTURES OF THE SKULE by palpation in the posterior wall of the pharynx, if the hemor- rhage there is considerable. Ecchymosis just in front of the mas- toid process, or a hematoma and puffy swelling over the seat of the fracture, may determine its location. Unconsciousness Resulting from Other than Surgical Causes. — There are certain conditions associated with loss of con- sciousness and delirium which must be differentiated from trau- matic intracranial lesions. These conditions are (a) the coma from opium-poisoning ; (h) the unconsciousness in uremia ; (c) the loss of consciousness from apoplexy; (d) alcoholic coma; and (e) hemorrhagic internal pachymeningitis. Coma from Opium-poisoning : The patient can be aroused un- less the poisoning is extremely profound, and can be made to understand, and will even reply to an inquiry. The face at first is pale, later it is flushed and swollen. The skin is warm and moist. The respiration is slow. The temperature is subnormal. The pulse is slow and full. The pupils are strongly, immovably, and symmetrically contracted. The reflexes may be absent. The Unconsciousness in Uremia: The patient can not be aroused. The face is white, edematous, and puffy. The breath has a sweetish odor. The respiration is frequent and irregular. The temperature is normal. The pulse is rapid. The pupils are dilated and sluggish. The urine usually contains albumin. The Unconsciousness from Apoplexy : The patient can not be aroused. The respiration is slow, irregular, and stertorous. The temperature is subnormal at first ; if a fatal termination is proba- ble, the temperature is high. The pupils are dilated. Unilateral paralysis of the face and the extremities usually is present. The affected extremities are warmer than those of the other side. The limbs may be relaxed, but in watching the patient carefully evi- dences of hemiplegia will appear. The history of previous hemor- rhages may be discovered pointing to hemorrhagic internal pachymeningitis. Alcoholic Coma : The patient can be aroused bv pressure upon the supra-orbital nerves — sometimes, however, with great diffi- culty. The breath may be alcoholic. The face is flushed. The respiration is regular. The pulse is rapid. The temperature is normal or low. The pupils are normal. There is an absence of EXAMINATION OF THIC PATIENT 3 1 the positive signs of a cerebral lesion. The temperature in cere- bral laceration is elevated. Alcoholic delirium will present an elevated temperature, but along with the elevated temperature of a lacerated brain there will be symptoms characteristic of a damaged brain. Hemorrhagic Internal Pachymeningitis: The occurrence of apoplectic seizures during the course of this disease makes it im- portant that it be recognized in connection with the distinctly traumatic hemorrhages under consideration. The characteristic course shows an acute diffused affection of the brain, usually in an elderly man and with severe symptoms. An acute attack is followed by a fair recovery and by interA^als of comparative health. During these intervals of comparative health the patient has some headache, slight diminution of intelligence, impairment of memory, drowsiness, partial paralysis of the limbs (usually unilateral), disturbances of speech, and sudden mental excitement without cause mixed with symptoms of paralytic dementia. Evi- dences of a sudden and increasing compression are headache, drowsiness, loss of consciousness, some fever, a pulse of compres- sion, and sometimes initial symptoms of irritation. The diag- nosis is assisted by the etiology and history of the case. In mid- dle meningeal hemorrhage a blow is necessarv" to cause alarming symptoms, whereas in hemorrhagic pachymeningitis a vers^ trivial injurs' or none at all is common. The longer duration of the symptoms would help to decide against middle meningeal hemor- rhage. There is often a rigidity of the limbs in hemorrhagic pachy- meningitis which is absent in middle meningeal hemorrhage cases. When called upon to see a case of head-injury, it must be remembered that the lesion can not always be determined by the first observation of the patient. It is absolutely necessary that there be, upon the part of the physician, a clear understanding of the method of onset and the sequence of symptoms from the receipt of the injury. Isolated signs are of less importance than relative symptoms. Examination of the Patient. — The following comprehensive method of examining an individual who has received a severe injur}' to the head should be carefully followed, bearing in mind always the possible cranial and intracranial lesions, and remem- 32 FRACTURES OF THE SKULL bering that a fracture of the skull as such is of secondary impor- tance, that an injury to the intracranial vessels is serious, and that a lesion of the brain itself is most important. If with brain symptoms there is no visible injury to the skull, the head should be shaved to facilitate careful examination. Acute localized pain suggests the seat of fracture. When was the accident? How much time has elapsed between the accident and the first accurate observation? What was the accident ? Was it a fall or a blow ? What is the age of the patient? Are the arteries atheroma- tous, and therefore easily ruptured by trivial injury? Is it the skull of a child — which is softer and less brittle than that of an adult? What was the condition of health previous to the accident? Was it poor — suggestive of kidney-disease and uremia ? Was the man alcoholic, or is the present condition masked by alcohol taken subsequent to the accident? The General Condition of the Patient: If unconsciousness is present, was its onset immediate, or was there a lucid interval after the accident? Has the unconsciousness been continuous, and is it deepening or lessening ? What are the evidences of shock present? What is the condi- tion of the pulse, of the respiration, of the skin? What is the temperature taken in the rectum? Has vomiting occurred? Have there been involuntary dejections? Has there been invol- untary micturition? The Local Condition : The wound of the scalp or skull or brain maybe evident. If hemorrhage is present, what is its source? Is it from the nose, the mouth, the ear, or into the orbit ? When did the hemorrhage occur? What was its amount? Was it con- tinuous or not ? Palpation should be made of the skull, the neck, the face, the spine, the jaw, and the temporo-maxillary joint. Are any localizing signs present ? What is the condition of the pupils, and of the muscles of the face, the arms, and the legs? What is the condition of the reflexes and of the respiration ? Does hemiplegia, either partial or complete, exist ? Finally, the whole body should be examined systematically for any other injuries than those to the head and to the nervous GENERAL OBSERVATIONS 33 system. Associated injuries, if discovered, may assist in inter- preting the nature of the cerebral injury. A diagnosis nnist be based upon all available evidence. One will have to consider concussion and laceration of the brain and pressure upon the brain by serum, blood, and bone. The im- portant signs to be studied in diagnosis are the different aspects of unconsciousness; the relative and actual conditions of the respiration, pulse, and temperature ; the occurrence of hemor- rhage; restlessness and muscular twitching; localizing signs of pressure. If the symptoms are not positive, if there is no history of trauma, if the histor\- of a lucid interval preceding uncon- sciousness is doubtful, or if there is no histor\- at all, then the diagnosis will be most difficult. It is when positive symptoms are absent that one must particularly consider those conditions already mentioned in which coma is a prominent sign — namelv, opium-poisoning, uremia, apoplexy, alcoholism. General Observations. — An unconscious man having a scalp wound and a breath smelling of liquor is not, necessarilv, drunk. He may have an intracranial lesion. ^lultiple lesions may be present in any case. A diffuse lesion may obscure a localized lesion. Xot only must the location of a lesion be determined, but also its character, if possible. The symptoms must be recorded in the order of their appearance. The manner in which various symptoms develop should be noted. The danger to the brain is greatest in perforating and sharply depressed fractures. Slight fissures may be associated with extensive hemorrhages. Great comminution of bone may be devoid of much danger. In cases of compound fracture fissures apparently closed afford the possi- bility of cerebral and meningeal infection through dirt having entered when the fissure was open. Unconsciousness and a superficial head-lesion, with or without fracture of the skull, must make one suspicious of an intracranial lesion. An immediate loss of consciousness indicates a diffused contusion or concussion of the brain. If the primary uncon- sciousness is prolonged, probably hemorrhage has occurred, or possibly a serous exudation with its resulting pressure upon the brain. If there is a conscious inter^-al preceding the unconscious- ness, a hemorrhage is probable. Momentar\- unconsciousness 34 FRACTURES OF THE SKULL means concussion. Recurring unconscious periods indicate hem- orrhage. Deepening unconsciousness indicates increasing intra- cranial pressure — probably hemorrhage. Immediate profound unconsciousness suggests hemorrhage from the rupture of an in- tracranial sinus. The temperature in all intracranial lesions is usually slightly above normal. Intoxication and shock depress the temperature. In a small intracranial hemorrhage there will be a slight rise of temperature, perhaps to 99° F., following the initial drop a few hours after the injury. In cerebral laceration one finds a higher initial temperature than in hemorrhage, and in fatal cases the temperature remains elevated. If the temperature rises quickly and early, a considerable laceration is present; if after several hours of unconsciousness the temperature remains about 99° or 99.5° F., there is probably a hemorrhage rather than a severe direct lesion; if, on the other hand, the temperature rises higher, there is a cerebral lesion, alone or associated with a hemorrhage. If the temperature does not rise very high and advances rather slowly, there is a contusion or a concussion with slight laceration or a slight hemorrhage. A slow, full pulse with stertorous respira- tion suggests pressure; it may be from extradural hemorrhage. Barly and very slow respiration is associated with pressure upon the medulla. Paralysis of the limbs and the face is characteristic of serous exudation, hemorrhage, or bony pressure. Irregular muscular contractions suggest laceration of motor areas. Mental disturb- ance may be due to cerebral lesions. That brain-tissue escapes from the ear does not necessarily signify that the patient will not recover. Fractures of the base of the skull occur without marked symptoms and recover without the necessity of operation. Treatment. — There are cases of injury to the skull so serious that it is evident that operation will be of no avail. There are cases of simple concussion in which only careful nursing is de- manded. There is a large and increasing number of serious head- accidents in which operative interference will prove of great value. The collapse from shock may be well-nigh complete, but restora- tive measures are not to be neglected upon this account. If hemorrhage is suspected, stimulation of the circulation must be TREATMEXT 01* FRACTURES OF THFC SKULL 35 ven' guarded. The patient should be placed horizontally, with the head slightly raised, and kept quiet. The whole body should be wrapped in warm blankets. Warm water-bottles should be put on the outside of the bed about the patient not next the skin, one at each foot, three along each side of the body. The water in these bottles should be comfortably warmed — 110° F. Hot water is never to be used. Patients under these circumstances are insensible to heat, and severe burning of the skin may occur if ver\' hot water is used in the bottles. If there are no indications for immediate operation, and local- izing symptoms are absent, the patient is to be treated sympto- matically. The pulse is to be carefully watched to detect varia- tions in strength, rate, and rhythm. The character and frequency of the breathing are to be likewise noted. Gentle stimulation sub- cutaneously by sulphate of strychnin (^^ of a grain), administered as needed, will often steady a pulse remarkably. A special nurse or an intelligent watcher should be with the patient constantly, to note any localizing signs of pressure, such as twitching of the muscles of the face or limbs and variations in the pupil, to record movements of the limbs, and to make hourly obserA'ations of the pulse, temperature, and respiration, and any variation in con- sciousness. These observations will be of inestimable value in determining diagnosis, prognosis, and treatment. The various cavities exposing the brain to infection should be cleansed. The Xose. — The nose should be douched with boric acid solu- tion (i : 30), and plugs of sterilized absorbent cotton should be placed in each nostril. The Ear. — The ear should be douched with boric acid solution (i : 30 j, and dried carefully with small wisps of cotton. Boric acid powder should then be blown gently into the external audi- tory- meatus. A bit of sterilized gauze or absorbent cotton may be left in the meatus. The Scalp. — The directions for cleansing the scalp pertain to cases with or without scalp w'ounds associated with important cerebral symptoms. The whole scalp should be shaved, scrubbed with hot water and soap, with chlorinated soda solution (i : 20), with boiled water, and then with corrosive sublimate solution FRACTURES OF THE SKULL (i : looo), and covered with a dressing of sterilized gauze that has been moistened in a solution of corrosive sublimate (i : 5000). The wound of the soft parts should be carefullv irrigated with sterilized salt solution, and sponged and swabbed with great care with corrosive sublimate solution (i : 5000). The swabs used should be tiny ones, so as to reach to the smallest recesses of the wound. Corrosive sublimate solution should not be allowed to touch the brain-tissue. The Mouth. — Thorough cleansing, with corrosive sublimate solution (i : 3000), of the teeth and tongue and all the folds of the mucous membrane about the lower and upper jaws is important. The swabbing of the tonsils and the posterior pharyngeal wall, the care of the nose and the ear, — these pro- cedures will reduce to a minimum the chances of infection. The nose and mouth will require constant at- tention. The ear will require at least daily cleansing. The fre- quency of the cleansing required will depend A^ery largely upon the amount of moisture and discharge from the part involved. If the packing of cotton soon becomes moistened, the douching should be repeated, and fresh, dry pack- ing should replace the old. If there is great restlessness, it may be necessary to restrain the patient, that he may not harm himself. This is done by means of a sheet folded and passed about the bed and body of the patient. Operative interference is demanded in penetrating or sharply depressed fractures, in all compound fractures, and in all simple fractures with symptoms of intracranial hemorrhage increasing in severity or distinctty localized (see Figs. 21, 22, 23). Opera- tion should be undertaken in these cases for three distinct rea- sons: to insure cleanliness, to elevate and, if necessary, remove bony fragments, and to check hemorrhage. The details of opera- tive treatment must necessarilv be omitted. Fig. 21. — Sites where extradural hemor- rhage is usually found. TREATMENT OF FRACTURES OF THE SKULL 37 All cases of injury to the head, even cases of simple nondepressed fracture of the skull \vithout symptoms, are to be watched with great care by trained observers for at least one month following b Fig. 22. — Location of anterior branch of middle meningeal artery. Draw a line from the glabella backward {a d), parallel to the line 6 c, from the lower edge of the orbit through the external meatus. Line from glabella to mastoid, a e. From the middle of this last line, a line drawn perpendicular to it will intersect the line a rf at about the site of the arten.'. A line running from the front of the mastoid perpendicular to the line b c intersects a dzX. about the site of the posterior branch. Fig. 23. — Perpendicular lines from the mastoid and from just in front of the ear include tlie motor area of the central convolutions. The fissure of Rolando is shown. the accident, and then are to be seen at inter\-als for many months afterward. The reason for this prolonged obserA'ation is that meningeal hemorrhage may develop in the immediate future, and 38 . FRACTURES OF THE SKULL that after an interval of months a brain-abscess may manifest its presence. In fracture of the base with pronounced symptoms, drainage of the fossa involved, whether anterior, middle, or posterior, should be considered. It has occasionally been of service. Prognosis. — The prognosis of head-injuries is the prognosis of their complications and sequela?. Prolonged unconsciousness is not usually dangerous in itself. Late unconsciousness is dan- gerous. The severity rather than the form of the lesion is to be made the basis of prognosis. The temperature is of great value in prognosis. By its persistent depression the danger from pri- mary shock is gauged ; a little later in the course of the case the amount of hemorrhage is judged by it ; later still, its rapid and pro- gressive rise will denote the magnitude or severity of a meningeal or cerebral lesion. A temperature as high as 105° F. is of grave prognosis. A sudden rise of temperature late in the progress of a case, probably due to a meningitis, or a continued subnormal temperature at any time after the reaction from the primary shock, is always an unfavorable sign. Symptoms often change suddenly in cases apparently doing well. One's prognosis must, therefore, always be guarded. LATER RESULTS OF FRACTURE OF THE SKULL Very little is known of these cases in this country. Dr. Bul- lard, of the Boston City Hospital, has contributed so valuable a paper upon this subject that the results are here stated : Seventy patients were examined after having had fracture of the skull : 37 presented no symptoms when examined some time later. The most frequent consequences were headache, deafness, dizziness, and inability to resist the action of alcohol on the brain. Out of 1 5 cases in which operation (trephining) was performed, 1 2 had no resulting symptoms; in one case it was doubtful whether the symptoms present were due to injury ; in one case the symptoms were slight (headache rare, tension over the wound while lying in bed). The other case was deaf, but had no other trouble. Dr. Bullard concludes, so far as these statistics lead, that those cases in which trephining was performed have shown much better ILLUSTRATIVE CASES 39 results, so far as the symptoms previously meutioned are con- cerned, than those in which no operation was performed. CASES OF HEAD INJURY The following cases, related in some detail, illustrate a few of the varieties of injuries to the head from a clinical standpoint : Case I.— A fall upon the head.— No visible evidences of injury.— An inte?-val of consciousness followed by unco?isciousness.— Localizing signs of pressure.— Diagnosis, middle meningeal hemorrhage with fracture of ,knii ^Operation.— Fracture and hemorrhage fo2ind.— Recovery. M A. B , sixty-nine years old, a spinster, fell, upon being struck by a coasting-sled, one and one-half hours previous to the exam- ination. , _ 1 • 1 u u Examination.— She does not know of the accident which has be- fallen her. She talks coherendy. She recognizes her sister. There is slight shock. The pulse is 64 and of fair strength ; the respira- tion is 16 ; the temperature is 97.5° F- There is bleeding from the right ear There is some dry blood about the nostrils. Ihere is no visible external injury. There is no paralysis. All the superficial reflexes are present. The pupils are contracted equally and react to light. The patient is not very restless, although she talks consider- ably and affirms again and again that she is not hurt. The ears were washed out carefully and treated antiseptically. _ She vomited two or three times during the night. She was quite restless, moving and turning in bed. She slept two or three hours altogether. There were no evidences of intracranial pressure m the morning. At about noon of the second day she talked a little inco- herently. She did not answer questions as readily as m the morning. At X o'clock in the afternoon of the second day examination finds the pupils equal and reacting to light. She understands what is said to her, but does not talk coherently or distinctly. There is almost complete paralysis of the right arm. There is paresis of the right leg The face is not paralyzed. The pulse has increased in rate to 85 and is particularly full and bounding. The knee-jerk is much less active upon the right than upon the left side. At 4.30 P.M., one and one-half hours after the previous observa- tion, all the symptoms were considerably intensified. The face was uneven, the wrinkles being most marked on the left. The breathing was becoming labored and almost stertorous. It was hard to arouse the woman. She moved the left arm freely. The right arm she moved slightly or not at all. There were no abdominal reflexes active. -Bleed- ina from the right ear continued to a slight extent all day. A diagnosis of middle meningeal hemorrhage on the left side was made. Immediate operation was decided upon. , 1 r^ Under ether anesthesia an elliptic incision was made upon the lett side of the head, beginning just in front of the ear, and was carried 40 INJURIES TO THE HEAD up across the temporal muscle and down to the zygoma of the same side. A quarter-inch trephine was used. The hemorrhage was found to be from a branch of the middle meningeal artery, and from within the dura, which was lacerated. A large clot and much fresh blood were lying over the temporal and parietal regions. This blood was carefully sponged away. The middle meningeal branch was tied with a silk ligature. Gauze wicks were placed well down deep toward the base of the skull. The dura was not sutured. The bleed- ing vessels of the diploe were stopped with wax. The skin flap was replaced and sutured, leaving a small gauze drain down to the dura. The pulse was poor, and there was evidence of considerable shock at the conclusion of the operation. Proper stimulation with strych- nin and enemata of salt solution and brandy had a good effect. The temperature rose to i io° F. during the night, but dropped immediately and gradually came to normal. The following day uncon- sciousness was present, the par- alysis was unrelieved, the breathing was stertorous and puffing. The second day after the op- eration the gauze drain was re- moved and two smaller gauze drains were inserted. Some signs of consciousness appear. She takes notice of people com- ing into the room. The fifth day following the operation she notices friends. The paralysis is still present. The sixth day after the op- Fig. 24.— Case i. Line of incision shown. eration she moves the right leg a little. No articulate speech is present. Understands questions and grunts in answer to all ques- tions. She can express no idea in words. The tenth day after the operation she moves the right arm. The mental condition is clearer. On the eighteenth day she moves the right leg, and the arm has more power. The thirtieth day was an important one for the patient. She walked alone for the first time since the accident. One year after the accident the patient is found to be having occa- sional attacks of dizziness, accompanied by " falling- fits." She is perfectly sane, and talks, often very well ; then there come times of difficulty in talking, when she can not find the right word to express herself. Just after one of these attacks of fainting, etc., talking is less easy. ILLUSTRATIVE CASES 41 Three years after the operation the foUowiiiL,^ examination was made: The speech is thick, slow, and with effort. The facial muscles of the left side are stiff and slightly drawn ; they do not move so well as on the right side. The left nasolabial fold is more accentuated than the right. The left eyebrow is lower than the right. The patient thinks that she can hear better with the right ear than with the left. The right hand gets cold "and does not look natural." The right fore- finger is often whiter than the other fingers of the right hand. It is difficult to pick up needles or pins with the fingers of the right hand. There is no increase in the Avrist-jerks. The knee-jerk is slightly greater on the right side than on the left. The patient says she is enjoying excellent health, eats and sleeps well, and is out of doors much of the time. She is taking bromid of potassium regularly once a day in small doses. About once a month she has a fainting or ' ' weak spell. ' ' These attacks are growing less pro- nounced and less frequent. This case illustrates the important fact that after a severe head injury with almost no external visible sign, the patient should be kept under very careful observation through the hours immediately succeeding the accident. Relative symptoms are of far greater importance in head injuries than isolated observations. Bleeding from the ear as a symptom in head injuries does not necessarily imply fracture of the petrous portion of the temporal bone. Rupture of the tympanum may cause bleeding from the ear. There was no frac- ture of the skull detected after care- ful examination in this case. The interval of consciousness in this case was a somewhat short and hazy one. Immediately after the accident the woman was dazed, and at no time w^as she herself mentally. It is to be remembered in this connection that the interval of clear consciousness may be so masked by the symptoms of concussion as to be completely overlooked. Case II. — An open depressed fracture of the skull. — Absence of unconsciousness. — Paralysis of one-half of the body. — Operation. — Recovery. This case illustrates that consciousness may be unimpaired following an injury to the head severe enough to cause paralysis. A boy, nine years old, was struck on the head by a brick falling from a height. He was seen immediately after the injury and found to be conscious. He answered questions naturally. There was a large Fig. 25.— Case 1 1 . Open depressed frac- ture of the skull : X^ the mid-point be- tween glabella and inion ; A, middle of depressed bone. 42 INJURIES TO THE HEAD scalp-wound over the parietal bone and a little anterior to the parietal eminence to the right of the median line. The bone beneath the scalp-wound was fractured and depressed into the brain -substance. The left arm and the left leg were completely paralyzed to motion. The right pupil was dilated ; sensation was present. The right upper eyelid drooped. There was a scar in the right cornea. Immediately after the injury the temperature was 96° F., the pulse was 74, the respiration was 26. When examined one hour after the accident the pulse had fallen to 68, he had vomited once, and had been somewhat nauseated. The operation of elevation of the depressed fragments of bone was done under ether. The fragments of bone removed were about the size of a silver half-dollar. There was no fissure in the skull. The Fig. 26. — Case III. dura mater was torn and the brain slightly lacerated. Upon elevating and removing the depressed bone hemorrhage occurred from the ves- sels of the dura mater. The depressed bone was not replaced. The dura was left open and the cavity was drained by a wick of gauze, which was removed upon the third day. A few hours after the operation the boy was perfectly conscious as before the etherization, the pupils were normal, and motion had returned in the paralyzed limbs. Three weeks after the operation a small, granulating wound remained and there was a slight tendency to hernia cerebri. Four months following the accident the boy's condition is as fol- lows : The wound is nearly healed and continues to discharge at times. He walks naturally. There is no paralysis of arm or leg. No mental symptom is present. ILLUSTRATIVE CASES 43 The interesting and unusual fact in this case is that after a blow sufficiently severe to cause a depressed fracture of the skull and paralysis of one-half of the body the patient remained conscious. The exact location of the injury to the head and brain is shown in figure 25. ■ J- Case' III. -/ /'Aw upon the head. — Unconseiousness wimediate. — Slight bulging of right eye.— Middle meningeal hemorrhage.— Frac- ture of skull. — Operation. — Recovery. Examination found edema of the right temporal region. Uncon- sciousness present. An interval of consciousness was absent. Slight bulging of the right eye. Operation in the right temporal region. A skin-flap was made over the fracture and edematous area. A fracture was detected running from about the middle of the temporal ridge an inch back of the coronal suture outward and forward across the squamous part of the temporal bone to a half-inch behind the pterion. The bone anteriorly to the fracture was depressed. The trephine was applied over the depressed portion behind the coronal suture. Upon exposing the dura no pulsation was seen. The dura was dark in color. A slight amount of extradural blood escaped. On follow- ing the fracture down to the base of the skull the dura was found lacerated, the anterior branch of the middle meningeal artery was torn, and blood-clot and lacerated brain-tissue were present. The anterior branch of the middle meningeal artery was tied and the hemorrhage ceased. The blood-clots were removed, the exposed area was cleansed with boiled water, and gauze drainage introduced. All the gauze was removed in four days. No unusual symptoms attended convalescence. Recovery was complete in three months (see Fig. 26). This case is of interest because no fracture was detected before the operation, and it was supposed that the bulging of the eye indicated an increase of intracranial pressure, which proved to be true. The method of operating was comparatively simple, in that the fracture was followed down until the bleeding vessel was found. This necessitated the free removal of bone below the trephine opening. There was no interval of consciousness in this case, and the condi- tions found easily explained its absence. The man was suffering from concussion and laceration of the brain as well as from intracranial pressure, and the interval of consciousness was obscured by the presence of the concussion. The recognition of an interval of con- sciousness is of very great importance. If, however, the interval of consciousness is not present, as in the case reported, intracranial pres- sure from hemorrhage can not be said to be absent, for concussion attendant upon the injury may mask the interval of consciousness which might have been present had the injury been less severe. CHAPTER II FRACTURES OF THE BONES OF THE FACE FRACTURES OF THE NASAL BONES Anatomy. — The anatomical relations of the nasal bones (to the perpendicular plate of the ethmoid, the vomer, the cartil- aginous septum, the superior maxillary bone, and the frontal bone) make their fracture of far greater importance than a mere super- ficial disfigurement of the face would indicate (see Fig. 27). The Vertical ethmoid plate. Frontal sinus. Nasal bone. Quadrilateral cartilage. Lower lateral cartilage. , Sphenoidal sinus. Vomer. Fig. 27. — Median section of nose. site of the fracture is usually near the lower edge of the bone. Most fractures of the nasal bone are open through either the skin or the mucous membrane. In nearly all nasal fractures the carti- lage of the septum is more or less injured. The upper lateral car- tilages may be torn from their attachments to the nasal bones, simulating fracture of these bones. The resulting deformity of this accident is well illustrated in figure 28. A high fracture of the nasal bones with lateral deformity is shown in figure 30 : the nasal bone of one side has been impacted with the frontal bone, 44 FRACTURES OF THE NASAL BONES 45 Fig. 28. — Separation of cartilage from nasal bones (Harrington). Fig. 29. — Fracture and lateral displace- ment of each nasal bone. Fig. 30.— Case of fracture of nasal bones. Lateral displacement (Harrington). Fig. 31.— Fracture and lateral displace- ment of each nasal bone. Side view of figure 29. 46 FRACTURES OF THE BONES OF THE FACE and the nasofrontal articulation upon the opposite side has been separated. Figures 29 and 31 show a case in which, bv a direct blow squarely upon the nasal bones, the bones were separated and one was laid on one nasal process of the superior maxillary bone and the other was laid upon the corresponding bone. The septum was intact, as is shown by the persistence of the natural position of the tip of the nose. Figures 32 and 33 show a syphilitic nose, the septum gone, and the nose fallen in. The contrast in these two cases is instructive. Fig. 32.— Syphilitic deformity (Harrington). Fig. 33.— Syphilitic deformity (same case as Fig. 32). Symptoms. — Pain, swelling, crepitus, and deformity are usu- ally present. The subcutaneous swelling is often so considerable as to obscure deformity. Gentle pressure is often sufficient to detect crepitus in this fracture, when a firm grasp determines little or nothing. Complications. — Through infection of the internal or the ex- ternal wounds suppuration begins, abscesses form, and necrosis of bone and liquefaction of cartilage may occur. Emphysema may be noticed if the fracture is open into the nasal cavity (see THE NASAL SEPTUM IN FRACTURE OF THE NOSE 47 Fig. 34). It will disappear after a few days untreated. The lachrymal duct may be obstructed if the nasal process of the superior maxillary bone is involved. The nasal bone may be forced up into the floor of the anterior fossa of the skull, and cere- bral complications arise (see Fig. 16). If the deformity following fracture of the nasal bones is not corrected, there is great likeli- Fig. 34. — Case of open fracture of the nasal bones. Emphysema over the forehead and the upper part of the face. hood of trouble, either immediately or in after years, because of damage to the nasal septum. The Nasal Septum in Fracture of the N'ose (see Figs. 35, 36, 37, 38, 39). — The starting of the quadrilateral cartilage of the septum at some of its bony attachments may be evident at once after the fracture of the nose as a marked dislocation, or no change may be seen until long afterward, when a ridge due to inflammatory thickening is found along the previously loosened border. The 48 FRACTURES OF THE BONES OF THE FACE septum may be dislocated from its attachment to the superior maxilla, and deviate into one nostril or the other like a curtain. The commonest dislocation occurs at the junction of the cartilage of the septum with the vomer and the ethmoid. Lesions of the septum due to fracture occur usually in the pos- terior two -thirds of the cartilaginous and in the anterior half of the bony septum. Fractures rarely extend through the septum to the posterior nares. In fractures of the nasal bones with little displacement the septum may show no changes. Even with considerable depression and comminution of the nasal bones, the septum as a whole may appear unchanged, the lesions of the sep- tum being confined to bowing or tearing at the seat of fracture. When the nasal bones are much deviated, the free edge of the septum deviates with them. Fractures of the nasal bones may Fig- 35- Fig- 36- Fig. 37. Fig. 38. Figs. 35-39. — The septum in fractures of the nose (Mosher). occur alone or in combination with fractures of the septum. Severe cases of broken nose usually combine the two conditions. Fractures of the septum which admit of classification follow one of two types — horizontal fractures or vertical fractures. The verti- cal fracture is much the rarer. It may occur anywhere in the course of the cartilaginous septum, but when situated well back, is to be distinguished from dislocation of the cartilage. The hori- zontal fracture produces a gutter-like deformity roughly parallel with the floor of the nose. The convexity appears in one naris, the concavity in the other. Closely allied to these last two frac- tures are the sigmoid deviations, in which the relation to fracture is unsettled. They are so common that they are mentioned for the sake of completeness. The name describes them. They occur in the same two types as the Angular variety. THE NASAL SEPTUM IN FRACTURE OP THE NOSE 49 Treatment.— The nasal cavity should be inspected bv mirror and light to determine any lesion of the septum. Cocain anes- thesia is necessary for this examination. If a deviation is found, it should be corrected along with the correction of the external nasal deformity. For this, primary' anesthesia will be needed, as the manipulation is extremely painful. By external manipulation combined with elevation of the fragments and internal pressure with Roe's elevator (see Fig. 40) the deformity usually can be over- come. Any strong, narrow, and thin instrument will be of service as an elevator. For fractures high up with displacement, gauze Fig. 40. — Fracture of nasal bones. Elevation of depressed bone by instrument introduced into the nostril. packing carried w'ell up will be required to retain the elevated bones. For lower deviations the Asch tube will be needed. If the nose is crushed, it will be necessar\^ to model the nose over the Asch tube, one being placed in each nostril to preserve the con- tour and lumen of the nose. If there is no tendency for the de- formity to recur, the use of splints is not indicated. Care must be exercised to avoid sudden pressure on the nose from the rough use of the pocket handkerchief. In the treatment of these cases special cleanliness, perfect drainage, and frequent dressings are important. If there is a recurrence of the external deformity, 4 50 FRACTURES OF THE BONES OF THE FACE localized pressure may be exerted in various wavs, all of which are more or less unsatisfactorv. The tin splint fixed to the forehead by a circular plaster band is of service. This tin splint (see Fig. 41), made from ordinary sheet tin, consists of a forehead and a nasal portion. The nasal portion may be twisted or bent laterally to secure the desired pressure upon the nose, the counterpressure being obtained through the fixation secured by the adhesive plaster band. Re- peated adjustments of this splint are needed to make the splint of continued efliciencv ; with all care, however, the tin splint is not generally eft'ective. The use of adhesive plaster strips (after Davis) from cheek or malar bone to nose with small compresses is of limited value. Cobb's nasal splint, shown in figure 42, is expensive, but is very satisfactory for mak- ing direct pressure upon the nasal bones. The splint is made of a band of steel, fitted to the head like the hat-band of a hat. To this band are attached an arm and a pad with screw adjustment. A strap OA'er the head and one beneath the chin prevent downward and upward displacement. Coolidge's Splint (see Fig. 43). — This consists of a tin pad for the forehead with strap encircling the forehead for the reten- tion of the pad in position. To the lower border of the pad are soldered two wire arms upon which slide two small felt pads. The arms can be bent so that counterpressure may be obtained upon the firm parts of the face, while direct pressure with the other pad is brought to bear upon the nose. This splint is inexpensi^-e and is efficient. The nasal cavity should be cleansed at least twice daily with antiseptic douches. Seiler's tablets, one tablet dissolved in a quarter of a tumbler of warm water, used with the Birmingham glass douche, make a satisfactory wash. The external wounds should be dressed according to general surgical principles. It is well to remember in this connection that suppurating wounds do Fig. 41. — Fracture of nasal bones. Tin nose- splint applied. THE NASAL SEPTUM IN FRACTURE OK THE NOSE 5 1 far better if dressed frequently than if left to accumulate purulent discharges. After a l)l()\v upon the nose, even if there is no immediate de- formity, the nose should be examined to determine the presence of swelling upon the cartilaginous septum. Even a slight blow upon the nose may cause a hematoma of the cartilaginous septum (see Fig. 44). This hematoma is liable to become infected and to suppurate. Considerable destruction of cartilage may follow, resulting: in marked disfigurement of the nose. Fig. 42.— Cobb's splint applied to a case of fracture of the nose. The head-band is so adapted to the shape of the head that it remains fixed and offers a point of counterpressure. The involvement of the base of the skull adds a serious element to an ordinary simple accident (see Figs. 16, 18). The prognosis as regards the resulting deformity must always be guarded. Union usually takes place within two weeks of the accident and is firm in one month. In treating fracture of the nose it is important to be ever mindful of hematoma of the septum, and of abscess of the septum resulting from the hematoma. The external deformity that follows fracture does not tend to increase, but the internal deformity does. It is, therefore, of even more importance to correct the internal deformity than the external. Unless both are corrected, the nose mav be straight but obstructed. 52 FRACTURES OF THE BONES OF THE FACE FRACTURES OF THE MALAR BONE Examination, — Palpation of the malar bone is somewhat difHcult. The best method of doing it is to stand behind the sitting patient (see Fig. 45), and to feel both malar bones at the Fig. 43. — Coolidge's nasal splint: a, Forehead plate; b, pad; c, screw controlling position of pad ; li, head-strap. 7* Fig. 44. — Hematoma of the nasal septum (after Roe). same time — the left one with the left hand, the right one with the right hand. The malar process of the superior maxilla is felt inferiorly by pushing the skin of the cheek upward. The orbital part of this process is felt superiorly at the middle of the inferior border of the orbit. Following the orbital margin out- FRACTURES OF THE MALAR BONE 53 ward and upward, the orbital border is palpated up to the frontal process. Following the malar process of the superior maxilla backward, the free inferior border of the malar is felt continuous backward with the zygomatic process. vStarting on the frontal process, the posterior border of the malar may be palpated down- ward and backward to the upper border of the zygomatic process of the temporal bone. The inferior surface of the malar may be felt by placing the fingers, palm upward, in the superior sulcus of the cheek and following backward until the coronoid process of the lower jaw is felt. In the case of a fracture that is as often Fig. 45. — Proper position from which to palpate the malar bones. The fingers touch the inferior borders, the thumbs the posterior borders, of the malar bones. unrecognized as is this one it is important to be ven.' familiar with the details of the outline of the bone. Symptoms. — Fracture of the malar bone is caused by a severe blow upon the cheek. It is rather unusual to find a fracture of the body of the bone. More often there is a fracture of one of its processes, the line of fracture being continuous with a fracture of some adjoining bone. The malar is depressed as a whole, or tilted inward toward the zygomatic fossa because of a loosening of one or more of its articulations or because of a fracture or crushing of the superior maxilla. The deformity consists of a depression to the outer side of and below the eye. The line of fracture or separation can sometimes be palpated. ^Mobility and crepitus are rarely obtained. If the depression of the malar or of an asso- Fig. 46. — Depressed fracture of the left malar bone. Note swelling of the left cheek and slight hollow outside left orbit (Warren). Fig. 47. — Depressed left malar bone. Same case as figure 46. Note depression behind and below left orbit (Warren). 54 FRACTURES OF THE MALAR BONE 55 ciatcd fracture of the zygomatic arch impinges upon the space in whicli the coronoid process nio\-es in the opening of the mouth, the motions of the lower jaw will be restricted (see Fig. 48). The limitation of motion of the lower jaw may be temporary or per- manent, depending upon whether it is due to hemorrhage and swelling or bony pressure. The coronoid process of the lower jaw may be fractured by the same force which fractured the zygoma or malar. Localized subconjunctival hemorrhage may appear if the orbit is involved. If the floor of the orbit is frac- Articular pro- cess of infer- ior maxilla. Coronoid pro- cess of infer- ior maxilla. Fig. 48. — Note relations of coronoid of inferior maxilla to zygomatic process and malar bones ; the space on either side of the coronoid process is filled by muscle. tured so that the infra-orbital nerv^e is implicated, there will ap- pear prickling sensations throughout the area of distribution of that nerve — namely, along the upper gum, the skin of the cheek, of the nose and of the upper lip. Treatment. — It is oftentimes impossible completely to correct the deformity except by operative means. If any interference with the movements of the lower jaw persists after the acute swell- ing disappears, — that is, after two weeks, — or if it is very evident at the outset that the limitation of motion is due to the depression of bone, then operative interference is demanded. Before a cut- 56 FRACTURES OF THE BONES OF THE FACE ting Operation is resorted to an anesthetic should be administered and an attempt made by pressure with a blunt instrument under the malar from inside the cheek to raise the depressed fragment. If this can not be effected, a small incision should be made at the most advantageous point, avoiding making the fracture an open one. Through this incision access is gained directly to the bone. By means of a narrow periosteum elevator, retractor, hook, or a screw elevator, the fragment can be raised into its nor- mal position. Union occurs in two weeks. There is no tendency to a recur- rence of deformity, therefore no retentive apparatus is necessary. The surgeon is not uncommonly asked to remove the slight depression attending a healed fracture of the malar bone. This may be most difficult. It should be attempted, however, as in fresh injuries, without a cutting operation, or by an incision within the mouth through the mucous membrane, or, if necessary, by an external incision. FRACTURE OF THE SUPERIOR MAXILLA Fracture of the superior maxilla occurs so frequently from a bicycle injury that it may properly be called the bicycle accident. The blow causing this fracture is usually not in the direction to damage the base of the skull, but to tear the bones of the face. The nasal process of the superior maxilla may be broken when the nasal bone is fractured. The anterior wall of the antrum may be broken by the same blow. The alveolar process may be broken. The damage to the bones of the face, and particularly to the upper jaw, is associated with injuries to various contiguous bones. Blows result in many irregularly disposed fractures. The diagnosis is made by inspecting the mouth, nose, and cheek. These fractures being open, there is little difficulty in detecting them. A very careful inspection should be made, with an anesthetic if necessary, to determine the extent of the lesions. Emphysema and great swelling of the face occur. There may be no wound of the skin. Whether the injury to the upper jaw is associated with injury to the base of the skull or not can be deter- mined in the absence of visible signs by the subsequent develop- I'RACTURl'S OF THE SUPERIOR MAXILLA 57 ment of cerebral symploms. Necrosis of bils of bone is rare after upper-jaw fractures, excepting fracture of the alveolar border. Hemorrhage may be considerable, but it is easily controlled by pressure. The infra-orbital nerve may be damaged. The lachry- mal canal mav be temporarily compressed or obliterated. Treatment. — If there is no wound of the skin and much de- pression of the jaw, so that the face is knocked in, it will be necessary to devise some method of elevating the depressed bone and of restoring the normal contour of the face. To avoid a visible scar, the mucous membrane should be incised on the inner side of the upper lip, and the fragments elevated by an instru- ment introduced through the incision. As little bone as possible should be removed, so as to leave sufficient support to the soft parts of the cheek after healing. Only thus can a falling in of the cheek be prevented. If access through the mouth is unsuc- cessful, it may be necessary to incise the skin over the fracture. This, of course, is to be avoided if possible. The accidental wounds should be thoroughly and vigorously swabbed with a solution of corrosive sublimate (i : 5000). The use of tiny swabs of gauze held by forceps w411 facilitate this procedure. The avoidance of sepsis in these cases is of paramount importance. If the wounds become septic, there is great danger of an extension of the inflam- matory process to the deeper parts or even to the meninges of the brain. Lacerations of the soft parts — lips and cheeks — ma}' have their edges approximated to secure less scar than if left unsutured. Loose small bits of bone should be removed with forceps and scissors. Loosened teeth should be left in good posi- tion in their sockets. A mold of the lower jaw should be taken in composition or plaster-of- Paris, if possible, by a competent dentist, and a rubber splint made from this mold to fit the teeth and alveolar border of the lower jaw. When this splint is applied, its upper surface may be brought up against the teeth of the upper jaw and held snugly in apposition by an external bandage, as in fracture of the lower jaw. This splint will materially assist in reducing the displacement of the upper-jaw fragments. It may be possible for a dentist to apply a splint directly to the alveolar margin and teeth of the upper jaw^ If this is possible, greater securitv of fragments will be obtained than by any other method 58 FRACTURES OF THE) BONES OF THE FACE of treatment. The physician may greatly assist in immobiHzing the fracture, until a permanent dressing is applied, by making quickly a temporary splint of dental wax or dental composition, and applying it to the teeth and alveolar margin of the upper jaw. This composition is softened and made malleable by placing it in hot water ; it can then be molded on the jaw, and in two or three minutes is firm (see Fracture of the Lower Jaw) . After Care. — Six weeks to two months will be necessary to insure firm union and freedom from complications. The swelling associated with the reparative process will gradually subside. Great care must be exercised in the nursing of the patient after this injury, as the element of shock is an important one to be considered. Strychnin sulphate (-g'^ of a grain), given two or three times daily, is indicated if there is evidence of shock following the accident. This should be continued each day for as long a period as shock is evident. Proper nourishment under these adverse conditions of adminis- tration is to be given careful consideration. Liquids alone are to be used the first week. These may be given by enemata or by the mouth with a tube to the back of the pharynx or by a nasal tube if necessary. Nasal feeding is simply and easily carried out. A rubber tube three feet long is needed, to one end of which is attached a funnel and to the other end a soft-rubber catheter, in size No. lo F. The patient is half reclining while the surgeon introduces the catheter into the nose until it passes well back and down into the pharynx. The funnel, somewhat elevated a foot or more above the patient's head, is kept filled with the liquid nourishment so that its contents run slowly into the esophagus. A plug of absorbent cotton, moistened with a four per cent, cocain solution, and placed in the nose for a few minutes before feeding, facilitates this procedure. The nose and mouth should be douched and swabbed regularly each day. This should be done after feeding the patient, and oftener if necessary in order to avoid all odor from the mouth. Listerin, two teaspoonfuls to half a cup of water, is a satisfactory wash for this purpose. The profuse dribbling of saliva which attends this fracture demands drainage of the mouth by wicks of gauze placed in the cheeks and gauze handkerchiefs for keeping KRACTURlvS OF THE INFERIOR MAXILLA 59 the surrounding parts dry. Wiring the fragments of bone may be necessary if there is great displacement. Wiring the alveolar border to the bod>- of the jaw may be demanded. vSuture of the bony fragments with chromicized catgut will often steady them in position until union takes place. FRACTURES OF THE INFERIOR MAXILLA With the exception of the superior internal surface of the artic- ular process, practically the whole of the inferior maxilla may be palpated. Fractures of the inferior maxilla are caused by direct Fig. 49.— Fracture of the inferior maxilla (interdental splint) (X-ray tracing). pig_ 50.— Fracture of the inferior max- illa in two places. Alinement of teeth per- fect (X-ray tracing). violence. The seat of the fracture will be determined by the force and direction of the blow, by the location of the teeth in the jaw (the jaw being weakest where the teeth have been lost), by the presence of any foreign body between the teeth (such as a pipe), and by the presence or absence of muscular relaxation. Fractures of the base of the skull through blows on the jaw are more likely to occur if the mouth is open. Fractures of the body of the bone are common ; of the ramus behind the molar teeth, rather uncommon ; of the condyloid and coronoid processes, very uncommon. The seats of fracture of the inferior maxilla are shown in the accom- panying illustrations (see Figs. 49, 50, 51. 5^)- 6o FRACTURES OF THE BONES OF THE FACE Excepting those of the condyloid and coronoid processes, frac- tures of the inferior maxilla almost always open into the mouth. They occasionally open through both the mucous membrane and the skin. Examination. — Even when the patient can not open the mouth sufficiently to admit the examining finger, palpation of the body and ramus of the jaw, with one finger in the cheek and another finger upon the chin, will often reveal the seat of frac- ture. Symptoms. — Pain, crepitus, and ab- normal mobility may be present. Immedi- ate swelling of the gum appears at the seat of the fracture. Teeth contiguous to the fracture of the body of the maxilla will be either displaced or loosened. The displacement of the fragments in fracture of the body and ramus will be most Fig. 51. — Fracture of the inner side of the alveo- lar process, from a force applied to teeth. Fig. 52.— Fracture of the lower jaw, showing loss cf alinement of teeth. easily detected by noticing the differences in level of the teeth on each side of the fracture (see Fig. 52). The face appears swollen. FRACTURHS OF Tlllv INFERIOR MAXILLA 6i After a few days the submaxillary and adjoining cervical 1\ nipli- atic glands become enlarged. The salivary secretions are increased in quantity, and because of the disinclination to painful swallow- ing, the saliva dribbles out of the mouth. If the fracture opens into the mouth, suppuration often appears and pus mingles with the saliva. Particles of decomposing food between the teeth and in the spaces outside the jaw within the cheeks add to the bacte- rial pabulum. The odor from this mass of foul material is char- acteristically penetrating" and offensive. After a few weeks necrosis of bone may occur at the seat of fracture, with abscess formation. A discharging sinus pointing to the disease appears. Fig. 53. — Aluminium splint to be placed on teeth. For closed fracture, a continuous capping of gold or aluminium or other metal cemented upon the teeth. These cervical abscesses, often diflficult to manage, occupy the region of the body of the jaw. The submaxillary and upper carotid triangles may be filled by a brawny infiltration associated with necrosis of a fractured jaw. On the other hand, with proper treatment and in less difficult cases the course of the healing pro- cess is simple and of easy management. Suppuration is pre- vented. There is no necrosis, and the repair of the fracture takes place unhindered. Treatment. — The primary object of treatment is the preser- vation of the natural alinement of the teeth. This object is attained by a complete reduction of the fragments of the fractured 62 FRACTURES OF THE BONES OF THE FACE bone. If a tooth interferes with the perfectly accurate closure of the mouth, and if the adjustment of the fragments is prevented by the position of the tooth, it should be extracted at once. Ordinarily, there is but slight displacement. This displacement can be corrected by digital pressure upon both fragments. Fracture of the Body of the Jaw. — The simple fracture of the body of the jaw without much displacement may be temporarily treated by the four-tailed bandage, which should hold the teeth of the lower jaw closely in apposition with the corresponding teeth of the unbroken upper jaw. As soon as practicable, a dental Fig. 54.— Four-tailed bandage for fractured jaw. Splint of rubber or aluminium should be made and applied by a dentist. This aluminium splint fits the crowns of the teeth some distance upon each side of the fracture, and holds the fragments firmly in apposition (see Fig. 53). It also permits of opening and shutting the mouth. The old-time four-tailed bandage and extra- dental splint of millboard (see Fig. 54) is inefficient. As a per- manent dressing it should be discarded. It is useful only as a temporary support. In the simple cases, in the absence of a com- petent dentist to make the aluminium or rubber dental splint, a splint of silver wire passed around many teeth upon each side of the seat of fracture is often efficient. The method of wiring two FRACTURE OF THI- BODY OF THE JAW 63 adioining teelh, those on each side the fracture, is unsatisfactor>' in that the strain loosens the teeth and displacement is easily effected (see Fig. 55). Ficr. =;;.— Fracture o'' the lower jaw. Wiring with silver wire. Pig. 56.— Hard-rubber splint, with arms anu posl-rior strap. Fracture of the body toward the angle of the jaw. through the region of the molar teeth, is often less easily held in good position. To the dental rubber splint the dentist should add lateral arms of 64 FRACTURES OF THE BONES OF THE FACE wire, held in position by a posterior strap (see Fig. 56). These wire arms increase the efficiency of the dental splint, for a band- Fig. 57.— Hard-rubber splint, with arms and bandage, applied. Similar to figure 56 (Moriarty) . pjg_ jg. — Hard-rubber splint ; wire arms and chin-piece held together bj' metal rods and nuts. age is passed under the chin between the wires and thus steadies the jaw by upward pressure (see Fig. 57). If a still more efficient method is demanded, the dentist uses an extradental chin-piece FRACTURE OF THE BODY OF THE JAW 65 Fig. 59.— Same splint as seen in figure 5S ; superior view. Fig. 60.— Front view of splint (figure 58) with mouth closed (Moriarty). 5 66 FRACTURES OF THE BONES OF THE FACE Fig. 6i. — Side view of splint (figure 5S) ; arms and chin-piece in position (Moriarty). Fig. 62. — Splint similar to figure 5S. Mouth maybe opened without impairing efficiency of splint (Moriarty). THE MAKING OF THE DENTAL SPI.IXT 67 of metal (see Fig. 58), which is adjusled by screws so that firm, evenly graduated pressure upon the fractured jaw is maintained between the inside denial sj^lint and the outside chin-piece. While wearing this s])Iint the mouth can be opened easily (see Figs. 60, 61, 62). The Makiiiy of the Dental Spli)tt. — If an impression is desired of the crowns of the teeth and the adjoining gum, it is best made by using the modeling composition manufactured for the use of dentists. The necessary amount of the composition is dropped into hot water; when soft, the composition is put into the metal Fig. 63. — Modeling- cups : A, Used for the upper jaw ; B, used for the lower jaw. impression-cups (see Fig. 63). The surface of the composition is warmed by holding it over a flame or holding it again in hot water ; then the impression-cup containing the softened composition is placed in the mouth and the impression made. Immediately upon the removal of the mold from the mouth the composition cools and hardens. From this mold is made the duplicate of the alveo - lar border and the teeth in plaster-of- Paris (see Fig. 64). The lines of fracture are clearly indicated upon the plaster cast, ^^'ith a fine saw the cast is cut upon these lines and the lower teeth are articulated with the plaster cast of the upper jaw, which has been Fig. 64. — Plaster cast of fracture of the jaw. Fig. 65. — Plaster cast of lower jaw articu- lating with upper jaw. Fig. 66.— Simple vulcanite splint, with boxes vulcanized on each side (Moriarty). Fig. 67.— Hard-rubber splint in position, upper teeth resting upon it (Moriarty). TREATMKNT 69 made. Plaster cream is used to hold the sawed portions to- gether. In other words, the fracture has been reproduced and reduced in plaster-of- Paris. Both upper and lower casts are then put upon an articulator (see Fig. 65). A vulcanite splint is made from this reconstructed lower jaw, and when this is applied to the fractured jaw as an interdental splint, the deformity is corrected and comfortably prevented from recurring (see Figs. 66, 67). Fraciitre of the Ramus of ihe Inferior Maxilla Just Behind the Molar Teeth. — The displacement is difficult to correct. The frac- ture is usually oblique from before backward and downward, as seen in the tracing (see Fig. 50). The body of the jaw drops Fig. 68.— Interdental splint used in fracture of the jaw when no teeth exist in upper alveolar arch (after Moriarty). downward and backward and the ramus slides forward. No den- tal splint is practicable, because there are no teeth on one side of the fracture to w^hich the splint could be attached. Etherization will often be found helpful, and at times necessar}", in the reduc- tion of this deformity. Reduction is accomplished by pressure backward upon the ramus with the thumb in the mouth and a simultaneous lifting forward and upward of the body of the jaw. Reduction is maintained by an outside pad and metal chin-piece and a buckle and strap splint. This buckle and strap splint (see Fig. 69) is of great advantage because it is easily adjusted, and the amount of pressure can be graduated. It is of importance to 70 FRACTURES OF THE BONES OF THE FACE note here that even after this fracture has been reduced and is at the outset apparently held reduced by the bandage, yet it will usually slump away a little and at the end of the first twenty-four hours after setting the fracture the fragments will be found to be partially unreduced. Upon a second application of pressure by tightening the bandage the fragments will come into apposition with comparative ease. By careful and repeated adjustments of the bandage and padding, after a week and a half even in the most obstinate cases, the jaw will be found to be in good position, with the teeth articulating. Fracture of the Body of the Ratnus upon the Savie or Opposite Sides of the Inferior Maxilla. — The fracture is difficult to hold Fig. 69.- -Molded leather chin-piece with buckles and straps for graduated pressure upon a fracture of the inferior maxilla (after Moriarty). fixed. In this case the dental aluminium or rubber splint will be needed, together with the outside pressure made by the metal chin-piece. Whichever method of treatment is adopted, the fracture at first should be inspected daily in order to insure accurate adjust- ment of apparatus. The mouth and teeth should be kept scrup- ulously clean. When practicable, the teeth should be scaled by a dentist before permanent apparatus is applied. Brush and swab with some mild antiseptic wash, such as Listerin, one part in four of water, should be used after taking nourishment and before bed- time and upon rising in the morning. The liquid nourishment of TRIvATMUNT 7 1 the patient sliduld he- ,i;i\(.n llu'diii^li a j^lass IuIk' at lirst. If it is unwise to o])c'ii the nioutli, a ruhbcr catheter nia\- he used behind the molar teeth. 'I'he rul)I)er catlieter with a si])hon attached is a very satisfactory method of feeding. The general health should receive careful attention. A patient with this fracture is apt to beconu" despondent and anxious about himself, ])artieularly if suppuration exists. The repeated swallowing of foul secretions impairs the appetite, causes indigestion and generally poor health. The loss of variety in diet favors this condition. Out-of-door exercise, plent\- of sleep, a mild tonic, such as ferrated elixir cali- Fig. 70.— If no lower teeth exist, the artificial teeth may be utilized, as seen above, as a splint. Boxes seen on sides of plate, to which arms and chin-pieces can be attached (after Moriarty). saviE and sulphate of strychnin, and a little wine, will all assist in restoring and maintaining good health. Abscesses which appear should be treated by incision, evacua- tion of their contents, drainage, and antiseptic dressings. Bits of necrosed bone should be removed. Union in fracture of the jaw occurs ordinarily in from three to five weeks. The apparatus is to be worn until the union of the fracture is firm. Fracture of the coronoid and articular processes is to be treated bv simple immobilization of the jaw. These various methods of immobilization mentioned may fail in some unusual fractures; if so, suturing of the fracture through the bone with silver wire or other material should be undertaken. CHAPTER III FRACTURES OF THE VERTEBRAE Anatomy. — The forked spine of the axis may be felt beneath the occiput upon deep pressure. The spines of the third, fourth, and fifth cervical vertebrae recede from the surface, and can not be felt distinctly. The spines of the sixth and seventh vertebrae project distinctly, and can be palpated. At the bottom of the furrow in the middle line of the back are felt the spines of the dorsal and lumbar vertebrae. The spinous processes from the seventh cervical to the third sacral are rather easily palpated. The spinal cord extends from the lower edge of the foramen mag- num to the lower border of the body of the first lumbar vertebra. The phrenic nerve leaves the spinal canal between the third and fourth cervical vertebrae. By palpation through the mouth (see Figs. 71, 72) the bodies of the vertebrae may be felt down to about the upper border of the body of the fifth vertebra. The cervical enlargement of the spinal cord is more marked than the lumbar. It commences at the third cer\acal vertebra and ends at the second dorsal vertebra. The lumbar enlargement com- mences at the level of the ninth dorsal vertebra and reaches to the twelfth dorsal vertebra. The spinal cord is well protected from injury (see Fig. 73). The vertebrae commonly fractured are the fourth, fifth, and sixth cervical, the "twelfth dorsal, and the first lumbar. The in- jury to the vertebrae is caused in one of three ways : by a direct blow, fracturing the arches ; by a fall upon either the head or the buttocks, crushing the bodies of the vertebrae; or by forced flexion or extension of the spine, causing a dislocation with or without fracture of the bodies and articular processes. More than one-half of the fractures of the cervical vertebrae are frac- tures of the spinous processes. More than two-thirds of the cases of fracture of the dorsolumbar vertebrae are fractures of the bodies 72 ANATOMY 73 of those vertebrae. A dislocation without fracture may occur in the cer^'ical region ; it is rare in other regions of the spine. pig_ 71.— Palpating the bodies of the first and second cervical vertebra; through the nioulh. Fig. 72.— Palpating the bodies of the cervical vertebrae through the mouth. Finger reaches about to the fourth cervical vertebra. It is important in locaHzing spinal-cord lesions to know the point at which each nerve arises from the spinal cord, because the point of origin does not correspond with that at which the nen.-e 74 FRACTURES OF THE VERTEBRA emerges from the spinal canal (see Fig. 74). The point of origin is higher than the point of exit. Many of the nerves pass obliquely from the cord, lying still within the vertebral canal after leaving the cord (see Fig. 75). These nerves within the canal are liable to pressure from the vertebral fracture. For example, a fracture of the eleventh dorsal vertebra would injure not only the cord Fig- 73 -The cord and its membranes in relation to a vertebra (diagram) : a, Extradural space; d, dura ; c, subarachnoid space ; d, spinal cord. Fig. 74.— Frontal section of fourth, fifth, and sixth cervical vertebras and cord, showing the origins of spinal nerve-roots (after Riidinger). F'g'- 75- — Frontal section of third, fourth, and fifth dorsal vertebrae, showing oblique course of nerve bun- dles running downward (after Riidinger). at this level, but in addition might injure the last dorsal and upper lumbar nerves. The lower the spinal nerves arise, the longer is their intraspinal course. The points of origin of the spinal nerves from the cord with reference to the spines of the vertebrae are as follows (see Fig. 76) : The eight cervical nerves arise from the cord between the occiput and the sixth cervical spine. The upper six thoracic nerves arise from the cord between the sixth cervical EXAMINATION 75 sj)iiK' and llic fourth dorsal spine. TIk- lower six thoracic nerves arise frtmi the cord between the fonrth and tenth df)rsal spines. The five lumbar nerves arise from the cord opposite to the eleventh and twelfth dorsal spines. The five sacral nerves arise from the cord opposite to the first lumbar spine. Xo hard-and-fast rule at present is applicable to the enumeration of the lesions following fractures and dislocations of definite vertebrae. From the com- bined experience of such clinicians as Gowers, Thorburn, Kocher, Putnam, Dennis, Walton, Bullard, Thomas, and others the follow- ing table is constructed, and is valuable for practical use : TABLE STATING LESIONS FOLLOWING INJURY TO DEFINITE VERTEBR.-E. Spinal Seg.ments. Muscles Involved. Vertebr.*; Dislocated. Cervical : First, second, third . . . [Death]. Skull on atlas, atlas on axis. Fourth . , . Diaphragm. Axis on third cervical Fifth .... Biceps, supinators, deltoid. Third on fourth. Sixth .... Pronators, triceps. Fourth on fifth. Seventh . . . Extensors, flexors of wrist. Fifth on sixth. Eighth and first dorsal . . . Intrinsic muscles of hand. Sixth on seventh. Reflexes In- volved. Pupil is small and reaction sluggish. Dorsal : Second to twelfth . . Intercostal and abdominal ... Epigastric, ab muscles (trunk). dominal. umbar : Second . . . Cremaster. Eleventh on twelfth Cremasteric. dorsal. , Adductors. Third 1 Fourth : . Fifth Outward rotators. „ .^, ^ . , Gluteal. , ,. , „ Twelfth on hrst lumbar. ^. . , Extensors of thigh, flexors Knee-jerk. of knee. Sacral : First .... Extensors of foot. Second . . . Calf muscles. Third, fourth, fifth , . . Perineal muscles. First on second lumbar. Plantar and ankle - clo- nus. 76 FRACTURES OF THE VERTEBRA Examination of an Injury to the Spine. — Four questions are to be answered : What was the nature of the accident ? What does palpation of the spine reveal as to the nature of the lesion? What is the level of the lesion? Is the lesion partial or com- plete ? General Symptoms Common to Fractures of the Vertebrae. — Signs of shock will be present. At the seat of the bony lesion will be found pain, tenderness, abnormal mobility and sometimes y..S cervical nerves- v_Jl-' 6 dorsal , Lohier 6 dorsal rierves- 5 sacral n- Fig. 76. — Diagram of spinal origin of nerves, according to the level of the spinous processes. crepitus and deformity. The deformity will ordinarily be a back- ward bending, or kyphosis, of the spinal column at the seat of frac- ture, unless there exists a unilateral dislocation, when the deform- ity will be irregular in appearance. The chief symptoms depend upon the injury done to the spinal cord. In general it may be stated that motor and sensory paralysis, either partial or com- plete, will be found up to the level of the lesion. The reflexes are ordinarily below the lesion, wanting at first and increased later. If SYMPTOMS 77 a complete lesion is present the reflexes will be entirely wanting. Retention, and later incontinence, of urine and feces will exist. Cystitis of the urinary bladder will develop at an early date. Bed- sores and great sloughing areas of skin upon dependent parts will be discovered early. Priapism occurs. Symptoms of Fracture of the Different Regions of the Spine, the Cord Being Involved. — Injuries to the Last Dorsal and Lnmhar Vcrtcbrcc (see Figs. 77, 78, 79). — The spinal cord ends opposite the lower border of the first lumbar vertebra. Any pressure at this point or below will involve the cauda equina in Fig. 77. — Fracture of the twelfth dorsal vertebra. Anesthesia to the height of the anterior superior spinous processes in front. Second lumbar nerve involved. whole or in part (see Figs. 80, 81). Local evidences of the bony lesions may be present. The paralysis of the legs may be partial or complete. The anesthesia of the lower limbs is partial rather than complete and up to the level of the bony lesion. Retention or incontinence of urine and feces exists. The paralyzed muscles rapidly become wasted. Constant pain and hyperesthesia may be present both above and below the lesion. The patellar and plantar reflexes are usually lost. The prognosis is not altogether unfa^'orable to recover\\ Par- tial recover}- is possible. Later, muscular contractures will exist in the lower limbs, which impede walking. If at the end of six 78 FRACTURES OF THE VERTEBRAE Fig. 78. Fig. 79. Figs. 78, 79. — Fracture of the twelfth dorsal vertebra without involvement of bar nerve-roots, the ilioinguinal, iliohypogastric, and external cutaneous nerv involved. the first lum- es not being Fig. 81. Figs. 80, St.— Injury to the cauda equina, which has involved the third sacral nerves. Frac- ture of the first lumbar vertebra or the second lumbar vertebra. SYMPTOMS 79 weeks e\'i(leiices of l)e,i;innin,L,^ recovery da not appear, or if recover)- once begun has ceased, it will be wise to operate ui)on injuries to the Cauda equina. Injuries to the Dorsal Vertebrcc (second to the eleventh) (see Fig. 82. — Sixth dorsal vertebra fractured. Anesthesia at the level of two inches above the umbilicus. The eighth or ninth dorsal nerve involved. Fig. 83. — Lesion of spine between fifth and sixth cervical vertebrse. Note position of arms, due to paralysis of subscapularis. Biceps brachialis anticus, supinator longus and deltoid muscles intact. Elbow flexed, shoulders abducted and rotated outward (afterThorburn). Fig. S4. — Luxation of sixth and seventh cervical vertebree ; typical attitude; center for subscapularis not involved. Contrast figures 83 and S4 (after Kocher). Fig. 82). — The simple distribution of the spinal dorsal nerves below the first makes the interpretation of injuries to this region much easier than similar injuries to the cervical or lumbar regions. The arms escape paralysis. The motor and sensory paralysis extends ordinarily to the height of the bony lesion. In a few cases 8o FRACTURES OF THE VERTEBRA in which the nerve-trunks within the canal are not imphcated the level of the paralysis wull be lower than the lesion. The patellar reflexes are at first generally lost in the severer types of fracture. If the patient recovers, there will be spastic paralysis if the injury is above the lumbar enlargement. If the lumbar enlargement is involved, there may be great pain in the legs. Injuries to the Cervicodorsal Region, Opposite the Cervical En- largement of the Spinal Cord. — The arms escape paralysis, perhaps, at first, but become involved after several days. The paralysis is often partial. Respiration is diaphragmatic only. Pain in the arms is quite constant. If the sixth vertebra is dislocated upon Fig. 85. — Lesion of spine between sixth and seventli cervical vertebras. Position in case of complete transverse destruction of the cord just below nuclei for subscapularis ; areas of anesthesia shown {after Thor- burn). Fig-. 86. — Atlas, axis, and third cervical vertebra from the front. Case : man, thirty- eight years of age; fell from a cart. Frac- ture of odontoid process. Slight hemor- rhage into the medulla. Death after forty- eight hours (Cabot). the seventh, the intrinsic muscles of the hand will be paralyzed. If the fifth vertebra is dislocated upon the sixth, there wdll appear a characteristic position of the upper extremities (see Fig. 83) : abduction of the arms, flexion of the forearms, with rotation out- ward of the whole extremity. If the injury is above the sixth cer^dcal vertebra, there will be anesthesia of the entire limb ex- cepting the shoulder. The attitude after lesions between the sixth and seventh cervical vertebrae is shown in figure 84. The charac- teristic attitude in lesions between the sixth and seventh cervical vertebrae is also shown in figure 84. Injuries to the Midcervical Region. — A lesion of the third cervi- PROGNOSIS AND TREATMENT 8 I cal vertfljia will iiuolvc the phrenic nerve. The diaphragm will be paralyzed. Death will occur \vithin a few- hours. Injiincs to flic I-'iist Two Cervical Vcricbnc (see Figs. 86, 87). — If the displacement is slight, life may be spared until sudden dis- placement occurs or a secondary myelitis causes death. Cases of recovery are recorded. Death usually occurs instantly. Per- haps one person in fifty thus injured recovers (Gow-ers). Prognosis. — The prognosis depends upon the amount of injury to the spinal cord. The prognosis is less grave than it was thought to be a few years ago. There is a probability of saving a certain proportion of cases. In general, the nearer the fracture approaches Fig. 87. — Fracture of the atlas and axis. Man, sevent3--four years of age; fall; imme- diately left arm paralyzed. No loss of consciousness, speech thick. Neck movements nor- mal. Twenty-four hours after the accident, suddenly difficult breathing appeared and death followed (Brooks). the medulla oblongata and the foramen magnum, the more serious does the outlook become. Patients with fracture in the dorsal and lumbar regions die in the course of months from cystitis, pyelitis, and exhaustion. Patients with fractures in the upper dorsal and low^er cervical regions die in a few days or weeks from hypostatic pneumonia. Patients with fractures high up in the cervical region die instantly or in a few hours from shock and direct pres- sure upon the medulla oblongata. Treatment. — The object of treatment is to relieve the cord from pressure and to immobilize the fracture. The cord will be uninjured, slightly injured, or injured seriously. If the cord is 6 82 FRACTURES OF THE VERTEBRA uninjured, the bony parts may be left untouched or they may be replaced by manipulation or operation. If the cord is injured, the advisability of operative interference will depend upon whether the lesion of the cord is transverse and complete, or whether it is partial. If there are evidences of a transverse lesion, operation is unavailing and obviously illogi- cal, for the cord can not be re- paired. It is necessary, there- fore, to distinguish between the signs of a transverse lesion and those of a partial lesion. In a complete transverse lesion the history of the onset of the symp- toms is a sudden one, the symp- toms appear immediately fol- lowing the fracturing trauma; whereas, if a partial injury is present, an interval will have elapsed before the symptoms de- velop; the appearance of symp- toms is gradual rather than sud- den. In a complete transverse lesion the motor paralysis is found to be complete, and the paralyzed muscles are flaccid; whereas if the lesion is a partial one, the motor paralysis is limit- ed, some muscles of the limbs are paralyzed, others are not, and there is often noticed muscular spasm in the affected limbs. In a complete transverse lesion sen- sation is entirely gone ; whereas in a partial lesion some sensation is present. The knee-jerks are variable; in the complete trans- verse lesion they are absent. In the partial lesion the knee-jerks are apt to be absent at first, and they may return later. In the transverse lesion the paralysis of the bladder and rectum is com- plete ; whereas in the partial lesion paralysis of these organs is not Fig. 88. — Fracture of the cervical spine ; cord compressed by bone and blood. Hemorrhage into the cord at the seat of the lesion and below the lesion (Warren Museum). (Drawn by Byrnes.) TREATMENT 83 Fig. 89. — Spine sawed in sagittal sec- tion, showing fracture through the inter- vertebral disc between the sixth and seventh cervical vertebrae, with disloca- tion forward of the upper fragment. Par- tial crush ot the cord (Thomas). Fig. 90.— Spine sawed as before. Fracture of the spinous processes of the seventh cervi- cal and first and second dorsal vertebrae. Fracture of the bodies of the fifth, sixth, and seventh cervical vertebrae with displacement backward o{ the upper fragment. Total crush of the cord. The section passes a little to one side of the cord, which is seen in place, and the staining of the cord by hemorrhage into its substance shows plainly through the mem- branes, even in the photograph. The spinous processes of the second and third dorsal verte- brae were found fractured at the operation, and were removed (Thomas). Fig. gt. Figs 91 and 92.-Spine sawed as before. Fracture of spines of fiftli cervical and fourtli, fifth and sixth dorsal vertebra. Fracture of body of sixth dorsal vertebra. Displacement forward of upper fraRnient. Total crush of the cord, the softened substance of which has been removed by the saw, leaving only the empty and blood-stained meninges at this point. Figure 91 shows the spine as sawed ; figure 92, the same hyperextended, showing the oblitera- tion of the narrowing of the spinal canal (Thomas). TREATMEXT 85 always present. Priapism, sweating, and involuntary muscular twitchings are seen more commonly in case of injury to the spine associated with complete lesions of the cord than in cases with partial lesions of the cord. In partial lesions variations from the Figs. 93 and 94.— The two halves of the spine sawed in sagittal section. Fracture of the seventh cervical vertebra, with dislocation forward of the upper fragment. Fracture of the arch of the sixth and of the spine of the seventh vertebrae. Total crush of the cord. The discoloration of the cord from blood shows plainly in the plate (Thomas). definite types of symptoms are seen. The symptoms are more or less irregular. In total lesions of the cord operation can do no good. The cases of pressure from fragments of bone — that is, those occurring for the most part in the cer\-ical region, in which the laminae of the vertebrae are fractured — demand operation. 86 FRACTURES OF THE VERTEBRA All other cases of bony pressure are those due to dislocation of vertebrae which are remediable either by operation or manipula- tion. In these cases the prognosis depends upon the damage done the cord. It is the result of experience that in cases of injury to the spine severe enough to do damage to the cord usualh^ irreparable injury has been done by either a distinct crush of the cord or hemorrhage into the cord. Hemorrhage into the cord takes place often ex- tensively and some distance from the seat of the chief lesion, so Fig. 95. — Case: Man, fracture of spine; transverse section of spinal cord above tlie lesion. Hemorrhage into posterior horn (Taylor). (Drawn by Byrnes.) that even if the seat of the crush of the cord were reached by operation, damaging lesions would still remain unrelieved. It is also a result of experience that removal by operation of the laminae and spines of the vertebrae in the suspected region of frac- ture very rarely — almost never — reveals any remediable condi- tion or affords any evidence of the exact seat of the lesions or their extent. The reason for these facts is that the dura at the seat of a crush of the cord, whether partial or complete, remains intact and untorn, and that extradural hemorrhage is unusual. The surgeon, therefore, after removal of the laminae, is as much in doubt as he was before. Operation, therefore, in complete lesions holds out no hope of benefit. It is said that the chances of the TREATMENT 87 s^•nlptoms being clue to pressure by extradural blood-clot or bone justify operative interference in these apparently hopeless cases. This is true in those cases in which the lesion of the cord is partial, but never when the lesion is completely transverse. Operaiivc iiifcrferciicc, then, may be sii))i))i jiM^" ^^ ,;'^ [ '4 _^ ij^^i ^ ^Ihs ' "^ Fig. III. — Fracture of the ribs. Starting the application of the adhe.sive-plaster swathe to encircle the trunk. Fixation of initial end of the swathe at the spine. Notice that the swathe is held taut as it is applied. Fig. 112. — Fracture of the ribs. Finishing the application of the adhesive-plaster swathe to the trunk. TREATMENT 99 plaster, each strij) bt-in.i^- four inches wide, imbricated in the appH- cation, will often prove more comfortable than a single swathe. The comfort attending the wearing of such a swathe speaks much for its efficacy. Operative Treatment. — If the fracture is comminuted or if there is great displacement that is irreducible by pressure, an incision and elevation of the parts and immobilization by suture are to be considered. After-treatment. — The upright position will give the most com- fort. The swathe should be changed at least once each week. It will require about three weeks for the union to become firm. A cotton swathe may be worn during the third and fourth weeks in place of the adhesive-plaster swathe. At the end of four weeks all swathes may be removed. Massage to the seat of fracture will, after the first week, hasten healing and a restoration of the parts to the normal position. If there have been any pleural or lung complications, great precaution should be exercised in the after- care. The avoidance of exposure to cold and of great bodily exertion for a period of two months or more following recover}- from the complication is necessary. Other injuries, such as strains of the shoulder and back, are likely to appear some days after the acute symptoms of a fracture of the rib have subsided. It is ^Yell to examine the patient wdth a fractured rib for associated injuries. These associated sprains often cause considerable anxiety to the patient for fear that more serious trouble than a broken rib exists. In patients over fifty years old "neuralgic pain" at the seat of fracture will sometimes persist for several weeks after the fracture is firmly united. This may be relieved by applications of moist heat to the affected part and by count erirritation of a more vigorous kind. The use of tincture of iodin and blisters is often a great help. In the aged the shock of the injury is considerable. In feeble persons a pleurisy or pneumonia may prove fatal. Treatment directed to the removal of the emph3'sema is ordi- narily unnecessary. The emphysema usually disappears in a week or ten days. If the distention of the subcutaneous tissues is extremely painful and increases very rapidly it may be wise to make several antiseptic incisions over them, allowing the air to escape, to relieve the tension of the skin. CHAPTER V FRACTURES OF THE STERNUM It is difficult to palpate the sternum accurately. The episternal notch is felt between the two inner ends of the clavicles. The junction between the first and second portions of the sternum is distinctly felt opposite the second costal cartilage as a ridge. The different sites of fracture are shown in figure 113. The fracture Fig. 113. — Sites ot fracture of the ster- num (after specimens 5149, 978, 5151, 5150, 976, 977, Warren Museum). Fig. 114. — Separation of manubrium and gladiolus; displacement of lower por- tion forward ; side view. that is usually due to direct violence is seated in the upper part of the second portion of the sternum, near the junction of the first and second portions. The upper fragment is displaced backward behind the upper end of the lower fragment (see Fig. 114). The displacement, the abnormal mobility, and possibly crepitus after TREATMENT OF FRACTURE OF THE STERNUM lOI each respiratory act or upon couf^hiiig, the locaHzed area of pain, all increased by pressure, help to make the diagnosis certain. The patient stands in a characteristic fashion with body bent forward. It is almost impossible to distinguish a dislocation at the junction of the first and second portions of the sternum from a fracture within the first portion of the sternum. Careful palpa- tion alone and consideration for the age of the patient will enable one to decide. The ossification of the sternum takes place irregu- larly. At the twenty-fifth year all parts are usually ossified. The lesions sometimes associated with fracture of the sternum — viz., fracture of the ribs and injury to the lungs and heart — are Fig. 115. — Position in, and method of reduction of, fracture of the sternum. Notice positions of liands of surgeon and assistant. usually SO severe that the patient does not recover from them. If no complicating lesions are present, the outlook for recovery is favorable. Treatment of Fracture of the Sternum. — Spontaneous reduc- tion has occurred in several instances upon coughing or sneezing. If the patient is placed upon his back with his head extended over the end of the table and the arms are then raised above the head and rotated outward slowly and forcibly, the deformity is some- times reduced. The body of the patient, meanwhile, is steadied by an assistant. Traction and.countertraction are thus made upon the two fragments (see Fig. 115). An adhesive-plaster swathe should be placed about the chest high up, and held firmly in posi- I02 FRACTURES OF THE STERNUM tion by straps across the shoulders. Union takes place in from three to four weeks. The fracture is not solid for from six to eight weeks. After resting on the back in bed for three weeks the patient may be allowed to be up occasionally with care to avoid violent exertion. For the greatest precaution a Taylor steel back-brace, with apron and head-support, should be used for two months after the patient is up and about. This brace is similar to that used in high dorsal caries of the spine. Operative Treatment. — Incision and elevation of the depressed fragment have been done successfully, and are to be considered in difficult cases after the shock of the original injury has passed away. Cyanosis and dyspnea may be in part dependent upon the displacement of the sternal fragments. Relief from these symptoms is often immediate upon the correction of deformity. CHAPTER VI FRACTURES OF THE PELVIS The pelvic bones are generally considered inaccessible (see Fig. ii6); but with a systematic anatomical examination, espe- cially if assisted by digital examination by the rectum and the vagina, practically all parts of the pelvic bones may be palpated. Movement of the hip will often determine the integrity of the acetabulum, which is, of course, most difficult to palpate even posteriorly by the rectum. Fractures of the pelvis are occa- sioned by great violence. Fracture occurs most often in falls from a height, and is due to the sudden pressure upon the pelvis through the thighs and hips (see Fig. 117) or through the spinal column upon the sacrum and sacro-iliac synchondroses. Antero- posterior pressure and lateral compression, as in the car-coupling accident, are common causes of fracture. From a clinical stand- point these fractures fall into two groups — fractures of the indi- vidual bones without injury to viscera, and fractures at different points in the pelvic ring usuallv associated with visceral lesions. Fractures of the sacrum, the coccyx, the symphysis pubis, and the ischium are extremely rare. Examination. — The examination should be systematically made in order to cover thoroughly the irregular bones of the pelvis. The ilium of each side should be palpated to detect a fracture of either crest. Then the two ilia should be crowded genth- but firmly together in order to determine crepitus due to the presence of fracture elsewhere. Then the pubis and ischium upon the two sides are to be palpated externally as far as is practicable. Finally a careful rectal and vaginal examination should be made of the pelvic bones. The patient should be catheterized to assist in determining the presence of an injury to the urinarv' tract. Fracture of the Ilium (see Fig. iiS). — This fracture is not un- usual. The crest of the ilium is commonlv broken. Pain, swell- I04 FRACTURES OF THE PELVIS ing, crepitus, and abnormal mobility may be present. Localized tenderness at the seat of fracture may be the only sign present. Crepitus, absent at first, may be ehcited several days after the Fig. ii6.— Normal pelvis. Note relations of pelvic ring. Fig. 117.— Fracture of acetab- ulum ; force transmitted through femur (Warren Museum, specimen 1053). Fig. 118.— Fracture of crest of ilium (Warren Museum, specimen 593S). injury. There is comparatively little displacement. Union occurs in from three and a half to four weeks. The patient or- dinarily requires but restraint in bed. The outlook is for a good TREATMENT OF I-RACTURES OF THE PELVIS 105 recovery unless there is a visceral lesion. Slight deformity may be noticeable upon full recovery (see Fig. 1 19). Fiacture of the pubic portion of the ring of the pelvis is the com- monest fracture. It is usually associated with other fractures or separations of bony surfaces of the pelvis. Injury to the urethra is not uncommon in this fracture (see Figs. 120, 121). Treatment. — A snugly fitting swathe encircling the pelvis should be applied to assist in immobilizing the fracture. If the fracture is of the ilium alone, the swathe should be applied loosely enough to avoid displacing the fragment of the crest inward, thus Fig. 119.— Case : Fracture of the crest of the right ilium : A, Deformity due to inward displace- ment of fractured bone; B. Posterior lateral view (Porter). causing permanent deformity Csee Fig. 119). The patient should, in all cases, except simple fractures of the crest of the ilium, be placed upon a properly fitting Bradford frame. Upon this frame, and in no other way, can the patient be comfortably nursed. The bed-pan can be adjusted with ease and without disturbing the fracture. The bed can be most readily changed and the patient kept clean and comfortable. If it is probable that movements of the hip-joints cause motion at the seat of the fracture, the thighs should be fixed so as to immobilize these joints. The long out- side wooden splint extending from the axUla to below the heel and attached at its foot end to a slat at right angles to the long io6 FRACTURES OF THE PELVIS upright — a T-splint — is the simplest means of securing this inimobihzation. If the patient is on a Bradford frame, suffi- cient immobilization is easily accomplished by encircling the thighs separately or together and the frame with a towel swathe. Extension of the limbs by weight and pulley may be needed in New bone at seat of separation. Fracture. Sacro-iliac synchondrosis. Fracture. Fig. 120.— Fracture of rami of pubes; fracture and separation at sacro-iliac synchondrosis; much displacement; bony union (Warren Museum). Fig. 121.— Fractured pelvis : on the right, fracture across pubes and ischium ; on the left, frac- ture involving acetabulum and sacrosciatic notch (Warren Museum, specimen 3857). addition in certain cases to secure immobilization of the fracture. Wiring or suture of the fractured bones may be entertained and practised. Wiring is indicated if comminution or displacement of fragments is great. Visceral Lesions. — Associated with fractures of the pelvis there RUPTURE OF THE URETHRA 107 may be lesions of important viscera. These visceral lesions render fractures of the pelvis of the very greatest seriousness. The trauma causing the fracture may at the same time occasion a rup- ture of the kidney. The bladder, urethra, or bowel may also be ruptured. The shock associated with a fracture of the pelvis is great. If there is a visceral lesion, the primary and secondary shock will be ver\- great. Bladder. Sacrum. — Rectum. Symphy- ~ sis pubis. Anus. Urethra. Fig. 122.— Median section of male pelvis. Notice close relation of bladder and urethra to the symphysis pubis. Fracture of pubic bone may injure bladder or urethra (frozen section by Professor Thos. Dwightj. Rupture of the Urethra.— This is sometimes associated with fracture of the pelvis (see Fig. 122). It may be due to the original trauma, as a fall or blow on the perineum, or it may be caused by bonv fragments lacerating the urethra, or by a simple separation of the symphysis pubis. Pain at the seat of the lesion, pain upon pressure in the perineum, retention of urine, urethral hemorrhage, swelling in the perineum, usually exist. Under these circum- stances perineal section is indicated in order to drain the wounded area and the bladder. If a catheter can be passed to the bladder Io8 FRACTURES OF THE PELVIS and the local swelling does not increase, permanent or interrupted catheterization is indicated. The patient should, however, be watched carefully for the signs of extravasation of urine. If at any time the catheter can not be passed, operation should be done at once, as in the first instance. If the urethral rupture is caused from above, the inferior surface of the canal may be intact. If so, the passage of the catheter (if difficult) may be facilitated by depressing the instrument slightly, hugging the inferior wall of the urethra. Rupture of the Urinary Bladder. — This may be either extra- or intraperitoneal. When the bladder is empty, it is low down in the pelvis and can be injured only by a fracture of the pelvis. The rupture of the bladder due to fracture of the pelvis is usually extra- peritoneal and it is situated on its anterior surface. On account of the fracture the patient can not walk. Rupture of the bladder itself might occasion inability to walk, at least any long distance. There is great hypogastric pain, frequent desire to micturate and inabilit}^ to pass urine. A few drops of bloody fluid escape from the meatus. Dullness may be present in the lower abdomen and loins. Soon after the accident, if not imme- diatelv, there is great prostration. Evidences of shock are seen in the pallor of the face, the anxious expression, the feeble pulse, the cold, clammy skin, and feeble voice. The abdomen becomes distended, the temperature rises, and delirium, coma, and death follow with certainty unless operative interference has relieved the condition at a very early hour after the accident. The patient dies from shock, hemorrhage, or septic peritonitis. If the patient is seen soon after the accident, before untoward symptoms have appeared, and has not micturated for some little time, he should be catheterized. An empty bladder will be found or a small amount of bloody fluid will be withdrawn, which rather confirms the other evidences of ruptured bladder. If there is doubt as to the rupture of the bladder, the symp- toms should be watched. The symptoms of rupture may be masked or delayed by the associated lesions. The urine may be tinged with blood because of a contusion of the bladder. The catheter mav be passed through the bladder-wall, and be felt to enter the abdominal cavity, evacuating bloody fluid. All fluid PROGNOSIS 109 havini; been renioNed from the Ijladder, if a measured amount of sterile water is injected into it, and all that was injected does not return, presumption of rui)ture of the bladder is very great. Under such circumstances the dull area in the groins and lower abdomen of extraperitoneal rupture will be increased. Exploratory laparotomy should be done, and if the extrava- sation proves to be extraperitoneal, drainage of this area is de- manded. Temporary drainage of the bladder, either urethral or through perineal section, will be needed to permit healing of the bladder wound. The bladder wound is usually inaccessible to suture in these cases. Prognosis. — A guarded prognosis should always be given in any case of fracture of the pelvis. Fractures of the iliac crest ordinarily recover in a few weeks. In fractures complicated by rupture of the bladder or bowel the prognosis is extremely grave. CHAPTER A^II FRACTURES OF THE CLAVICLE Anatomy. — The claA-icle is subcutaneous throughout its whole length (see Fig. 124). The acromioclavicular joint is at its outer end. The sternoclavicular joint is at its inner end. The clavicle Fig. 123. — Normal left clavicle viewed from above. Fig. 124. — Muscles arising from and attached to the clavicle, showing the muscular plane in which the clavicle lies. X points to the coracoid process. lies in a muscular plane made up of the trapezius and sterno- cleidomastoid muscles above, and the deltoid, pectoralis major, and subclaA'ius muscles below (see Fig. 124). It is important to no SYMPTOMS III recognize the sitiialion and the direclion of the acromioclavicular joint in order to discriminate between a fracture of the outer end of the clavicle and one of the acromial process. It is likewise important intelligently to palpate the normal shoulder, to deter- mine that the acromial process does not form the outer limit of the shoulder, but that it is formed by the greater tuberosity of the humerus. Symptoms. — The common seat of fracture is in the middle third of the bone (see Figs. 1 25-1 28 inclusive). The shoulder, having lost the support of the clavicle, falls forward and drops inward, consequently the outer fragment that moves with the Fig. 125. — Fracture at the inner and middle thirds of right clavicle from above (Warren Museum, specimen 1214). Fig. 126. — Fracture toward middle of clavicle, a little to the inside (common site). Right clavicle from above (.Warren Museum, specimen 987). Fig. 127. — Fracture at the outer and middle thirds of left clavicle from above (Warren Museum, specimen 9S7). Fig. 12S. — Fracture at the outer end of clavicle. Left clavicle from above (War- ren Museum, specimen 7900). shoulder drops below the inner fragment and overlaps it in front. The inner fragment, having attached to it the sternocleidomastoid muscle and being comparatively free to move, is drawn slightly upward. The attitude of the patient is characteristic (see Figs. 129, 130): he stands with the head inclined to the injured side, thus relaxing the pull of the sternocleidomastoid muscle upon the inner fragment. The shoulder upon the side fractured is de- pressed ; the elbow and forearm upon this same side are supported by the well hand. This is the attitude of greatest comfort. The shoulder — i. e., the space between the base of the neck and the greater tuberosity of the humerus — is shortened upon the injured side (see Fig. 141). If the fracture lies within the limit of the 112 FRACTURES OF THE CI.AVICLE coracoclavicular ligament or outside of it, there will be no appre- ciable displacement (see Fig. 131). The diagnosis under these cir- cumstances will be difficult. Localized pain and the disability of the arm will suggest the lesion present. Fracture of the Clavicle in Childhood. — More than one-third of all fractures of the clavicle occur in children under five years of age. A trivial injury is the usual cause of the fracture. A little child may fall from a low chair or out of bed and fracture the bone. The fracture is almost always incomplete or greenstick. Fig. 129.— Case : Comminuted fracture of the left clavicle. Attitude characteristic ; deformity visible; wired (Mixter). The child cries upon moving the arm. Lifting the child by placing the hands in the armpits causes pain. The arm of the injured side may be used as naturally as the other or there may be some disability, perhaps simply a disinclination to use the arm. If the fracture is greenstick, a tender swelling appears at the seat of the fracture. If the fracture is complete, an unevenness will be felt at the seat of fracture according to the amount of displace- ment. The displacement is usually slight in childhood. The characteristic attitude seen in adults (see Figs. 129, 130) is much less marked in children, and if the fracture is greenstick, there is TREATMENT IN ADULTS "3 no tilting of tlic head and dcjn'cssion of the shoulder. If the child, as so often occiu's, ])ersistenlly holds the head so that a careful examination is impossible, then it is best to place the child on its back, and while its legs and arms are held firmly, the head and shoulder may be gently and gradually separated. The examina- tion can then be completed. Fig. 130. — Attitude characteristic of a recent fracture of the right clavicle. b C d Fig. 131. — Diagram ot the ligaments attached to and near the clavicle on its under surface : a. Rhomboid ; b, conoid; c, trapezoid ; rf, coraco-acromial. Treatment in Adults. — The displacement should be corrected and the corrected position maintained (see Figs. 132, 133). The indications are to carry the shoulder, and with it the outer frag- ment, upward, outward, and backward. The Recumbent Treatment. — The displacement is most satis- factorily corrected by the patient lying recumbent upon a firm pjg 132.— Fracture of the clavicle. Method of correction of falling inward and downward of shoulder, in overriding of fragments previous to the application of the modified Sayre dressing. Fig. 133-- -Fracture of the clavicle. Same as figure 132. Posterior view, showing extreme backward position of shoulders. 114 Fig. 134. — Fracture of the left clavicle. Mod- ified Sayre dressing. Towel circular of upper arm held by adhesive plaster. Adhesive-plaster strap ready. Fig- io5- — Fracture of the left clavi- cle. First adhesive-plaster strap applied. Shoulder carried backward. Fixed point established above middle of humerus. Fig. 136.— Fracture of the left clavi- cle. First adhesive-plaster strap applied. Second adhesive-plaster strap being ap- plied. Hole in plaster for olecranon visi- ble. Note pad for wrist and folded towel protecting skin of arm and chest. Fig. 137.— Fracture of the left clavicle. First and second adhesive-plaster straps applied. Pad in left hand. Shoulder pulled backward and elevated. 115 Il6 FRACTURES OF THE CLAVICLE mattress. The weight of the shoulder in this position docs not impede reduction, as in the upright position, but assists it. A firm and small pillow should be placed between the shoulders. The shoulders fall backward of their own weight over the pillow carnyang the outer fragment backward at the same time. Pad- ding of the fragments of the clavicle, the application of pressure to the elbow, may be more satisfactorily accomplished in the re- cumbent than in the upright position. Union ordinarily occurs within three wrecks. At the time of union or shortly after the patient mav be allowed up with a simple retentive dressing, a sling, and a swathe. The bed treatment is hard to enforce because the fracture is the cause of so little real permanent disability. If there is much displacement and deformity can not be corrected and held properly, the bed treatment is indicated. In the simul- taneous fracture of both clavicles the recumbent bed treatment is the best (see Operative Treatment of Fracture of the Clavicle). The Modified Sayre Dressing. — The shoulder and arm are un- wieldv in adults. It is, therefore, necessary in treating a fracture of the clavicle by an ambulatory method to secure a very firm hold upon the shoulder in order to maintain the clavicular frag- ments in a good position. The modified vSayre adhesive-plaster dressing is the best. It is applied as follows: Provide three strips of adhesive plaster, four inches wide, and long enough to extend once and a half around the body. The skin surfaces that are to come in contact — namely, the axilla and chest and forearm — are separated by compress cloth and powder. A dressing towel, folded like a cravat, is snugly pinned high up about the upper arm (see Fig. 134). This towel mav be held neatly by a strip of adhesive plaster. One end of the first adhesive strap is fastened loosely about the towel-pro- tected arm with a safety-pin. While an assistant holds the shoulder well back the arm is carried backward, and held by the fastening of the first adhesive strap about the body (see Fig. 135). This affords a fixed point at the middle of the upper arm. The second strap, with a hole in it to receive the point of the elbow, is started upon the posterior surface of the injured shoulder (see Fig. 136) and carried under the elbow of the injured side and over the well shoulder (see Fig. 137). The forearm is flexed, and rests upon TREATMENT IN CHILDREN 117 the chest. In applying this second strap the shoulder is raised and the elbow is carried forward, thus forcing the shoulder slightly upward and backward of the fixed point used as a fulcrum (see Fig. 138). A third strap may be placed around the trunk and arm to steady all in good position. Oyer this dressing may be put a \'clpeau bandage for the comfort of the support which it affords (see Fig. 139). The adhesiye plaster may be covered with Fig. 13S. — Fracture of the right clavicle. Modified Sayre dressing. Posterior view. Shoulder elevated and pulled backward. Folded towel seen in axilla for protection to skin. Fig- 139- — Fracture of the clavicle. Method of application of a Velpeau bandage. Xote the order and direction ot the turns i, 2, 3,4, and 5. Xote position of the forearm and arm of the unin- jured side. bits of gauze bandage, in part to protect the skin from undue chafing, sufficient plaster surface remaining uncovered to prevent the straps from slipping. Occasionally, pads (see Fig. 140) upon the clavicle mav be used to correct the deformity, but the bone is so subcutaneous that the skin can not bear great pressure without damage. If pads are used, they must receive frequent inspection. Treatment in Children. — The skin of the child must be pro- ii8 FRACTURES OF THE CLAVICLE tected by powder and careful drying before the arm is done up. If it is a greenstick fracture and there is slight deformity, this de- formitv should be corrected by pressure with the thumbs. An anesthetic should be used. After the deformity is corrected and in cases without deformity it is necessary' simplv to restrain the movements of the arm for two weeks. This is best accomplished by a cotton swathe about the body and upper arm, held by straps Fig. 140. — Fracture of the clavicle and subluxation of the acromioclavicular joint. Notice elevation of shoulder by pressure on the flexed elbow and counterpressure on the clavicle by a bandage and a pad (X) placed internal to the acromioclavicular joint. over the shoulders and by a cravat sling. In warm weather and also in cool weather, for that matter, the arm is to be inspected frequentl}-, as often as evers* third day, when all the dressings are removed, the parts bathed with soap and w^arm w^ater, powdered, and the simple retentive dressing reapplied. With this care only can chafing be avoided. If it is a complete fracture, the modified Sayre adhesive-plaster dressing should be used as in adults. The PROGNOSIS 119 skin is to be carefully prolected. and the dressing most assiduously watched. It requires l)ut forty-eight hours for great chafing to occur with the resulting discomf(jrt and the slow healing which often results. If union is firm after two weeks or two weeks and a half, the plaster dressing should be removed and the shoulder put up in a simple retentive swathe and sling, at first, inside the clothes; after three weeks, outside the clothes. In very active children the sling should not be removed until four weeks have elapsed. ^Massage should be given to the forearm, elbow, and Fig 141. — Fracture of the riglit clavicle. Shortening of the shoulder. shoulder after the first week, together with passive motion of the elbow. In both children and adults the adhesive-plaster dressing should be reapplied at least once ever\- ten or twelve days. If the dressing chafes or slips, it may need more frequent renewal. Prognosis. — Useful arms and shoulders usually result after fracture of the clavicle. Almost all complete fractures of the clavicle with displacement of fragments, after repair has taken place, show unmistakable evidences of deformity at the seat of fracture, of shortening of the width of the shoulders, and in manv I20 FRACTURES OF THE CLAVICLE instances in children of a slight lateral deformity of the spinal column (see Fig. 141). Fractures within the coracoclavicu- lar ligament having little displacement of fragments show no resulting deformity. Very great deformity does not preclude a useful arm. An ununited fracture of the clavicle is unusual; it may exist and cause no especial inconvenience; it may be un- known to the patient. An ununited fracture of the clavicle with considerable callus-formation may simulate malignant disease of the bone. Laboring men are rarely kept from their work more than two months. Fractures of the clavicle in young children, if carefully treated, should unite with practically no deformity or disability. Greenstick or incomplete fractures may show a general bowing of the whole bone, which it has been impossible to correct. Operative Treatment. — In recent fractures: If there is great displacement which can not be held reduced, if sharp fragments threaten vessels or nerves, if there is pressure upon either nerves or blood-vessels, if the fracture is a comminuted one, and if the bone is fractured in two or more places (multiple fractures), it is wise to consider operative measures. The fragments can be ex- posed, replaced, and held in position by suturing. Good results follow this treatment. After operation for fracture of the clavicle a simple retentive dressing of a swathe and cravat sling will be needed. It should be worn for at least three weeks. In Ununited Fractures. — If the cause of delayed union of the fracture is a misplaced bony fragment, an interposed strip of fascia or periosteum, or an interposed subclavius muscle, operative interference may be undertaken with a reasonable expectation of securing a good result. If, on the other hand, nonunion has ex- isted for a long period (a year or more), it is highly probable that the ends of the fragments will be so attenuated that refreshing these ends for suture would shorten the fragments to such an ex- tent that suture would be impracticable. CHAPTER VIII FRACTURES OF THE SCAPULA The spine and acromial process, the coracoid process, and the vertebral and axillary borders of the scapula can be palpated with comparative accuracy. Fracture of the scapula is of rather un- usual occurrence, and always follows great violence (see Figs. 142, 143, 144)- Fracture of the body of the scapula is transverse between the axillary and vertebral borders or comminuted in various di- rections (see Figs. 145, 146). Crepitus, abnormal mobility, local swelling, and tenderness are present. Pain is felt upon attempting to abduct the arm. It may be impossible to raise the arm to the head. Fracture of the Acromial Process of the Scapula. — The epiphysis of the acromion unites with the scapula about the twen- tieth year. If there is a fracture present, and not a separation of the epiphysis, which sometimes occurs, the line of fracture is ordi- narily outside the acromioclavicular joint. A fracture may occur through the acromion nearer to the spine of the scapula. Locahzed pain, swelling, and tenderness, and a flattening of the shoulder are present. Crepitus may at times be felt. If the fracture is inside the acromioclavicular joint, the flattening of the shoulder will be considerable. The head of the humerus is felt in the glenoid cavity, thus ruling out a dislocation. Fracture of the neck of the scapula is most unusual. If present, it may be mistaken for a dislocation of the humeral head. The acromial process is prominent. The upper arm is length- ened. On lifting the arm forcibly upward with the elbow flexed, the deformity is corrected, and crepitus is detected. The deform- ity recurs if this upward pressure is removed. The reappearance of the deformity and the crepitus serve to distinguish this injury from a dislocated shoulder. In a thin person palpation of the edges of the glenoid cavity itself will prove rather satisfactory; Fig. 142. — Normal scapula. Axillary view. Fig. 143. — Normal scapula. Ventral view. Fig. 144. — Normal scapula. Dorsal view. 122 TREATMENT OF FRACTURES OF THE SCAPULA 123 the crepitus and aljuornuil mobilily can thus be more accurately located. Treatment in General. — Immobilization of the whole upper extremity, except the forearm and hand, is necessary. Localized pressure may assist in retaining fragments in place. If there is fracture of the body of the scapula, the forearm should be flexed to a right angle and held in a sling. The skin- surfaces coming in contact should be protected by powder and compress cloth. A swathe of cotton cloth should be fastened Fig. 145.— Fracture of the body of the scapula. Bony union with moderate displace- ment (Warren Museum, specimen 8111). Fig. 146. — Multiple fractures of scapula. Railroad accident. Man, forty-three years of age. Lived one day (Warren Museum, specimen 6028). about the upper arm and trunk. If the cloth swathe is not suffi- cient to hold the scapula steady, a swathe of adhesive plaster should be used, broad enough to extend from the acromion to the elbow. Fracture of the Acromial Process : The skin-surfaces must first be protected from chafing. The forearm being flexed, pressure upward should be made upon the elbow, so as to lift the arm and relax the pull on the small acromial fragment. At the same time counterpressure is made upon the inner fragment and incidentally 124 FRACTURES OF THE) SCAPULA Upon the inner shoulder (see Fig. 140). This pressure and coun- terpressure will hold the part reduced. The bandage must be inspected frequently each day, in order to detect and to relieve too great pressure upon the elbow and bony parts of the shoulder. Union will take place in from three to four weeks. It is ex- tremely difficult to maintain the reduction of the fragment of the acromion by any apparatus. The one previously suggested meets the indications better than any other. Massage will materially assist in hastening the absorption of blood and will relieve pain. No very great functional disability results if union occurs with bony displacement. CHAPTER IX FRACTURES OF THE HUMERUS FRACTURES OF THE UPPER END OF THE HUMERUS Anatomy.— The clavicle may be felt throughout its entire length from sternum to acromion. The acromial process of the scapula articulates with the outer end of the clavicle. This acromioclavicular joint has an anteroposterior direction, and if the line of this joint is continued anteriorly, it will pass down the Pig_ 147.— View of bones of the shoulder from above. Notice acromioclavicular joint, its relations to bicipital groove and coracoid process. The point of the shoulder is made by the great tuberosity of the humerus. front of the upper arm (see Fig. 147). The outer edge of the acro- mion is continuous downward and backward with the spine of the scapula. The great tuberosity of the humerus projects beyond the acromial process, and is covered by the deltoid muscle. The point of the shoulder itself is made by the humerus and not by the acromion (see Figs. 147, 149). 125 126 FRACTURES OF THE HUMERUS Examination of the Shoulder. — The uninjured shoulder should be examined before the injured shoulder. In injuries doubtful in character, associated with much swelling of the shoulder, and which are painful upon gentle manipulation, the examination should be made with the aid of an anesthetic. Great Head of humerus. Glenoid fossa. Fig. 148. — Transverse section of trunk, showing obliquity of shoulder-joint in relation to chest, and the inclination of the glenoid cavity. Coracoid process. Clavicle. Acromial process of scapula. Head of humerus. Fig. 149. — Relations of bones to surfaces of shoulder region. Great tuberosity of humerus projects beyond the acromial process of scapula. Relations of coracoid to clavicle and head of humerus (compare with Fig. 155). swelling suggests great trauma ; absence of all swelling appreciable to the eye suggests slight trauma. For the examination the patient should be seated upon a rather high stool, so that the shoulder comes to an easy level for manipu- lation. The shoulder should be grasped, so that the head of the humerus can be felt between the fingers and thumb of one hand ^'^M ^1 ^k' -rm^M t^. >^H ^L '*' 'T^^^^H wl t,^^^^^H w ^ ^^^1 n Fig. 150.— Examination of shoulder. Method of palpating head ol humerus with thumb and fingers. Elbow grasped by other hand. Fig. 151.— Examination of shoulder. Movements of the shoulder. Normal maximum abduc- tion. Notice method of grasping head of humerus. 127 128 FRACTURES OF THE HUMERUS pressed under the spinous and acromial processes. The other hand should grasp the flexed elbow firmly, in order to make the necessary movements at the shoulder-joint (see Fig. 150). If the head of the humerus is intact and in its normal place, it will be felt to move with the shaft of the humerus, as upon the unin- jured side. All the normal movements of the shoulder-joint should be made passively and actively — naraelv, the movements Fig. 152. — Examination of shoulder. Maximum adduction. The bend of the elbow, when the forearm is flexed to a right angle, comes to the median line of trunk. of abduction, adduction, forward and backward swing, and rota- tion (see Figs. 151, 152, 153). Those movements which are pain- ful and limited should be carefully noted. Unless the normal individual standard of movement is known, as determined by ex- amination of the well shoulder, there can be no definite interpre- tation of the conditions existing in the injured shoulder. The condition of the circulation and the presence of paresis or paralysis in the limb should be observed. The shaft of the humerus should EXAMINATION OF THE SHOULDI'R 129 be measured : the measurement best taken is the distance between the edge of the acromial process and the external condyle of the humerus. The patient should be seated with the elbow at the side if possible, and Hexed to a right angle (see Fig. 154). The forearm should rest on the thigh of the same side. The direction of the long axis of the humerus should be carefully noted. The coracoid process of the scapula in all injuries to the shoulder should be palpated, for a knowledge of its position assists in locat- pjg_ i53._Examiiiatioii of shoulder. Maximum oulvvard rotation. Notice position of examining hands. ing the head of the humerus intelligently (see Fig. 155). The examiner should stand in front of the patient, and place the left hand upon the right shoulder and the right hand upon the left shoulder, the hands being open. The thumb should fall below the clavicle a full finger's-breadth, when the end of the thumb will touch the coracoid. It is generally possible to feel the coracoid even in very stout people and when much swelling is present. Diagnosis. — It is sometimes impossible to determine the exact 9 I30 FRACTURES OF THE HUMERUS lesion following an injury to the shoulder. Anesthesia and the Rontgen ray are invaluable aids to diagnosis. It is of the first importance to know whether the head of the humerus is in the glenoid cavity or whether it is dislocated ; this is determined by palpation and by noting the direction of the long axis of the humerus. It is next in importance to learn whether there is a fracture of the humerus. If the humeral head rotates with the Fig. 154.— Method of measur- ing the length of the shaft of the humerus from the acromial pro- cess to the external condyle. Fig. 155. — Examination ot shoulder. Palpating the coracoid processes. Note the position of the hands and thumbs. shaft, there is probably no fracture unless there is one with impac- tion. If the humeral head does not rotate with the shaft, then there is a fracture. If crepitus is present, the diagnosis is con- firmed. After injury to the shoulder the following fracture lesions may be present, and are to be considered : Fracture of the anatomical neck of the humerus. Separation of the upper humeral epiphysis. Fracture of the surcrical neck of the humerus. DIFFERENTIAL DIAGNOSIS 131 In any one of these instances a dislocation of the humeral head from the glenoid cavity may exist and complicate the case. Simple Dislocation of the Humeral Head, Subcoracoid (see Fig. 156). — The attitude is characteristic: the affected arm is held flexed, with the elbow away from the side and the arm rotated inward. The anterior axillary fold is lowered upon the injured side. The long axis of the shaft of the humerus is inclined inward. Fig. 156. — Dislocation of the left shoulder. Note the flat deltoid. Prominence under coracoid. Direction of the long axis of the humeral shaft. Lengthening of upper arm. Left nipple lowered. Anterior axillary fold lowered. The roundness of the shoulder is flattened. The acromial process is prominent. The head of the humerus is out of the glenoid cavity, and most often lies under the coracoid process. The elbow can not be brought in front tow^ard the median line, nor can the hand of the injured arm be placed upon the opposite shoulder. Active and passive movements at the shoulder- joint are greatly restricted. Measuring from the acromial process to the external epicondyle of the humerus, the upper arm, in a subcoracoid dis- 132 FRACTURES OF THE HUMERUS location, is lengthened. A soft crepitation may be detected in manipulating the shoulder, which simulates bony crepitus. Fracture of the Anatomical Neck (see Figs. 157, 158, 159, 160, 161, 162). — This is rare. It occurs in elderly people. Swelling of the shoulder is evident. Anesthesia is necessary for a careful examination with deep palpation. There is thickening of the neck of the bone. Crepitus will be felt unless the fracture is im- pacted. There will be pain upon moving the shoulder. Abnor- Fig. 157. — Fracture of the anatomical neck ol the left humerus. Atrophy of the shoulder muscles. Deformity at the seat of the fracture, seen a little below acromial process upon the anterior surface of the shoulder just inside the white line. mal mobility may be felt high up the shaft close to the head of the bone. This fracture lies wholly within the capsule of the joint. Separation of the Upper Epiphysis (see Figs. 163, 164, 165, 166, 167). — The separation of the upper humeral epiphysis will not necessarily open the joint cavity, for the capsular ligament is firmly attached to the epiphysis and the synovial membrane is but loosely attached to the diaphysis. The line of the separa- tion of the upper epiphysis of the humerus begins on the inner side of the head of the bone and runs across almost hori- zontally, rising toward the center of the shaft, and ends in the DIFFERENTIAL DIAGNOSIS '33 outer side of the bone, so that the epiphysis ineJudes the tuberosities. This liappens to young people, but never after the twentieth year. The most frequent period is between the ages of nine and seventeen years. Ordinarily, the upper end of the lower fragment projects forward and inward, producing a characteristic deformity. The head of the bone is in the glenoid fossa, but rotated by the muscles attached to it so that its articular surface looks downward. Fig. 158. — Normal right shoulder. Compare with figure 159. Same case as figure 157. Fig. 159. — Fraciure of the anatomical neck of the left humerus. Sharp deformity ante- riorly characteristic. Compare with figures 157 and 15S. It does not rotate with the shaft. The crepitus is of a softer qual- ity than in cases of fracture — i. e., cartilaginous. Localized pain and swelling are present. A puckering of the skin, caused bv the hooking of the lower fragment into the skin is characteristic (see Fig. 164). Palpation reveals the upper end of the shaft. A high lesion near the joint in a young patient, showing displacement forward and inward of the shaft, is very suggestive of epiphyseal separation. \ Clavicle, \ Shaft of humerus. Fig. i6o.— Fracture of high surgical or anatomical neck of humerus. Recovery with useful arm. Slight limitation of movements only (X-ray tracing). Shaft of humerus. Glenoid cavity of scapula. Fig. i6i.— Fracture of the anatomical neck of the humerus (X-ray tracing). 134 Fig. 162.— Man, sixty years of age. Fracture of anatomical neck of humerus, six months previous to this (X-ray tracing). Backward swing and abduction slightly limited, otherwise normal movements. Useful arm. Coracoid process. Clavicle. — Acromion. — Epiphysis. -- Epiphyseal line. — Glenoid fossa. Fig. 103.— Normal shoulder, showing epiphysis of upper end of humerus (X-ray tracing). 135 Fig. 164. — Separalioii of upper epiphysis of the humerus immediately after the accident. Note, especially, position of upper arm and position of head, and deep crease in skin made by the catching of the skin in the upper end of the lower fragment. Same as figure 165. Fig. 165. — Separation of the upper epiphysis of the humerus (left). Notice shortening of the upper arm. Unusual fullness internal and above normal position for head. Same as figure 166. Fig. 166. — Separation of the upper epiphysis of ilic Icfl humerus. Notice prominence below normal place for humeral head. This prominence is made by the upper end of lower fragment. Same case as figure 164. 1^,6 Fig. 167. — Fracture of high surgical neck, or separation of epiphysis with rotation of head (X-ray tracing of figure 164). Epiphysis. Lower fragment and callus. Fig. 168.— Old fracture of surgical neck high up, simulating true epiphyseal separation (X-ray tracing). 137 Head of hu- merus. Shaft of hu- merus. Fig. 169. — High fracture of surgical neck, simulating separation of the upper epiphysis ot the humerus. Displacement of lower fragment inward. Old fracture unreduced (X-ray tracing). Fig. 170. — Impacted fracture of the sur- gical neck and tuberosities in section (War- ren Museum, specimen 8539). Fig. 171.— Fracture of the surgical neck of the humerus. Much displacement. Fi- brous union only (Warren Museum, speci- men 991). 1^,8 Fig. 172. — Diagram showing usual displacement in fracture of the surgical neck of the humerus. Fig- 173- — Fracture of the surgical neck (X-ray tracing). — Head of humerus. — Shaft of humerus. Fig. 174. — Fracture of the surgical neck of the humerus. Displacement of the shaft outward. Impossible to reduce without open incision (X-ray tracing) (Eliot). 139 140 FRACTURES OF THE HUMERUS Fracture of the Surgical Neck (see Figs. 170, 171, 172, 173, 174, 175). — Any fracture below the epiphyseal line of the upper end of the humerus and well within the upper fourth of the shaft of the bone may, for all practical purposes, be regarded as a frac- ture of the surgical neck of the humerus. Fracture of the surgical neck is the common fracture of the upper end of the humerus. Fracture of the anatomical neck is most often seen in the aged. Separation of the upper humeral epiphysis occurs in youth. The head of the bone is found in the glenoid cavity. Passive movements are associated with pain, and elicit crepitus and abnor- ■~ Upper fragment. -- Lower fragment. / Fig. 175. — Fracture of surgical neck of the humerus. Same as figure 174 after reduction by open incision and wiring with silver wire. Recovery as to motion complete (X-ray tracing) (Eliot). mal mobility at the seat of fracture, provided, of course, the frac- ture is not impacted. The arm is slightly shortened. The arm is held flexed, with the elbow at the side. If after an injury to the shoulder no positive evidences of frac- ture or dislocation exist, and there is tenderness and localized swelling about the joint, and motion is painful, it is probable that simply a contusion exists. Treatment. — Fracture of the Anatomical and the Surgical Neck and Separation of the Upper Humeral Epiphysis. — The importance of these lesions demands, as has been said, an examination with I-RACTl'RES OF THE UPPER END OF THE HUMERUS 141 the aid of an anesthetic. It is even much more important, how- ever, that the first retentive dressing be appHed with the assist- ance of an anesthetic. Traction, countertraction, and manipula- tion will secure coaptation of the fragments. To hold these frag- ments securelv is difficult. To hold a separation of the upper epiphvsis in position may be impossible without operative assist- ance. To hold any one of these fractures without operative inter- ference may be impossible. The following is the best and simplest method of treatment: The upper arm, shoulder, and trunk should be thoroughly pow- dered. The hand, forearm, and elbow should be bandaged evenly, smoothlv, and firmly with a bandage of flannel — not cut on the bias. A V-shaped pad (with the apex of the V in the axilla) con- structed of sheet wadding with cardboard outside and covered with cotton cloth, should be placed in the axilla of the injured side (see Fig. 176). This pad is firm, and fitted to the trunk in order to support the inner side of the upper arm (see Fig. 1 77). If thought wise, a thin coaptation splint may be placed between this pad and the inner side of the upper arm for more direct support. The forearm is held flexed. The shoulder is now well padded with one laver of sheet wadding. A plaster-of- Paris shoulder-cap is applied so as to cover the whole shoulder, the anterior and poste- rior aspects of the chest, and the outer side of the upper arm down to the external condyle of the humerus (see Fig. 17S). This shoulder-cap is made of w^ashed crinoline, six layers thick, into which has been rubbed plaster-of-Paris cream. Its exact shape and extent are seen in the plates. A gauze bandage encircling the trunk, arms, and shoulders should be used, in order to hold the upper arm at the side and closely applied to the coaptation splint and the axillars' pad, and in order to secure the shoulder-pad firmly in place. Often better than the plain gauze bandage is a roller bandage of unwashed crinoline, which is applied just after dipping it in lukewarm water (see Fig. 179). The starch of the crinoline bandage after being wet, stiffens the crinoline as it dries and makes a particularly firm and efficient dressing. A towel folded thin or a piece of compress cloth should be placed against the trunk upon the well side. Against this the circular turns of the bandage rest, thus causing less discomfort to the patient than Fig. 176. — Fracture of the upper end of the humerus. Note hand, forearm, and elbow ban- daged ; axillary pad and strap. Fig. 177. — Fracture of the upper end or shaft of the humerus. Posterior view. Note bandage to forearm and elbow ; axillary pad and strap. Note shape of axillary pad. 142 FRACTURES OF THE UPPER EXD OF THE HUMERUS 143 if they bear directly upon the chest. The forearm is supported by a cravat sHng (see Fig. 178). By this method of immobihza- tion no active traction is exerted upon the lower fragment. The weight of the arm, being unsupported at the elbow, exerts slight traction. On account of the absence of active traction, ambulatory appa- ratus can not hold a fracture of the shoulder properly if there is much displacement ; particularly if the fracture is oblique. Am- Fig. 178. — Fracture at upper end of the humerus. Note hand, forearm, and elbow bandaged ; axillary pad and strap, plaster- of-Paris shoulder-cap, sling. Fig. 179. — Fracture at upper end of hu- merus. Arm and elbow bandaged. Axil- lary pad and shoulder-cap in position. Ap- plication of circular bandage to trunk and shoulder. Sling not shown. bulator\" apparatus can modify muscular action, insure quiet and rest to the part, and, except in the instances just noted, approxi- mately maintain the position secured by manipulation and trac- tion and countertraction. On account of its limitations, therefore, it is important that apparatus should be removed at regular and frequent inten>-als and that the whole shoulder should be examined in order to determine errors in position and, if possible, to correct them. After-care of a Fracture of the Shoulder. — Ordinarily, the great 144 FRACTURES OF THE HUMERUS swelling associated with this injury disappears in two weeks. As the swelling subsides, the normal contour of the shoulder becomes apparent again. It is necessary, therefore, to alter the shoulder splint and to apply a fresh one. When the patient wearing a shoulder-cap lies down, there is a tendency for the shoulder-cap to ride up and away from the shoulder. This can be guarded against by carrying the retaining bandage under the firm axillary pad and well over the shoulder. Pressure points should be care- fully watched, and the pressure removed. In the course of the treatment of a single case this change of dressing will have to be made two or three times. Union will be firm in from three to four weeks. As soon as union is firm, all splints may be omitted. The forearm should then be held by a sling supporting the wrist. At night it will be wise to apply a single swathe the first week after the apparatus is left off in order to avoid undue motion at the shoulder during sleep. In these injuries about the shoulder- joint passive motion should be made rather early. At the end of two weeks or two weeks and a half repair will have proceeded far enough to allow of the gentlest movement at the shoulder without causing any displacement of fragments. The sooner these gentle movements can be resumed at regular and short intervals, the more rapidly the shoulder will improve. The common occurrence of a periarthritis after an injurv to the shoulder emphasizes the neces- sity of massage. It should be begun as early as the second or third week. Prognosis and Result. — In young subjects a useful arm will result (see Fig. i8o). At first, if there is great difficulty in main- taining the reduction of the fragments, the surgeon will expect a poor result, but if he persists in efforts at retention and uses pas- sive motion early, gradually the movements of the arm will return and to a surprising degree. In people past middle life there usually is a little shortening of the upper arm and impairment in some few of movements of the shoulder, as in abduction and external rotation. In individuals over fifty years old, excepting those with rheumatism, a useful but not a strong shoulder results (see Fig. i8i). The Prognosis in vSeparations of the Epiphysis: Bony union is to be expected. If there is little or no displacement of frag- FRACTURES OF TlIE UPI'lCR END OF THE HUMERUS 1 45 merits, complete restoration of function will result. If there is some deformity rcmainin,;:;: after consolidation of the injurv. the Fig. iSo.— Young aduU. Fracture of the surgical neck of the humerus (X-ray tracing, four years after tlie accident). Abduction and rotation very slightly limited. Useful arm. ^ Head of \ humerus. Fig. iSi. — Fracture. Man fifty-five years of age. High surgical neck of humerus. Atthe end of five years recovery with very slight limitation of motion in all directions. Abduction is limited nearly one-half. Useful shoulder (X-ray tracing. Massachusetts General Hospital, 1021). usefulness of the shoulder is ultimately and usually restored. The deformity becomes less apparent as the sharp bony corners are 146 FRACTURES OF THE HUMERUS smoothed off by the newly forming callus. It is not to be forgot- ten in considering the prognosis after all shoulder injuries that much of the persisting disability may result from too prolonged immobilization of the arm, even though bony displacement may not have been very great. The growth of the shaft of the humerus in length proceeds largely from the upper epiphysis. It has been thought by many that an arrest of growth of the humerus will follow separation of this upper epiphysis. It has been reported to have occurred in eight cases but in no others. In several of these cases the injury to the shoulder was thought at the time to have been a simple contusion or sprain. A loss of growth is not likely to occur, but may follow injury to the upper humeral epiphysis. Oblique Fracture of the Surgical Neck with Great Displacement. — This fracture can sometimes be held by placing the patient in bed upon the back and making direct traction to the upper arm and countertraction upon the shoulder by weight and pulley. If the fracture can not be easily held reduced, it will be wise to make the closed fracture an open one and to unite the two fragments by suture (see Figs. 174, 175). Fracture of the Shoulder, Surgical or Anatomical Neck of the Humerus, or Separation of the Upper Epiphysis of the Humerus, Together with a Dislocation of the Upper Fragment. — The head of the humerus is found in an unnatural position and it fails to move when the arm is rotated. This is generally thought to be an un- usual accident, but by careful examination many of these cases may be detected. During the attempt at reduction of a dislocated shoulder, fracture of the humeral shaft is liable to occur. Among many cases of fracture of the surgical neck the fracture occurred fifty-nine times while an attempt at reduction of a dislocation of the shoulder was being made. Treatment. — Obviously, attempts at reduction by manipulation in the usual way will meet with failure. An attempt should al- ways be made to reduce the dislocation by abduction and traction upon the upper arm and pressure with the hand upon the loose head in the axilla. It may be possible to reduce the dislocation in this manner. If this method fails, an attempt should be made to reduce the dislocated head by open incision (arthrotomy) and FRACTURES OK THIC UPPER END OF THE HUMERUS 1 47 manipulation of the upper fragment assisted by the McBurney- Porter hook manaaiver. If this atteni])t is successful, the shaft should be sutured, with an al)Sf)rbable suture or fine silver wire, to the reduced head, and the shoulder treated as if a closed frac- ture existed. If it is impossible to reduce the dislocated head or if the head is much comminuted, it will be necessary to excise it. If operative interference has been decided upon, it is best to de- fer the operation until the acute symptoms have subsided and the damaged tissues have recovered themselves. It is the result of experience that operation through acutely damaged tissues is un- wise. The vitality of the tissues is lessened by trauma, hence the resistance to infection is temporarilv impaired. If the reduced head of the humerus becomes necrosed and ab- scesses form about the joint, an unusual occurrence, the head of the bone should be immediately excised. The After-treatment of Operated Cases. — If reduction and sutur- ing have been accomplished, passive motion should not be at- tempted until the repair at the seat of fracture is well under way. This will be about the second week. Then gentle movement may be made and gradually increased. If resection has been performed, passive motion should be gently begun almost immediately — i. e., within the first fort3^-eight hours — and persistently continued. The muscles of the shoulder should be massaged and treated by electricity. Abduction should not be attempted to any great extent for some weeks after the oper- ation for fear of displacing the upper end of the humerus too far from the glenoid cavity. The final results following reduction and suturing have been, as a rule, excellent, useful arms resulting in most cases. The results following excision are onlv fairly satisfactory. If the proper amount of bone has been removed, ankylosis will not occur. If too much bone has been removed, a dangling or flail joint will result. An excision is to be avoided if possible. FRACTURES OF THE SHAFT OF THE HUMERUS Fracture of the shaft of the humerus may occur at any point between the surgical neck and the condyles (see Fig. iSj). Its 148 FRACTURES OF THE HUMERUS common seat is at the middle or in the lower third of the bone (see Fig. 183). The twisting force exercised in the breaking up of adhesions in and about the shoulder-joint will often fracture a humeral shaft obliquely. The strength test of the arms, as seen in the illustration, has been the cause of spiral fracture of the humerus (see Figs. 184, 185). Symptoms. — The symptoms are readily recpgnized. They are swelling at the seat of fracture, pain, crepitus, abnormal motion, and ecchymoses. Paralysis of the musculospiral nerve may occur. Shaft of hu- merus, up- per frag- ment. Fig. 182. — Fracture of shaft of humerus, high. Displacement of lower end of upper fragment inward (X-ray tracing). Fig. 183. — Fracture of the shaft of the humerus in lower third. Displacement of both fragments forward (X-ray tracing). with the characteristic wrist-drop. Ordinarily, the attention of both the patient and the surgeon is so occupied with the fracture of the bone and its associated loss of movement that loss of power and sensation, because of involvement of the nerve, go unrecog- nized. If injury to the musculospiral nerve is not recognized at the outset, it may be overlooked until the splints are removed. The exact duration and the cause of the paralysis can not then be readily ascertained. The patient may wrongly attribute the paral- ysis to the pressure of the splints. Very rarely, injury or pressure upon the large vessels of the arm is met with. Damage to the Fig. 1S4.— Trial of strength of arms resulting sometimes in spiral fracture of the humerus (Monks). See figure 1S5. /c."i' n„, Fig. 185.— Illustrating spiral fracture of humerus (Monks). See figure 184. 149 I50 FRACTURES OF THE HUMERUS artery will be suggested by weak or absent pulse at the wrist or by local evidences of hemorrhage. A swelling appearing sud- denly, greater than that which would appear from the laceration of soft tissues alone, should suggest rupture of large vessels. Fig. i86. — Longitudinal fracture of shaft of humerus into the joint. Displacement of smaller fragment backward. Note space between fragment and shaft. Arm extended. Measurement of the humerus should be made from the edge of the acromial process to the external condyle of the humerus (see Fig. 1 54) . The amount of overlapping of the fragments will be shown by this measurement. TREATMENT OF I-RACTl'RES OF THE SHAFT 151 Treatment. — I'or purposes of trealment, fractures of the shaft may be grouped into those with Httle or no displacement and those with considerable displacement and difficult of retention after re- duction. The fracture should be reduced by traction upon the Fig. 1S7.— Same as figure 186. Note the disappearance of space between fragments with cor- rection of deformity upon flexing forearm. Position reduces the fracture. condyles of the humerus and countertraction upon the upper arm and by manipulation of the fractured bones. Treatment of Fractures of the Shaft of the Humerus with Little or no Displacement (see Figs. iS8, 189).— The following materials are needed for the apparatus to be used : Ordinary dusting-pow- ''^ CHAPTER X FRACTURES OF THE BONES OF THE FOREARM FRACTURES OF BOTH RADIUS AND ULNA The most common seats of fracture are in either the middle or lower thirds of the bones. The fracture of the radius is often a little higher than the fracture of the ulna (see Figs. 247-251 inclu- sive). Symptoms. — The arm can not be used without pain. In a muscular or fat arm with little separation of the fragments there may be no deformity excepting the localized swelling of the seat of fracture. Deformity will be determined by the displacement of the bones. If the seat of fracture is not obvious, the forearm should be grasped by the two hands (see Fig. 252) and gentle but firm movement attempted, to determine the presence of abnor- mal motion and crepitus. Motion should be attempted in all directions, for the bones may be fractured and yet be locked when movement is made in one direction only. Incomplete or Greenstick Fracture of the Bones of the Forearm (see Figs. 253, 254, 255). — This is a partial break across the bone, with bending at the seat of fracture. In children be- tween the ages of two and fourteen years injury to the bones of the forearm results usually in a greenstick fracture. Either one or both bones may be broken. One bone may be completely fractured while the other is incompletely broken. Deformity is very evident. Pain and tenderness at the seat of fracture are present. Crepitus is absent unless one bone is com- pletely fractured. Children having these fractures are often seen a week or two after the injury; they are said to have "sprained the arm" and "are unable to use it well at the present time." Careful inspection will detect the characteristic bowing at the seat of a greenstick fracture. Slight callus will be present if a little time has elapsed since the injury. 192 13 193 194 FRACTURES OF THE BOXES OF THE FOREARM Fracture of the Neck and Head of the Radius. — These frac- tures are rarelv unassociated with lesions of the humerus and ulna. A fracture of the external condyle of the humerus and backward dislocation of both bones of the forearm have been noted with these fractures. Local swelling and tenderness over the radial head and neck are apparent. The swelling is greater than in a simple subluxation of the radius, and is limited to the upper third of the radial side of the forearm. There is pronation of the forearm. Flexion and extension, in the absence of associated lesions such as fracture of Fig. 248. — Fracture of both bones of the forearm near the wrist, at about the same level. Radial displacement of whole hand. Deformity of wrist resembling somewhat that of Colles' fracture (X-ray tracing). Fig. 249. — Fracture of both bones of the forearm near the wrist ; different levels. Xo displacement in either place (Massachusetts General Hospital, 1384. X-ray tracing). the external condyle of the humerus, are possible. Attempted rotation of the radius, — that is, supination, — elicits pain, muscular spasm, and perhaps crepitus. The head of the bone does not usually rotate with the shaft, at least not as it does normally. vSubluxation of the radial head and fracture of the external con- dyle of the humerus are the two lesions with which a fracture of the radial neck and head is most often confused. The points of difference have been indicated. The X-ray is here of decided value. It is often difficult on account of overlying muscle and swelling of the soft parts to palpate the head of the radius with FRACTURES OF BOTH RADIUS AND ULXA 195 accuracy. Pressure over the shaft of the radius at about its mid- dle elicits pain, if a fracture of the radial neck l)e present, at the seat of fracture. An X-ray of the elbow will determine a diagno- sis. Fracture of the Shaft of the Radius (see Figs. 259-264 inclu- sive). — This is usually caused by direct violence. The fracture occurring at any part of the shaft presents no unusual symptoms. The head of the bone does not rotate with the shaft unless the fragments are locked. Abnormal mobility, pain, and crepitus are Radial head. Radial shaft. Greater sigmoid cavity of the ulna. Ulna shaft. Fig. 250.— Common displacement in fracture of the neck of the radius (after Mouchet). present. The displacements van.- with the situation of the frac- ture. Pronation and supination will be limited and painful. This fracture has been mistaken for a subluxation of the radial head. A fracture of the radial shaft at the junction of the lower and middle thirds will sometimes suggest ver\- plainly the lateral de- formit}- in a Colles' fracture, the prominent ulna and apparentlv shortened styloid process of the radius being in evidence. If the fracture occurs in the upper third of the bone, the displacement of the upper fragment will be considerable. Separation of the Lower Epiphysis of the Radius (see Figs. '/////, Fig. 251. — Fracture of both bones of the forearm at the middle, showing falling to- gether of broken ends (X-ray tracing). Fig. 252. — Fracture of both bones of the forearm, showing differences in level and that the seat of fracture is in the lower third of bones. Fig. 253.— Fracture of radius alone. Slight lateral, considerable anteroposterior, dis- placement. The fallacy of depending upon an X-ray taken in one plane only is here illus- trated (X-ray tracing). 196 FRACTURES OF BOTH RADIUS AND ULNA 1 97 265, 266). — The lower radial epiphysis unites to the shaft of the bone at the twentieth year. Previous to this age a separation of the epiphysis is not at all uncommon. Many cases of separa- tion of this epiphysis are thought to be Colics' fractures, and they are treated as such. The treatment of a Colles' fracture may pre- sent considerable difficulties. Ordinarily the treatment of a separation of this epiphysis is simple. There is little difficulty in maintaining the fragments in position in separation of the epi- physis. The epiphyseal separation requires a short time in splints. A soft, cartilaginous crepitus is felt. There are usually less swelling and less pain than in a Colles' fracture. The deformity Fig. 254.— Manner of grasping forearm to detect the presence of fracture. Xoie the firmness of grasp. is quite constant : a prominence near the carpus on the dorsum of the wrist and a prominence higher up on the palmar surface of the wrist. There is almost no tendency to reproduction of the deformity after it is once reduced. Fracture of the shaft of the ulna occurs usually because of a direct blow received upon the arm raised for protection. It is more uncommon than fracture of the radius (see Figs. 268, 269). Localized tenderness, pain upon attempting to use the forearm, obscure discomfort in the arm after an injur\- — these may be the only signs of fracture. There is no general swelling of the forearm. Ordinarily, there will be very little displacement, be- 198 FRACTURES OF THE BONES OF THE FOREARM cause the radius serves as a splint for the broken bone. Crepitus may be detected if the ulna is grasped between the fingers, placed either side of the fracture, and motion is attempted. The shaft of the ulna being subcutaneous throughout its entire extent, the tender seat of fracture can be easily determined (see Fig. 270). 'V'-&^-' Fig. 255. — Green- stick fracture of botii bones of the forearm (diagram). Fig. 256. — Greeiistick frac- ture of botli bones of the fore- arm. Notice characteristic de- formity (X-ray tracing). Fig. 257. — Complete frac- ture of uhia and greenstick fracture of radius (X-ray trac- ing). Fracture of the coronoid process of the ulna is associated with backward dislocation of the ulna. It is a rare accident. A very small fragment is broken off, and it is not much displaced. If in any dislocation of the forearm backward recurrence of the deformity after reduction occurs readily, a fracture of the coro- Fig. 258.— Right fore- arm bones in semipronatioii from front and inner side, showing epiphyses; child of eight years (Warren Mu- seum, specimen 334). Fig. 259. — Fracture of radius. Slight lateral displacement. See figure 260 (X-ray tracing). Fig. 260. — Fracture of radius. Slight an- teroposterior displace- ment (same as Fig. 259, X-ray tracing). Fig. 261.— Comminuted fracture of ra- dius, low down, and of ulnar styloid (.X-ray tracing). Fig. 262.— To illustrate so great damage to lower end of radius that complete restor- ation to normal is impossible (X-ray trac- ing). 199 Mu- . < a o V ^ rt A aci; D.e 2; M rt S s 2 n E 3 rt ■n rt I- ^ ^ u ri, O -■-< M o u a bi > < fe ni 200 TREATMENT 20 1 noid should be suspected. This will be confirmed by the dis- covery of a small hard mass in front of the elbow- joint just above the insertion of the brachialis anticus muscle; roughly, a finger- breadth above the bend of the elbow. This small hard mass may give crepitus upon being manipulated. It is very difficult to detect this fragment of the coronoid process even under the most favora- ble conditions. The Rontgen ray may discover it. Treatment of Fractures of the Forearm. — The objects of ;05rV5 Fig. 265. — Oblique fracture of the shaft of the radius. Fig. 266. — Separation of the lower epiphy- sis of the radius without displacement. treatment are to prevent permanent deformity and to preserve the movements of pronation and supination. Fractures of Both Radius and Ulna. — All fractures of the fore- arm attended with overriding or angular displacement that do not yield readily to traction, countertraction, and pressure should be reduced under complete anesthesia. While an assistant makes countertraction upon the upper part of the forearm the surgeon, holding the low^er end of the limb, makes strong, even traction, at the same time pressing the bones into position. \\'hen the angular deformity is corrected, the forearm should be strongly supinated. This supination will assist in preventing the bones becoming locked close together (see Fig. 273). 202 FRACTURES OF THE BONES OF THE FOREARM In order to immobilize a fracture of the shaft of a bone not only must the fracture itself be held firmly, but the joint immediately above and below the seat of fracture must be immovably fixed. If the arm is seen immediately after the accident, and the soft parts are not evidently bruised, and there is little swelling, a plaster-of- Paris splint should be applied. It should extend from the axilla above to the metacarpophalangeal joints below. The arm should be flexed to a right angle and the forearm semi- supinated (thumb upward) (see Fig. 274). Fig. 267. — Old fracture of both bones of the forearm ; pseudoarthrosis of ulna. Radial fracture has united (X-ray tracing). Fig. 26S. — Fracture of the shaft of the ulna. Slight lateral displacement. Local- ized tenderness clinically the only symp- tom (Massachusetts General Hospital, 1036. X-ray tracing). Precautions in Using the Plaster-of- Paris Splint: The forearm should be held in the corrected position by an assistant through- out the application of the plaster bandages. Two assistants will facilitate the putting on of the plaster. The forearm and upper arm should be thinly covered with one layer of sheet wadding; cotton wadding should not be used. No salt should be used in the water in which the plaster bandages are dipped. It will require about three or four bandages, three inches wide and four yards long, for an ordinary muscular adult arm. The plaster TREATMENT 203 roller slioiikl be applied deliheralely, evenly, and snugly from Ihe metacarpophalangeal joints to the axilla. Great lateral com- pression of the arm will be avoided if the bandage is applied as directed. There will be insuflicient compression to crowd the bones together and so produce deformity. After-care of the Plaster vSplints: When the plaster has set iirmlv, the assistant may place the forearm in a sling of comfort- able height to support the arm. Inspection of the fingers will de- termine the condition of the circulation in the limb. If there is too great pressure, if the splint is too tight, a blueness will appear, Fig. 269. — Fracture of ulna, low down, with considerable lateral displacement and shortening of shaft (X-ray tracing. Massa- chusetts General Hospital, 5693). Fig. 270.— Partial fracture of ulna. T- shaped line of the fracture (Warren Mu- seum, 3722). indicating a sluggishness in the circulation. If this sign appears, the splint should immediately be split from axilla to hand by a knife. This wall relieve the circulation. Ordinarily, there is no difficulty of this sort. The patient should be seen each day for the first week after the dressing is put on. Inquiry should be made for pain and throbbing in the arm and sleeplessness, which are evidences of too great pressure. If the arm is doing well, the splint should cause no discomfort. After one week the plaster splint should be removed, for the swelling of the arm will have diminished and the splint will have become loosened. Unless 204 FRACTURES OF THE BONES OF THE FOREARM this loosening is corrected, an opportunity for deformity to occur will then exist. Either a new plaster should be applied or the old splint, if suitable, should be reapplied and tightened by a bandage. If the splint is too large, it may be made smaller by removing a strip of plaster the entire length of the splint. The edges of the cut plaster should be bound with strips of adhesive Ulna. Radius. Fig. 271.— Sliowing dis- tance between bones and their relation to mass of soft parts. Median section of forearm (from frozen sec- tion by Dwight). Fig. 272. — Variations in the shape and width of the in- terosseous space between radius and ulna when the fore- arm is supinated, pronated, and semipronated. Semi- pronation presents the widest interosseous space (dia- gram). plaster to prevent chafing of the skin and crumbling of the plaster. The position of the bones at the seat of fracture should be noted. The degree of movement possible at the seat of fracture should be noted. At the end of each week the splints should be removed. After about three weeks, when union is well advanced, the plaster splint may be cut off below the elbow and the upper part dis- TREATMENT 205 carded, or a posterior splint of wood may be applied for lightness and convenience. If the force was a direct violence and there is injur}' to the soft parts, if the swelling is considerable and is likely to be greater, it will be best to use palmar and dorsal splints of wood upon the fore- Fig. 273. — Fracture of the forearm low down, or Colles' fracture. Anterior and posterior splints, three straps, radial pad. Anterior splint cut out to fit thenar eminence. Fig. 274. — Fracture of the forearm. Manner of holding arm and of applying the adhesive- plaster straps. Posterior splint of splint wood. arm and an internal right-angle splint at the elbow. The fore- arm is held in the position of semisupination. The maximum swelling occurs within the first forty-eight hours — barring, of course, inflammatory disturbances, which are not to be considered here. The splints should be of thin splint wood, which is stiff 2o6 FRACTURES OF THE BONES OF THE FOREARM enough not to yield to ordinary pressure. In width they should be one-fourth of an inch wider than the forearm. The posterior splint should extend from just above the middle of the forearm to the metacarpophalangeal joints. The anterior splint should extend from the same point on the forearm to the middle of the palm of the hand (see Fig. 273). The palmar splint is cut out on the thumb side, so as to avoid pressure on the thenar eminence. These two splints are padded with evenly folded sheet wadding Fig. 275. — Fracture of both bones of the forearm. Proper position of arm in sling. Note hand is unsupported by sling, and arm rests on ulnar side. Notice height of arm. no wider than the splints. About three or four thicknesses of the sheet wadding will be necessary. The posterior splint is padded alike through its whole extent. The anterior splint is so padded as to conform to the irregularities of the anterior surface of the forearm, particularly at the radial side near the wrist. The internal right-angle splint is padded evenly with four thicknesses of sheet wadding. It overlaps the wooden splints, and extends up to the axilla. It immobilizes the elbow-joint. The Application of the Splints: The forearm is held flexed at TREATMENT 207 a right angle and semisupinated and steadied by an assistant. The posterior and then the anterior splints are applied to the forearm. Three straps of adhesive plaster, two inches broad, are then applied — one at the upper ends of the splints, one at the wrist, and the third across the palm of the hand and around the posterior splint only. These straps should simply steady the splints snugly in position (see Fig. 274). The bandage is next applied, and it is by this that pressure is exerted upon the arm. There should be some spring left upon pressing the splints together after the bandage is applied. If there is none remaining, too Fig. 276. — Fracture of bolh boties of the forearm. Ulnar view of the anterior and posterior splints. Note length of splints and position of straps. Straps of the internal right-angle splint, 3 and 4. great pressure will be made on the arm and the circulation will be interfered with. The arm is placed in a sling of comfortable height (see Fig. 275). If the fracture of the forearm is above the middle of the bones, the tin internal right-angle splint should be used to immobilize the elbow- joint. This should be applied after the wooden splints are in place and v>-hile the arm is semisupinated. A bandage is then placed over both wooden and tin splints (see Figs. 276, 277, 278). After-care of Wooden and Tin Splints: The patient should be 2o8 FRACTURES OF* THE BONES OP THE FOREARM seen every day for two or three days after the fracture. The splints should be readjusted and applied more snugly by a fresh bandage. The comfort of the patient should be considered; any complaint on the part of a sensible individual should be inquired into. If the apparatus is applied with the bones in approximately normal position, there should be no subsequent discomfort. All splints should be removed at least twice a week throughout active treatment, and the presence of deformity noted and corrected. After the first week or week and a half, the swelling having sub- Fig. 277. — Fracture of the bones of forearm. Forearm supinated. Anterior and posterior splints and tin interna! angular splints, i and 2, Straps holding anterior and posterior splints ; 3, 4, and 5, straps holding internal right-angle splint. sided, it is often advantageous to apply in place of these splints of wood the plaster-of- Paris splint, which has been described (see p. 202). Fracture of the head and neck of the radius and fracture of the coronoid process of the ulna should be treated by the internal right- angle splint with the forearm semipronated — that is, with the thumb up (see Fig. 278). Fracture of the shaft of the radius, if above the middle of the bone, should be treated by the anterior and posterior wooden splints and TREATMENT 209 the internal right-angle splint. If below the middle of the bone, the internal right-angle splint may be omitted, although it may be well to retain it in most instances. If the fracture is in the upper third of the bone, it may be impossible to correct the de- formity without making an open fracture and suturing the frag- ments together. It may be possible to approximate the fragments by putting the forearm in a position of semipronation. No special splint is necessary to mJiintain this position ; the two wooden ante- rior and posterior splints and the tin internal right-angle splint fulfil all the indications. Separation of the lower radial epiphysis is treated h\ anterior and Fig. 278.— Fracture of both bones of the forearm. Anterior and posterior splints and tin internal right-angle splint immobilizing elbow-joint. Note arm in semipronation, "thumb up " ; position of straps ; padding of internal right-angle splint. posterior splints, similarly to the treatment of a Colles' fracture (see Fig. 273). Fracture of the shaft of the iilna should be treated as fractures of the shaft of the radius are treated. How long should splints be kept on in fractures of the forearm? Until union is firm enough between the fragments, so that firm pressure does not cause motion. ^A'hen the fracture is firm, ordi- narily after about three weeks and a half, the anterior and internal angular splints may be omitted, the posterior splint alone being left in place. If the posterior splint of wood is used, a broad (four- inch) strap of adhesive plaster, in addition to the two ordinary 14 210 FRACTURES OF THE BONES OF THE FOREARM Straps at each end of the sphnt, should be placed at the seat of fracture and a gauze bandage applied over all. At the end of the fourth or fifth week all splints should be omitted. Continual watchfulness is demanded in order that bowing at the seat of frac- ture may not take place. The application of the sling after the omission of splints should be carefully made to avoid backward Fig. 279. — Application of sling. Proper position of triangular bandage in first step. 2 is carried over right shoulder; i drops over left shoulder; i and 2 are fastened behind the neck ; 3 is brought forward and pinned, as shown in figure 280. bowing of the bones. A laboring man should not go to work for at least from four to six weeks after leaving off splints. A return to work too early causes bowing of the fracture and pain in the arm. Massage and passive motion should be employed as soon as union is firm and the anterior and internal angular splints have been removed. Massage may be given at first without removing PROGNOSIS AND RESULT OF TREATMENT 211 the arm from the splint. Convalescence will proceed more rap- idly in consequence of massage. When will the arm be restored to normal usefulness? It is im- possible to answer this question accurately. The conditions in each individual instance of fracture are so variable that no gen- eral statement can be made that will more than indicate the probable time of convalescence. It may be fairly stated that in an uncomplicated fracture of both bones of the forearm the arm Fig. 2S0. — Application of sling. Final position of arm. Two ends tied behind neck and the third end pinned. will be useful for working in from two to three months from the time of fracture. The treatment of open fractures of the forearm is best con- ducted by methods described under open fractures of the leg: briefly, absolute cleanliness, suturing of bones, sterile dressing, immobilization of the part. Prognosis and Result of Treatment. — There may be some limitation of supination and pronation immediately after the 212 FRACTURES OF THE BONES OF THE FOREARM splints are removed. As the callus diminishes and with persist- ent movements of the arm in ordinary use this limitation should diminish, and in some instances entirely disappear. If the frac- ture is in the upper or lower thirds of the bones, the limitation of motion will often be greater than when the fracture is at the middle of the bones. The interosseous space is greatest at the middle of the shafts (see Fig. 272); consequently, callus at this point is less likely to impair motion of the forearm. The arm Fig. 281. — Compound fracture and dislocation at tiie wrist. Hand saved. should be straight. Movements of the wrist and elbow should be perfectly normal. Nonunion of Fractures. — If after the usual time has elapsed for a fracture to have united firmly it has failed of union, delayed union is said to exist. If after a longer time no union occurs, nonunion is said to exist. A case of delayed union may result in nonunion or it may become united. The term nonunion does not, however, necessarily imply that no union exists between the bones, but simply that bony union does not exist. In cases of so- called nonunion fibrous union is often present. The causes of non- union are local and general. Of the local causes the commonest PROGNOSIS AND RESULT OF TRI-ATMENT 213 is the interposition of some soft tissue, such as torn periosteum, strips of fascia or muscle, between the fragments. A wide separa- tion and imperfect immobilization of the fragments are also factors in the occurrence of nonunion. Of the general causes it is thought that syphilis, pregnancy, prolonged lactation, the wasting dis- eases, rachitis, and the acute febrile diseases may contribute some- thing toward nonunion. The constitutional treatment of nonunion is of primary impor- tance, together with reduction and absolute immobilization of the fragments. If these measures fail after a fair trial, a rubbing of Fig. 282. — Method of applying force in completing a greenstick fracture of the forearm. The force is applied in the direction of the original force (diagram). the ends of the fractured bones together and then immobilizing them is sometimes effective. If this fails too, operative meas- ures should be instituted for making the fracture an open one for the removal of any interposed tissues. Careful fixation will, after such operative procedure, usually effect union. If for some unremediable constitutional reason union does not result after operation, a splint should be devised to make the damaged part as useful as is compatible with nonunion. Treatment of Greenstick or Incomplete Fracture of the Bones of the Forearm. — It is impossible to maintain the correction of the de- formity if the bones are sim.ply bent back into position. Even 214 FRACTURES OF THE BONES OF THE FOREARM with the greatest care in the use of pads and pressure the deform- ity will in part reappear. It is necessary, therefore, to administer an anesthetic, and to make a complete fracture of the greenstick fracture. This done, the arm is set as in a complete fracture. The best method of refracturing the greenstick fracture is to bend the arm with the two hands in the direction of the original force (see Fig. 282). The anterior and posterior wooden splints may be used with satisfaction. Ordinarily, the plaster-of-Paris splint as applied in complete fractures is the best apparatus. Union in children after fracture is more rapid than in adults. At the end of two weeks union will be found firm. It is well not to omit all apparatus in a child until four weeks have passed. If great caution is needed on account of an extremely active child, the posterior wooden splint should be kept on during the fifth week. FRACTURES OF THE OLECRANON The normal anatomical relations of the olecranon should be kept constantly in mind. The insertion of the brachialis anticus muscle is into the front and lower part or base of the coronoid process of the ulna. The insertion of the triceps muscle is into the posterior part of the upper surface of the olecranon and into the fascia of the posterior surface of the forearm. The small epiphysis of the olecranon unites to the shaft about the sixteenth year. A direct blow upon the olecranon together wdth violent muscular contraction of the triceps will produce the fracture. The fracture is usually transverse. A complete transverse fracture of the olecranon always opens the elbow- joint (see Fig. 283). Some of the varieties of fracture of the olecranon are seen in the accom- panying tracings of Rontgen-ray plates (see Figs. 284, 285, 286, 287). Symptoms. — Inability forcibly to extend the forearm, pain at the seat of fracture, and deformity, provided the fragment is separated from the shaft of the ulna. A depression marks the separation. Very great separation of the fragment is not often present. The interval between the fragments depends upon three conditions: The extent of the facial laceration — if the laceration FRACTURES OF THE OLECRANON 215 is moderate in extent, the interval between the fragments will be slight; if the laceration is extensive, the interval between the Fig. 283.— Showing relations of olecranon to elbow-joint ; practically all fractures are intra- articular. Seat of fracture. Fig. 284.— Splintered fracture of olecranon without much displacement (Massachusetts Gen- eral Hospital, 1536. X-ray tracing). fragments may be great ; the position of the arm, whether flexed or extended— if flexed, the separation will be greater than if ex- tended (see Fig. 288); the amount of synovial fluid and blood in 2l6 FRACTURES OF THE BONES OF THE FOREARM the joint — the greater the amount of fluid, the greater will be the separation of the fragments. The mobility of the fragments of Radius. Coronoid process. Ulnar shaft. Olecranon. Seat of fracture. Fig. 285. — Fracture of olecranon. No displacement detected clinically. No symptoms other than local tenderness and slight swelling (X-ray tracing). Olecranon. Ulnar shaft. Fig. 286.— Fracture of olecranon; separation of fragments upon flexing forearm (X-ray tracing). the olecranon is determined by grasping the olecranon firmly and attempting lateral motion (see Fig. 207). Crepitus may thus TREATMENT 217 be elicited. The general swelling about the elbow will be con- siderable if the traumatism was severe. There exists a traumatic synovitis of the elbow-joint. Line of fracture. Fig. 287. — Fracture of olecranon at about the epiphyseal line, without opening the elbow-joint (Massachusetts General Hospital, 1172. X-ray tracing). Fig. 288. — Diagrams to illustrate separation of fragment of olecranon by the triceps and in flexion of the elbow. Treatment. — If there is considerable swelling of the elbow, and if the arm is large and muscular, it is wise to rest the arm for a 2l8 FRACTURES OF THE BONES OF THE FOREARM few days (at least five or six) upon an internal right-angle splint before putting it up permanently. The swelling will disappear in the mean time, and a more accurate examination of the arm can then be made. If there is little or no separation of the frag- ments in the right-angle position, the arm may be kept at a right angle. This is doubtless the most comfortable position, and. ^^^■:. ■^"^■'U^SMS^^^^^M ^g J. p* ^^^^KF^^\Y7^^^Kfr f ^r^ .Jt^K^^^^^^^^k ' ^1 ■• i^SS^^^^B L^^^ I^H -^^^^^1 ^1 Fig. 2S9.— Fracture of the olecranon. Arm in extension. Long anterior splint. Note pad and strap above olecranon fragment ; pad in palm of hand. under these conditions, certainly is effective. If there is marked separation (half an inch or more), the arm should be extended and this position maintained by a long internal splint (see Fig. 289). This splint, made of splint- wood, should be the width of the arm, and should reach from the anterior axillary margin to the tips of the fingers. This is well padded with sheet wadding at the bend of the elbow (see Fig. 290). The contiguous skin sur- TREATMENT 2 19 faces of the fingers are protected from chafing by strips of gauze or compress cloth placed between them, and a pad is put in the palm for comfort (see Fig. 291). The splint is held in position by four straps of adhesi\e plaster, one placed at either end of the splint and one above and below the elbow-joint. The upper or loose frag- ment is pushed down toward the shaft of the ulna, and held in Fig. 290.— Fracture of olecranon. Arm in extension. Note upper and lower straps ; oblique olecranon strap ; padding of splint. place by a strap of adhesive plaster carried around the upper side of the olecranon fragment and fastened to the splint lower down. Sheet wadding and gauze roller bandages applied from the fingers to the axilla afford comfort and prevent undue swelling of the hand. >Should the separation be so great that reduction of the fragment is unsatisfactory, an incision and suture should be made (see Fig. 291). 2 20 FRACTURES OF THEI BONES OF THE FOREARM Treatment if the Fracture is Open. — The wound should, if nec- essary, be enlarged to permit of easy inspection of the joint surface. The joint should be thoroughly irrigated with boiled water. The wound of the soft parts should be very thoroughly cleansed by scrubbing with gauze wet in corrosive sublimate solution, i : 5000, and then the fragment of the olecranon sutured to the shaft. Fig. 291. — Fracture of olecranon. Bandage applied to the same case as shown in figures 2S 290. Note protection of fingers from chafing by compress cloth and bandaging of hand. The After-care. — If the arm has been put up temporarily at a right angle to await the subsidence of the swelling, gentle massage and firm bandaging of the arm, twice daily, until the swelling sub- sides sufficiently for accurate examination and a more perma- nent dressing, will be of very great service. The arm should be inspected each day for the first week. Daily massage should be continued not only to the joint region, but to the forearm and TREATMENT 221 Upper arm as well. The straps and bandages should be reapplied as they become too tight or are loosened by the disappearance of the swelling. After about two weeks the position of the forearm may be cautiously changed. The small fragment of the olecranon should be held fixed during the manipulation. If the arm is in the extended position, it should be gradually flexed some five or ten degrees, and returned to the extended position. If the arm is already at a right angle, it should be gradually extended, at first a Fig. 292.— Method of examination of wrist. Note supination of forearm ; posi- tion of examining hands and iingers ; pal- pation of the styloid process of the radius and the head of the ulna. The radial sty- loid is seen to be lower than the head of the ulna. Fig. 293. — Method of examination of wrist. Note pronation ot forearm ; posi- tion of examining hands and fingers; pal- pation of styloid processes of radius and ulna. The styloid of the radius is lower than the styloid of the ulna. few degrees only, and returned to the right-angle position. Xo pain should be experienced by the passive motion. Painful passive motion is harmful. After a few da^'S of these gentle pas- sive motions it will be wise to alter the angle of the splint so that the arm may rest in the changed position permanently. After about four or five weeks all splints should be omitted. A bandage should be worn after the removal of the splints to afford support to the elbow. 222 FRACTURES OF" THE BONES OF THE FOREARM Union of the fragments usually takes place in from three to four weeks. After six weeks to three months the movements of the elbow- joint should be normal. There may remain as a per- manent condition slight limitation of extension. The functional usefulness of the elbow depends more upon the approximation of the fragments and less upon the kind of union between them. The union between the fragments is more often ligamentous than bony. The short fibrous union, if of good width, — i. e., if it covers the whole of the broken surface, — is as efficient as a bony union. Fig. 294. — a, Tip of radius ; 6, styloid process of ulna ; c, ulnar head. i. Supination. 2. Pronation. To illustrate that, in comparing the level of the styloid of radius with lower end of ulna, as in figures 292, 293, in supination, i, the head of the ulna is felt, and that in prona- tion, 2, the styloid of the ulna is felt. A ligamentous union accompanied by great disability in the func- tional usefulness of the arm should be excised and the bony frag- ment sutured to the shaft. Suturing of the periosteum and fibrous tissue about the fragments will prove fully as satisfactory in many cases as suturing the bone with silver wire. Summary: If there is great swelling, delay the application of the permanent splint. Apply internal right-angle splint. Use compression and massage. If there is little or no separation of the fragments, use a right-angle splint. If there is marked sepa- COLLES FRACTURE 223 ration of fragiiK'Hts, use an fxtfiulcd ])()sitioii. If tlu- iVaclure is open, suture the fragnienls. If practicable, at the outset, renew the bandage and massage the arm twice daily. After two weeks cautious passive motion should be made daily. After three weeks the angle of the splint should be permanently changed. After four weeks all splints should be removed. After six weeks to three months a useful arm should result. TetcDius is rarely seen after fracture of bone. It sometimes appears after open fracture. Early amputation and the adminis- tration of tetanus antitoxin are the most rational means of treat- ment in these cases. COLLES' FRACTURE A fracture of the lower end of the radius within about one inch of the articular surface is common in adults and is unusual in child- hood. A fall upon the outstretched and extended hand is the most frequent cause. Anatomy. — In a case of traumatism to the wrist the normal Fig. 295. — Method of examination in a case of injury to the lower end of the radius. Grasp- ing the radiu.s above and below the probable seat of fracture. anatomical relations should be studied upon the uninjured wrist, and then a careful examination made of the injury. The normal wrist should be looked at from the front and back and from each side with the hand supinated. Anteriorly, the base of the thenar eminence is lower than that of the hypothenar eminence. Pos- teriorly, on the inner side, the styloid process of the ulna is visible with the marked depression below it. Laterally, on the radial 224 FRACTURES OF THE BONES OF THE FOREARM side, is seen the curve backward on the anterior surface of the radius where the base of the styloid process of the radius joins the shaft. Laterally , upon the ulnar side, are seen not only the styloid of the ulna and its associated depression, but the hollow above the prominence of the hypothenar eminence. The normal wrist should be felt with the hand both in supina- tion and pronation. With the hand supinated (see Fig. 292) the tip of the styloid process of the radius is found to be lower (nearer Fig. 296. — Diagram of fracture of base of radius with anterior displacement: "reversed CoUes' fracture" (term suggested by Roberts). Fig. 297.— Colles' fracture: the common "silver-fork deformity." Note dorsal and palmar prominences (diagram). the hand) than the head of the ulna. With the hand in pronation (see Fig. 293) the tip of the styloid process of the radius is found to be a little lower (nearer the hand) than the tip of the styloid process of the ulna. To ascertain the relative position of the sty- loid processes, the injured wrist should be grasped by the two hands and the styloids felt by the tips of the forefingers. The styloid process of the radius and the shaft immediately above it should be carefully palpated to determine the extreme thinness of the bone above the thick styloid process (see Fig. 295). The COLLES' FRACTURU — ANATOMY 22. width of the wrist between the styloid processes should be meas- ured by means of a tape, or, better, by a pair of calipers. The movements of the normal wrist and forearm should be carefully observed. Pronation and supination of the forearm and Fig. 29S.— CoUes' fracture. Characteristic appearance. Note backward displacement of the hand and wrist. Palmar prominence. Compare with figure 297. Fig. 293.— Colles' fracture, radial side. Marked crease at base of thumb. Dorsal and palmar prominences. Fig. 300.— CoUes' fracture, ulnar side. Absence of ulna on the dorsum of the wrist ; presence anteriorly. Marked crease in front of displaced ulna. Dorsal prominence marked. flexion, extension, abduction, and adduction of the hand should be carefullv performed. These simple observations quickly made upon the normal wrist enable one to establish a standard for com- parison wdth the injured wrist. In every case in which there is a 15 226 FRACTURES OF THE BONES OF THE FOREARM question of fracture the examination should be made by means of an anesthetic (see Fig. 295). If for sufficient reason complete anesthesia is contraindicated, primary anesthesia will prove to be sufficient. In the larger proportion of cases of Colles' fracture primary anesthesia will be satisfactory for both the examination and the first dressing of the fracture. Symptoms. — In Colles' fracture the wrist appears unnatural. The thenar eminence of the thumb is higher, nearer to the wrist Fig. 301. — Colles' fracture, anterior bulg- ing of flexor tendons ; absence of dorsal prom- inence of head of ulna. Fig. 302. — Colles' fracture. The dorsal prominence is not uncommonly seen after recov- ery from fracture of the radius when the displaced bones have been but partially reduced. Slight lateral deformity. Fig. 303.— Colles' fracture. Hand carried to radial side. Prominent ulna anteriorly. Thenar eminence lower than normal. than usual, as compared with the hypothenar eminence (see Fig. 303). Anteroposterior and lateral deformities are apparent to a greater or less degree. It is said that at times an anterior dis- placement of the lower fragment occurs, the reverse of the ordi- nary displacement. It is unusual (see Fig. 296). The anteroposterior deformity is caused by the projection of the lower end of the upper fragment into the palmar surface of the wrist, pushing the flexor tendons forward (see Fig. 297), and by the projection of the upper end of the lower fragment toward the COLLES FRACTURE — SYMPTOMS 227 dorsal surface of the wrist, pushing the extensor tendons back- ward. Impaction of the radial fragments may be another factor in the production of the deformity. This deformity is spoken of by the older writers as the silver-fork deformity. The reason is obvious (see Figs. 298, 299, 300, 301, 302). The lateral deformity (see Fig. 303) is caused by several factors : the impaction of the radial fracture, lateral displacement of the Fig. 304.— A form of comminution in Colles' fracture. Left wrist from back and below (diagram). Line of fracture. T-line. , J , Lower radial fragment. ZtJiZ- .^_^ Semilunar bone. -"^ / / / Styloid process of ulna. Fig. 305. — Colles' fracture. Anteroposterior view. Slight lateral deformity. Anterior view of figure 306 (Massachusetts General Hospital, 1028. X-ray tracing). lower fragment, and by rupture of the inferior radio-ulnar liga- ments. The abduction of the whole hand, the prominence later- ally of the lower end of the ulna, the disappearance of the ulnar head from the dorsum of the wrist, are to be noted. Because of the displacement of the radial lower fragment, the normal relations are no longer maintained between the styloid processes of the radius and ulna. There is a reversal of relations. The radial sty- 228 FRACTURES OF THE BONES OF THE FOREARM loid is higher than usual. It is on the same level with or higher than the head of the ulna. It is possible to have present a fracture of the lower end of the radius (a Colles' fracture) without any appreciable alteration in the levels of the styloid processes. The existence of the normal Lower radial fragment rotated. Scaphoid. First metacarpal. Styloid of radius. Fig. 306.— Colles' fracture. Lateral view of figure 305. Rotation of lower fragment on trans- verse axis. Cause of dorsal and palmar deformity evident (X-ray tracing). Lower fragment of radius. Fig. 307. — Simple transverse Colles' fracture. Anteroposterior view. Lateral deformity (X-ray tracing). relations of the styloids does not preclude the presence of a frac- ture. Direct pressure over the broken bones elicits pain, but crepitus is often undetected until the patient is examined with the aid of an anesthetic. A transverse ridge is sometimes present on the o .a o o — Q, O 2 30 FRACTURES OF THE BONES OF THE FOREARM posterior and external surface of the radius, corresponding to the line of fracture. In certain cases of Colles' fracture the wrist may not appear very unnatural. There may be scarcely an)^ deformity. Radius Line of fracture. I Ulna. Line of fracture. Pig_ 3io._Simple transverse Colles' fracture. Lateral view. Same as figure 307 (Massachu- setts General Hospital). V 1 ^, Styloid process. Fig. 3n.— Colles' fracture. Fracture of styloid of ulna. A T-fracture into the wrist-joint. Much lateral deformity (X-ray tracing). The normal relation may be nearly preserved. If there is little displacement of the fragments, it may be difficult to determine the existence of fracture. An appreciation of slight differences COLLES' FRACTURE — DIFFERENTIAL DIAGNOSIS 231 from the nonnal will, under these circumslances, prove of great value. The Rontgen ray will be of service in this connection. After injury to the wrist one must consider in the differential diagnosis — A sprain of the wrist, Fracture of the shaft of one or both bones Contusion of the bones near the wrist, low down, Dislocation of the wrist Imckward. Separation of the lower radial epipliysis. A sprain of the wrist is rather unusual. There very often exists in so-called sprains a definite anatomical lesion of bone. The deformity due to the distention of the synovial sac wath fluid is Ulna. Displaced styloid process of ulna. Fig. 312.— Colles' fracture with fracture of base of ulnar styloid; outward displacement of styloid fragment. Shaft of radius driven into the lower fragment (Massachusetts General Hospital, 1 173. X-ray tracing). pig_ 313.— Radial fracture upward and outward (Massachusetts General Hospital, 1126. X-ray tracing). conspicuous over the back of the wrist- joint and, therefore, near the hand. There is tenderness upon pressure over the synovial membrane anteroposteriorly. There is little or no tenderness over the radius upon deep pressure. There is an absence of the positive signs of fracture. It is not an uncommon experience to find an injury- to the lower end of the radius presenting no posi- 232 FRACTURES OF THE BONES OF THE FOREARM tive fracture signs, which is proved by the Rontgen ray to be a break of the lower end of the radius. A lesion somewhat resem- bling that shown in figure 304, the bone being cracked along those same lines but without displacement, is sometimes found to exist. Many of these obscure lesions are passed over as sprains of the Fig. 314.— Fracture of inner edge of \.he radius (X-ray tracing). Fig- 315.— Fracture of radial styloid (Massachusetts General Hospital, 1252. X-ray tracing). wrist. Any injury to the wrist, no matter how trivial, should be regarded with suspicion until there is absolute proof that fracture is absent. A Contusion of One or Both Bones near the Wrist-joint: Ten- derness is localized. Fracture signs are all absent. The Rontgen ray will assist in determining this diagnosis. Dislocation of the wrist backward is rare. The posterior promi- nence is lower down on the wrist than in Colles' fracture. The COLLES' FRACTURE — DIFFERENTIAL DIAGNOSIS 233 Upper surface of the displaced carpus can be felt. The relation of the two styloids is preserved. The deformity disappears and does not tend to reappear when traction is made on the hand and pres- sure is made over the dorsal prominence. Fracture of the shaft (see Fig. 317) of one or both bones low Radial epiphysis, outer fragment. Radial epiphysis, inner fragment. Displaced styloid pro- cess of ulna. Ulnar epiphyseal line. Fig. 316. — Fracture of the epiphysis of the lower end of the radius and of the styloid process of ulna (Massachusetts General Hospital, 712. X-ray tracing). Fig- 317- — Colles' fracture, with fracture at lower end of ulna (^X-ray tracing). down may simulate the anteroposterior deformity of Colles' frac- ture, but an absence of other positive signs is important. The Rontgen ray determines the exact seat of the lesion. Abnormal mobility and crepitus are readily obtained without the adminis- tration of an anesthetic. Fig. 318. — Case: Adult. Very great comminution of lower end of the radius. Extremely difficult to mold fragments into good positions. Note abduction of hand. 234 COLLHS' FRACTURE — ASSOCIATED LESIONS 235 A Separation of the Lower Epiplusis of the Radius: The lower epiphysis of the radius unites with the shaft about the twentieth year. The radius increases in length chiefly through growth from its lower epiphysis. This lesion occurs much more commonly than has hitherto been supposed. It is usually classed as a Colles' fracture, no very careful examination being made. There is usu- Fig. 319.— Reduction of Colles' fracture. Note position of hands in forcibly hyperextending the lower fragment ; breaking up impaction. Fig. 320. — Reduction of Colles' fracture. Note grasp upon forearui aiul the lower tiagment of the radius, traction and countertraction being made; breaking up the impaction. ally less deformity than is found in most Colles' fractures, and it is nearer the hand. The crepitus is soft and cartilaginous, and easily obtained without an anesthetic. The treatment of separa- tion of the lower radial epiphysis is similar to that of a Colles' frac- ture. A fracture of the lower radial epiphysis is occasionally seen; it is, however, a rare lesion (see Fig. 316). 236 FRACTURES OF THE BONES OF THE FOREARM Associated with every Colles' fracture there may be one or more of the following lesions : A fracture through the lower end of the ulna, which is rather rare (see Fig. 317). A fracture of the styloid process of the ulna, which occurs in about fifty to sixty-five per cent, of all cases (see Fig. 312). A rupture of the interarticular triangular fibrocartilage at its insertion into the base of the styloid process of the ulna. This is probably quite common, and accounts in part for the broadening of the wrist-joint. A perforation of the skin by the lower end of either the ulna or the shaft of the radius, making an open fracture. A fracture of the scaphoid bone, although occurring often alone, is not very uncommonly asso- ciated with Colles' fracture. A sprain of the hand, wrist, forearm, Fig. 321. — Reduction of Colles' fracture. Note position of the thumbs and fingers. Lower ragment is pushed into place while counterpressure is made by the fingers upon the upper fragment. elbow, or shoulder may occur. It is wise to examine the whole upper extremity, particularly a few days after the accident, as it is at this time that sprains associated with fracture are likely to be detected. Treatment. — The ordinary uncomplicated fracture is here under consideration. Reduction should be accomplished as soon as possible. Complete reduction can not be made satisfactorily without the administration of an anesthetic, either to complete or partial anesthesia. Very great force is needed to accomplish satisfactory reduction of impacted fractures of the radius. It is because of the use of too little force that often a slight bony de- formity remains after union has taken place. A Method of Reduction. — Grasp with the thumbs and forefingers COLLES' FRACTURE — TREATMENT 237 of the two hands the upper and lower fragments. Free the Icnver fragment completely from the upper by pressure and traction backward and forward and laterally upon the lower fragment, using all the force that is needed (see Figs. 319, 320). The lower fragment may then be forced into position by pressure of the two Fig. 322. — Fracture of radius near wrist. Method of applying the posterior splint and dorsal pad in displacement of lower fragment backward. Fig. 323. — Fracture of radius near wrist. Method of applying anterior splint and pad and of holding the two splints and arm for the application of straps. Anterior splint is cut out below the thenar eminence. thumbs upon the dorsum of the wrist (see Fig. 321). W-lien reduction is completed, the hand should be allowed to rest natur- ally without support to determine whether there is a recurrence of the deformity. If there is no recurrence of the deformity, the fracture may be fixed. If there is recurrence of the deformity, no- tice should be taken of the direction of the displacement of the 238 FRACTURES OF THE BONES OF THE FOREARM lower fragment, that proper pads may be applied to hold it in position. A pad of compress cloth placed on the dorsum of the wrist over the lower fragment will easily hold it if ordinarily dis- placed. A knowledge of the direction of the displacement of the lower fragment will suggest the prevention of the recurrence of the deformity. The Rontgen ray is making possible a more intelli- gent treatment of this fracture of the radius. The bone is so Fig. 324. — Fracture of the forearm near the wrist-joint. Anterior and posterior splints. Straps are taut. Note length of splints, the position of the three straps, and the cutting out of the anterior splint to clear the thenar eminence. Fig. 325.— Fracture of the forearm near the wrist-joint. Notice wrinkles in the straps. The straps are loose from the pressure of the two splints together. Thus is illustrated the fact that the straps should retain splints in position without exerting much pressure. nearly subcutaneous that one can take advantage of an accurate knowledge of the line or lines of fracture in attempting reduction of the malposition. Intelligently applied force can now be used in each fracture instead of the hitherto blind routine manipulation. Thus, less injury is done in setting the fracture, and better ana- tomical results are obtained. It is well to restore, if possible, the prominence of the lower end COLLES' FRACTURE — TREATMENT 239 of the ulna at the back of the wrist. Usually, after a Colles' frac- ture has healed and functional usefulness exists in the wrist and hand, the ulna will be found to have slumped forward — to have disappeared from the dorsum of the wrist. This can be prevented Fig. 326.— Posterior splint padded with two thicknesses of sheet wadding. Two straps Note length of splint and position of straps. Fig. 327.— Posteiior splint, three straps, and pad at the seat of fracture. Note comfortable position of forearm and hand. 2 ■ I z^M Bl jg. ^^^^y Fig. 328.— Completed dressing, similar to figures 326, 327. The bandage is applied evenly and uniformly. partially at the time of setting the fracture, by padding the ulna anteriorly and by completely correcting the radial deformity and strongly adducting the hand. Retenth-e Apparatus. — The simplest splint is the best. If there is considerable swelling about the seat of fracture in a rather 240 FRACTURES OF THE BONES OF THE FOREARM muscular and large arm, it is best to use the following apparatus : Two pieces of splint-wood, one for the back and the other for the front of the forearm, are provided. The back or posterior splint should extend from the heads of the metacarpal bones to a little above the middle of the forearm (see Fig. 322). The front or anterior splint should extend from the heads of the metacarpal bones to a little above the middle of the forearm (see Fig. 323). These splints are padded evenly and smoothly wdth sheet wadding, retentive pads at the seat of the fracture being used as needed. The hand and forearm are held in semipronation. The hand is adducted. The dorsal splint is applied and held in position. The anterior splint is then applied with the pads, and all are held in position by adhesive-plaster straps. The arm and splints are Fig. 329.— Hand and fingers extended. Dorsal surface of torearm and hand practically straight and in the same plane. The anterior surface of the forearm and hand are rounded and irregular surfaces. covered with a bandage. Direct pressure should be avoided over the head and styloid process of the ulna posteriorly, in order to minimize the disappearance of the bone from the dorsum of the wrist. A pad placed anteriorly and laterally over the lower end of the ulna is often useful in reducing the ulna head and styloid. The adhesive-plaster straps should be snugly but loosely applied. They are intended simply to retain the splints in position (see Fig. 324). After their application, pressing the two splints to- gether should show that there is considerable slack in the straps (see Fig. 325) ; a springiness should exist between the splints. The necessary pressure on the splints should be secured by the band- age. The fi gers are allowed to be free and movable. The arm is held in a sling. The sling ; hould be so adjusted as to receive COLLliS rKACTlRIC — TRICATMIvNT 241 the whole weight of the arm, the hand lying free from the upward pressure of the sling. The sling should be applied with the ends crossed in front of the neck. At the end of the first week in most cases, in place of the two anteroposterior splints, it will be wise to use one posterior splint only and an anterior pad over the seat of fracture. The posterior splint is applied evenly padded, and if necessary, a small pad is placed over the dorsum of the lower fragment. The splint is held in place by two adhesive-plaster straps — one at the upper end of the splint around the forearm, the other around the metacarpal bones at the lower end of the splint (see Fig. 326). The fracture should be held securely by a third strip of adhesive plaster at the seat of fracture over a compress-cloth pad, which fills up the anterior hollow of the radius (see Figs. 327, 330). This pad holds Fig. 330. — Anterior and posterior splints. Diagram of pad to fit the radial arch. the fragments securely. A roller bandage gives even compres- sion and support to the whole arm (see Fig. 328). The posterior surfaces of the forearm, wrist, and hand in the extended position are practically in one plane (see Fig. 329) ; hence, the reasonableness of the use of the posterior splint. The arm lies naturally upon it. The anterior surface only requires accurate padding. The difficulty in applying an anterior splint accurately to the forearm and wrist is rendered clear by the illustration. The front of the forearm and wrist is a rounded and uneven surface (see Fig. 329). In order accurately to control the bone by a splint applied to the anterior surface of the fore- arm, the padding must be applied with greater care than is ordi- narily exercised. Xo splint is manufactured that fits the wrist accurately. If the surgeon depends upon manufactured and molded splints, he is in very great danger of neglecting the fracture). It is best for the surgeon to use simple splints, 16 24' FRACTURES OF THE BONES OF THE FOREARM and to hold the fracture reduced by personally applied pads and straps. Until the time of union the arm should always be comfortable. The patient should be seen, if convenient, within the first twenty- four hours of the application of the splint. Swelling may occur after the splints are applied, causing blueness or swelling of the fingers. The bandage may need reapplying to relieve this in- crease of pressure. With the subsidence of the primary swelling Fig. 331.— Colles' fracture. Position of short dorsal splint of wood and palmar pad of com- press cloth. Note method of holding before the application of the strap. Fig. 332. -Colles' fracture. Short dorsal splint and palmar pad held in position by adhesive- plaster strap. the bandage naturally loosens and will require tightening. It is rare that the straps and padding will need more than slight readjustment during the first week of treatment. At least every three days the pads should be removed with great care, and the arm carefully inspected. The alinement of the fragments is main- tained by readjustment of the pads. Gentle massage should be instituted to the fingers, hand, wrist, and forearm during the second week. Passive and active move- COLLES FRACTURE — TREATMENT 243 ments of the fingers and wrist are to be made through the second week. During the second or third week it will be possible to shorten the dorsal splint and also to increase the amount of passive Fig. 333. — Colles' fracture. Cravat sling holding wrist improperly. Hand pronated. Fig. 33^.— Colles' fracture. Cravat sling holding wrist properly. Hand semi- supinated. Wrist resting upon ulnar side with hand unsupported. Fig. 335.— Right Colles' fracture in an old woman. Splints applied for five weeks with- out removal. Note deformity and flattening of hand and forearm. The fingers and wrist are stiff and swollen. Left hand is normal. and active motion. At the end of the second or third week the union will be found to be firm. During the third or fourth week the splint may be removed and the wrist be supported by a wooden 244 FRACTURES OF THE BONES OF THE FOREARM dorsal pad (see Figs. 331, 332) two inches long and the width of the wrist, and by a palmar radial pad of compress cloth and strips of adhesive plaster about two inches wide. The middle of the plaster should come at the line of the break in the bone. After the fourth week all padding may be removed, and the wrist sup- ported by a simple bandage. The fingers and hand may be used at this time. After the removal of the splint and while the arm is carried in a sling great care must be exercised lest lateral de- formity result through an improper adjustment of the sling (see Fig. 333). The forearm should rest in the sling upon the ulnar side, and the hand, being unsupported, should be slightly adducted (see Fig. 334). The treatment of a "reversed Colles'" fracture (see Fig. 296) will differ from the treatment of the ordinary fracture only in the method of reduction and in the position of the retaining pads. An anterior (palmar) pad will be needed over the lower fragment and a posterior (dorsal) pad over the shaft of the radius. Prognosis and Result. — The swelling about the fracture in elderly people will persist longer than in the young. A function- ally useful wrist-joint and hand should follow a simple uncom- plicated Colles' fracture in healthy young adults. For some weeks tenderness ma}^ exist over the styloid of the ulna. Limi- tation of pronation and supination may persist for some time, disappearing, after several months, more or less completely. Supination is the last movement to be recovered. Limitation of movement at the wrist and in the fingers is not incompatible with a useful wrist- joint. Bony union is rapid — within three weeks. Care must be exercised lest in the early removal of support the soft callus is molded, by the ordinary movements of the wrists and hand, into some permanent deformity. It is not uncommon for the line of the fracture of the lower end of the radius to extend into and involve the sigmoid cavity of the radius. Thus the inferior radio-ulnar joint is involved in the fracture. This fact is of importance, as it helps to explain the limi- tation of motion in pronation and supination which so often exists after fracture of the lower end of the radius. Often perfect supination is the last movement to be recovered, and this may in COLLES' FRACTURE — PROGNOSIS 245 part be explained 1)\- the imohenieiit of the inferior radio-uhiar joint. The destruction of parts of the lower fragment of the radius may have been so complete that it is impossible to restore the wrist to its normal shape, and some bony deformit}' will remain permanently (see X-ray plate, p. 234). Bony deformity is not incompatible with a functionally useful arm. In many instances it is impossible wholly to prevent a slumping forward of the head of the ulna and its corresponding disappearance from the back of the wrist. Complete reduction of the radial deformity together with a frequently re-adjusted pad upon the palmar surface of the wrist over the slumping ulna-head are the best methods for preventing the disappearance of the ulna from the dorsum of the wrist. Some slight widening of the wrist will re- main after most Colles' fractures. The changes in the tendon sheaths about the fracture, the periarticular adhesions that form, especially in elderly people, cause much more hindrance to recov- er\' of function than do the bony alterations (see Fig. 335). Early and persistent massage and passive motion will prevent these changes from becoming permanently troublesome. Old people are liable to have considerable difficulty in regaining the movements of the fingers, on account of adhesions within and without the tendon sheaths. The continued use of the hot-air treatment is of value in restoring mobility to the wrist and fingers. Colles' fractures that have bony union with marked deformity should be corrected by osteotomy, if the wrist is functionally im- paired. Colles' fractures two or three weeks old may be refrac- tured manually, if necessary, to correct existing deformity. The ease of refracture and the limits in time within which it is possible will vary^ with individual cases. The more nearly the deformity in Colles' fracture is corrected at the first setting, the milder will be the subsequent pain about the wrist. CHAPTER XI FRACTURES OF THE CARPUS, METACARPUS, AND PHALANGES FRACTURE OF THE CARPUS Simple fracture of the carpal bones is unusual. It is associated with other injuries. It is not uncommonly seen in crushes result- ing in open fracture. The scaphoid is found fractured in certain Colles' fractures and in falls upon the outstretched hand. There are many cases of painful wrist, "rheumatism" about the wrist, F'g- 336.— Normal wrist. No injury (X-ray tracing). weak wrist, and sprained wrist that are instances of unrecognized fracture of the scaphoid bone. The persistence of the difficulty necessitates a physician's examination. In these cases a Rontgen- ray examination will reveal the true nature of the lesion. In inter- preting X-rays of the carpus following injury it must not be over- 246 FRACTURE OF THE CARPUS 247 looked, as Prof. Thomas Dwight has observed, that in about i per cent, of all subjects the scaphoid is divided into two parts in the course of its development. Such an anomaly might be easily mistaken for a fracture of the scaphoid if the appearances in the X-ray alone were depended upon. After fracture of the scaphoid Radial fissure. Fig. 337. — Case: Fracture of the scaphoid and fissure of radius (X-ray tracing) (Balch). Crack of ulna. Epiphyseal line. Scaphoid fragment. Scaphoid fragment. Epiphyseal line of radius. Fig. 33S. — Fracture of the scaphoid. Lesion of epiphysis of ulna (X-ray tracing) (Balch). bone persistent, painful limitation of extension at the wrist is not at all uncommon. The os magnum is sometimes fractured by falls upon the hand. Treatment. — If there is displacement, immediate pressure and counterpressure, associated with extension and flexion of the wrist-joint, under an anesthetic will usually reduce the displace- 248 FRACTURES OF CARPUS, METACARPUS, AND PHALANGES ment. Immobilization of the wrist-joint should be secured by means of a dorsal splint extending from above the middle of the forearm to the heads of the metacarpal bones (see Fig. 326). It should be retained by two adhesive-plaster straps. Sheet wad- Fig. 339.— Fracture of the scaphoid. The two fragments are seen near the styloid of the radius (X-ray tracing) (Balch). Scaphoid fragment. -> C^ r Scaphoid fragment. -^ ' Fig. 340.— Case : Fracture of the scaphoid (X-ray tracing). ding and gauze roller bandages are then carefully applied to the arm the whole length of the splint (see Fig. 328). With the splint in position gentle massage to the wrist and fore- arm after the first week will hasten healing. Gentle passive mo- SYMPTOMS 249 lion with iiiuR' vi.^orous inassaj^c will be iiulicaU-d at the end of two weeks. At the vud of tlirrc or four weeks all supi)ort save a roller bandage may be omitted. vStiffness will persist after this injury, especially in elderly people (see Figs. 336-340 inclusive). FRACTURE OF THE METACARPAL BONES The third and fourth metacarpal bones are the ones most com- monly broken. The fracture is due to a blow upon the knuckles (see Fig. 341). Symptoms.— The deformity is characteristic. The very con- siderable swelling often obscures the outline of the bones, but pal- Fig. 341.— Metacarpus and phalanges showing epiphyses at fifteen years (Warren Museum, specimen 537). Fig.342.— Fracture of third metacarpal, showing dropping of knuckle. Ligament- ous preparation. pation detects the lower end of the upper fragment in the dorsum of the hand, while the upper end of the lower fragment is some- times felt in the palm of the hand (see Fig. 342). This deformity is characterized by a loss from the line of the knuckles of that knuckle corresponding to the fractured metacarpal (see Figs. 343, 344). Pain and crepitus are present. The hand can not be closed tightly on account of the swelling and pain. 250 FRACTUREIS OF CARPUvS, MEITACARPUS, AND PHALANGES To obtain crepitus easily and to assist in reducing the fracture, it is best to grasp the finger corresponding to the fractured meta- carpal with the whole right hand, steadying the injured metacarpus P'S- 343- — A, Fracture of neck of fourth metacarpal bone. Swelling of finger and knuckle. Knuckle has dropped downward toward the palm. B, Normal hand. Line of knuckles shown. Contrast with A. A B i« 1 ' ' ' ^ ; /^ • ' ^ '^'il>tt;iES» ■ f '< ' 'x 'i^^^^^B Fig. 344. — Fracture of the fourth metacarpal bone. View of two hands from behind : A, Normal line of knuckles. B, Knuckle of the ring-finger has dropped downward. Deformity well shown. with the left hand, and then to make steady and continuous trac- tion (see Fig. 344) . The distal fragment is so short and movable that unless this method is used to steady the fragment it will be difificult to determine crepitus and to reduce the fracture. This fracture Fig. 345.— Method of grasping hand and finger in examining for fracture of metacarpal bone, and in reducing such a fracture. Fig. 346.— Fracture of the neck of the second metacarpal. Method of securing extension. Note adhesive plaster, rubber tubing, peg, padding to finger, pad over proximal fragment. Counterextension by adhesive plaster about wrist. Ready for the application of a bandage. Pig- 347-- -Fracture of the metacarpal of the index-finger. Use of roller bandage. Position of roller bandage. Method of traction and countertraction. 251 2 52 FRACTURES OF CARPUS, METACARPUS, AND PHALANGES heals readily. Occasionally, however, a suppurative process may complicate recovery even when the fracture is not an open one. Fig. 348.— Fracture of the metacarpal of the index-finger. Completion oi traction. Pressure and counterpressure by thumb on the dorsum and on bandage in the palm of the hand. Fig. 349.— Fracture of the metacarpal of the index-finger. Completion of the application of the dressing. Adhesive-plaster straps holding hand and roller bandage in position. Bennett's fracture, commonly designated " stave " of the thumb, should be mentioned here. It is a fracture of the proximal end of the metacarpal of the thumb, oblique and into the joint with TREATMENT 253 the trapezium. (See figure of X-ray, No. 352.) Tlie metacarpal bone is displaced backward. There is great disability in opposing the thumb and index-finger. Grasping small objects is impos- sible. Pressure upon the ball of the thumb is painful. The injuries likely to be mistaken for this fracture are subluxa- tion of this same joint, a sprain of this joint, and a contusion of this part. Treatment. — After reducing the fracture by traction and pres- sure as suggested, it must be held in place by special padding, for Fig. 350. — Transverse fractures of the last three metacarpals (X-raj' trac- i'lg). P'S- 351- — Oblique fracture of the third and fourth metacarpals (Massachusetts General Hospital, 1142. X-ray tracing). the deformity tends to recur. The hand and forearm are sup- ported upon a properly padded palmar splint. A pad is placed in the palm over the prominent lower end of the metacarpal. An- other pad is placed upon the dorsum of the hand over the upper fragment. These pads are secured by narrow strips of adhesive plaster. The whole is then bandaged. If after carefully padding the two fragments and immobilizing them the deformity is repro- duced, the fragments slipping by each other, it may be necessar\^ to make permanent traction upon the finger (see Fig. 346). This is best done by applying narrow adhesive-plaster straps to the sides Proximal fragment Fig. 352. — Fracture of the upper end of metacarpal bone of thumb. Displaced upper fragment could be felt in the palm of the hand ( Massachusetts General Hospital, 1785. X-ray tracing). Phalangeal epiphysis. — Normal epiphyseal line — and epiphysis. — Phalanx. ~" Separated epiphysis second metacarpal. Fig- 353- — Separation of the distal epiphysis of the second metacarpal bone. Displace- ment into the palm of the hand. Rare (Massachusetts General Hospital, 1765. X-ray tracing). Fig- 354- — Fracture of terminal phalanx of thumb. Anteroposterior and lateral views (X-ray tracings). 254 TREATMENT '55 of the finger licld in ])lace b\- circular and oblique straps. The hand rests upon the ])almar s])lint. An adhesi\"e-plaster circular band passed about the wrist and si)lint ofl'ers continuous counter- traction. If the band is carried between the thumb and forefinger, greater security is obtained, and there is much less likelihood of slipping of the plaster. The extension upon the finger is obtained by fastening the extension strips to small pieces of rubber tubing, and carrying the tubing around a wooden peg or screw passed through a hole in the splint. Fig. 355. — Fracture of the finger. Wooden splint applied to the palmar sur- face. Note straps and length of splint. Fig- 356- — Finger splint ot copper wire applied. A simple contrivance for a fracture with little displacement is the use of a roller bandage (see Figs. 347-349 inclusive). A roller bandage of cotton cloth that is firm and not easily compressed and of a size comfortable for the hand to grasp is selected. This is placed in the palm of the extended hand ; the fingers and metacar- pal heads are drawn down firmly over it. This position is main- tained by a broad strip of adhesive plaster around the whole hand. Pads, as with the palmar splint, mav be used to reinforce the roller bandage. Unless great care is exercised, this method will result in posterior bowing of the metacarpal bone. If there is an anterior Fig- 357- — A, Finger splint of aluminium or tin, anterior surface. B, Finger splint applied to middle finger, three straps. Note position of splint in palm of hand. Fig. 358.— Palmar wooden thumb splint. Note shape, pads, straps, position. 256 FRACTURE OF THE PHALANGES 257 displaceuK'nt of either or both fragments, this roller-bandage ap- paratus is very eflicient in maintaining reduction of the deformity. This apparatus should be carefully inspected each day during the first week, to be sure that the position obtained is held firmly. After three weeks the splint may be omitted. Massage during the third week will be of benefit. Great care must be exercised in the use of the hand following the removal of the splint until the fourth week is passed, for deformity may result (see Figs. 350-353 inclu- sive). FRACTURE OF THE PHALANGES The bones lie subcutaneously ; fractures of the phalanges are, accordingly, comparatively easy to detect. Fractures near the Fig- 359— Lateral splint of wood for fracture of the thumb. Note pad at the side of first phalanx, to correct lateral deformity. articular surfaces are hard to detect because joint crepitus is de- ceptive. The so-called base-ball finger may, in many instances, be associated with a fracture of the head of the metacarpal bone, and, involving the joint, occasion a slow convalescence (see Fig. 342)- Symptoms. — Crepitus, pain, and abnormal mobility are pres- ent, and occasionally deformitv is seen. Treatment. — It is important that the alinement of the phalanx 17 258 FRACTURES OF CARPUS, METACARPUS, AND PHALANGES be maintained. Rotation of the lower fragment upon its long axis is especially to be guarded against. Temporarily, if there is much swelling, the broken finger may rest upon a palmar splint, the two adjoining fingers serving as lateral splints to steady it. The con- tiguous skin surfaces must be protected by strips of cotton cloth and a drying powder. A single splint of thin wood, extending from the middle of the palm of the hand to the finger-tip, and held in position by adhesive- plaster straps, is most useful (see Fig. 355). The splint-wood used should be cut thin and not left thick and bungling — half the thick - Fig. 360. — Thumb splint : a, Pattern— measurements are in inches ; 5, position of splint. Note extension of thumb (after Goldthwaite). ness of the wood of an ordinary cigar box is about right. The splint should be a little narrower than the finger itself. A narrow cotton bandage applied over the finger or a simple cot to cover the finger will be comfortable and will assist in immobilization. Or- dinary letter-paper, by continued folding, may be made into a narrow and suitable splint. This is simple and efficient. It should be held in place by a bandage or, preferably, by a cot. Ordinary copper wire may be used, as shown in the illustration, without any padding (see Fig. 356). This serves as a proper protection after the first week or two, and is not so clumsy as other splints. The aluminium or tin finger splint is easily made and satisfactory (see OPEN FRACTIKE oi" TIIH I'HAKANGIvS 259 ^'ig- 357)- An\- (lis])lacenR-nl in this rraclure may be easily ad- justed by narrow adhesive straps and small pads. Fractures of the iirst and second phalanges of llie thumb may be satisfactorily treated after reduction upon a dorsal or lateral splint of wood, if proper padding is em])loyed (see Figs. 358, 359). Frequently, however, the tin splint filled to Ihe cleft between the thumb and forefinger, as shown in the illustration (Fig. 360), will immobilize these fractures more securely and comfortably. Open Fractures of the Phalanges.— This is usually followed by profuse suppuration from necrosis of the fractured bones. This fracture is to be treated with extreme care, especially as regards antisepsis. Immobilization should continue at least four weeks. If at the end of this time union has not occurred, the patient may be given the option of continuing the treatment or of having the finger amputated. If union does not occur after four weeks of careful treatment, it is highly improbable that it will ever occur. Resec- tion of the bones may be attempted before amputation. CHAPTER XII FRACTURES OF THE FEMUR FRACTURE OF THE HEP OR NECK OF THE FEMUR Anatomy. — The crest of the ihum can be felt throughout its entire extent, from the anterior superior spine to the posterior superior spine. The posterior superior spine corresponds to the level of the center of the sacro-iliac synchondrosis. The great trochanter of the femur is easily distinguished even in fat individ- uals. Nelaton's line is determined by stretching a tape from the anterior superior spine of the ilium to the tuberosity of the ischium (see Fig. 361). The top of the great trochanter lies at or a little below Nelaton's line, and about opposite to the symphysis pubis. Fig. 361. — Nelaton's line (dotted line), from the anterior superior spine of the ilium to the tuberosity of the ischium. Brj'ant's triangle seen. Distance from top of trochanter to perpendicular dropped from anterior spine (X) is Bryant's measurement. After fracture this measurement may be less than normal. The internal condyle of the femur looks in the same general direc- tion as the head and neck of the femur (see Figs. 362, 363). The anterior superior spine of the ilium is of importance because from it measurement is made in taking the length of the legs after frac- ture of the femur. Normally, the fingers can be hooked behind the great trochanter toward the posterior surface of the neck of the bone. By this manipulation the posterior portion of the capsule of the joint can be felt. Fracture of the Neck of the Femur in Adults. — This accident occurs most frequently in elderly people. It ordinarily is associ- 260 SYMPTOMS 261 ated with a vcrv slij^hl injury, such as a trip and fall upon the floor from the standing position. Undoubtedly, in man},- instances the fracture precedes the fall. It is often dillkult to determine the exact seat of the lesion. \\'hether the fracture is within or without the capsule of the joint is of comparatively little moment. On the other hand, whether the fracture is impacted or unim- Fig. 362. — Femur, from front. Note normal relation of direction of head and neck to that of internal condyle. V' Fig. 363. — Femur, from outer side. Note normal anterior bowing and relation of direction of head and neck to that of in- ternal condyle. pacted is of the greatest importance. Fractures of the base of the neck of the bone — that is, fractures near the trochanter — are usually impacted. Fractures of the neck toward the head of the bone are usually unimpacted (see Fig. 365). Impacted fractures unite readily. Unimpacted fractures often remain ununited. Symptoms. — The patient is unable to rise from the ground. A contusion may be seen over the hip as a result of the fall. There is 262 FRACTURES OF THE FEMUR pain in the hip while the patient is lying still. This pain is increased upon motion at the hip. There is an inability to move the injured leg easily and painlessly. There is limitation of motion of the in- jured leg. While lying upon the back it is impossible for the pa- tient to raise the heel from off the bed. The foot is everted, the leg having rolled outward. The whole extremity lies helpless (see Fig. 366). There is a slight appreciable fullness below the fold of the groin. This fullness in the outer upper part of Scarpa's triangle corresponds to a non-depressible area associated with fracture of the neck of the femur. Slight shortening of the leg exists. After three or four days this shortening may increase to two inches. The Fig. 364. — Upper end of femur in a child: fl, a, Line of junction of epipliysis of head and shaft; b, epiphysis of greater trochanter; c, epiphysis of lesser trochan- ter (Warren Museum, specimen 334). Fig. 365. — Head and neck of femur of adult. The lines show the ordinary seats of fracture. trochanter is above Nelaton's line. The fascia above the tro- chanter is relaxed (see Fig. 367). This is especially noted in the standing position, with the patient resting the weight upon the well leg. If the fracture is an impacted one, crepitus will be ab- sent upon gentle manipulation, unless the impaction has been broken up by some unwise means. If the fracture is unim- pacted, crepitus can be detected by the hand while traction or gentle rotation of the leg is made. The foot is everted whether impaction is present or not. If the impaction is of the anterior portion of the neck, inversion will be present ; if the impaction is of the posterior portion of the neck, eversion will be present (see FRACTURK ()K Till'; HIP — EXAiMINATION 263 Figs. ,^68, 369). Impacted eversion can not be inverted nor can impacted inversion be everted without breaking up the impaction. In these cases of marked eversion and inversion a dislocation of the hi]) nuist be exchulcd if possible. Examination. — A prolonged search for crepitus and abnormal mobility must never be attempted. In order to avoid unnecessary movement of the hip and because inspection and gentle palpation alone will so often decide the diagnosis, it is wise to follow a routine examination. The history of the accident should be obtained. The presence and location of pain are determined. How much is the functional usefulness of the leg involved ? What does inspection reveal as to the local condition and the position of the limb? What does pal- Fig. 366.— Case : Impacted fracture of the left hip. Note helpless attitude of limb ; foot everted. pation reveal? How do the measurements of the leg and the tro- chanter compare with similar measurements of the uninjured leg? Last, — and to be avoided if a diagnosis has been reached, — what does gentle manipulation show as to the presence of crepitus in the hip? In order to make a systematic examination all clothing, of course, should be removed from the patient. He then should be placed upon a firm and even surface. A hard mattress, a table, or a com- forter spread upon the floor will provide the necessary conditions. An anesthetic is hardly ever necessary for diagnostic purposes. If an anesthetic is employed, the hip should be handled in the gentlest manner possible. All muscular spasm, which without an anes- thetic protected the hip from violence, is abolished ; therefore, move- ments of the hip are felt directly by the bone unprotected by mus- 264 FRACTURES OF THE FEMUR cular spasm. All sudden quick movements should be avoided. There is great danger that an impacted fracture of the hip may be changed by rough handling, especially in the movement of rota- tion, to an unimpacted fracture. Palpation of the neck of the femur with the thumb in front of, and the fingers behind, the great trochanter will detect any irregularity or thickening and tender- ness about the neck of the bone (see Fig. 377). By palpation of the great trochanter one may discover there the seat of fracture. F'g- 367.— Relaxation of the fascia lata as a result of fracture of the hip. Most obvious at point shown by the arrow. Swelling, tenderness, and crepitus may be found. Only gentle strong traction in the line of the long axis of the thigh should be made to elicit crepitus and abnormal motion. Measurement. — The absence of any preexisting injury or disease of the hip under consideration is always to be carefully noted. Measurement should always be made with the patient lying on the back. The leg should be brought gently alongside of its fellow, and steadied by an assistant. Measurement should be made from the anterior superior spine of the ilium to the internal malleolus FRACTl'RU OF TIIIC HIP — MKASUKKMKNT 265 upon each side (see Fig. 397). If lliere is sliorleniii.i; U])()n tlie ini'iired side, a fracture with some displacenienl is likel\- to have occurred. A normal diflVrence in the length of the lower limbs is, however, not unusual. It is, therefore, necessary to determine the presence of asymmetry if it exists, if any confidence is to be placed in the measurements of the legs. Measurements should, therefore, be made of tl»e tibia upon the two sides, and these compared. If no asymmetry appears to be present, any differences in measure- Fig. 368. — Fracture of the hip. Inward rotation of the leg because of impaction of the anterior portion of the neck of the bone. Fig. 369. — Fracture of the hip. Out- ward rotation of the leg because of impac- tion of the posterior portion of the neck of the bone. ment may be taken to be absolute. If it is impossible to bring the legs parallel, they must be placed in the same relative positions to the median line of the body. Bryant's method of measurement is simple and of service (see Fig. 361). The limbs are placed symmetrically. The top of the trochanter is marked upon the skin. A perpendicular line is dropped from the anterior superior spine to the table upon which the patient lies. Measurement is made from the top of the tro- 266 FRACTURES OF THE FEMUR chanter to this perpendicular line. If fracture of the neck of the femur has occurred, and there is displacement or shortening of the limb, the distance from the perpendicular to the top of the tro- Fig. 370. — Old fracture of femoral neck ; no union. Absorption of whole neck of bone. The contiguous surfaces of the frag- ments are of hard, compact bone. There is some atrophy of the whole shaft of the femur (Warren Museum, specimen 8075). Fig. 372. — Fracture between neck and shaft and fracture of great trochanter. Union so imperfect that fragments separ- ated in maceration (Warren Museum, spe- cimen 1075). Fig. 371. — Fracture of femoral neck. Impaction of base into the shaft, with down- ward and inward rotation of upper frag- ment (Warren Museum, s] ecimen 6303). Fig. 373. — Fracture of the neck of the femur and of the great trochanter in sec- tion. Impaction; union not firm (Warren Museum, specimen 5225). chanter will be less than a like measurement on the uninjured side. The position of the top of the great trochanter is determined with reference to Nelaton's line (see Fig. 361). If the leg is rolled out- ward, dislocation of the hip forward would be suspected, but the FRACTrRE OF THE HIP — MEASUREMENT .67 absence of the heatl of the bone anteriorly and the absence of other positive signs should eliminate dislocation. If the leg is rolled in- ward, a dislocation of the hip upon the dorsum ilii would be con- sidered. The absence of other positive signs of dislocation and the presence of the head of the bone in the acetabulum should con- Fig. 374. — Fracture of femoral neck, unimpacted ; fibrous union, with absorption of the neck (Warren Museum, specimen 3651)- Fig. 375. — Old impacted fracture of the hip ; penetration of the inner wall of the neck into the head of the bone; displace- ment and rotation of the head downward and inward (Warren Museum, specimen 10S6). Pig. 376.— Fracture of hip : impaction of neck of bone into the head ; rotation of head down- ward and backward ; view from behind (Warren Museum, specimen 10S6). vince one of the nonexistence of dislocation. In an elderly person who presents no well-marked sign of fracture, but who is unable to use the limb after ever so slight an injury, a fracture of the hip should be so strongly suspected that, until the Rontgen ray proves it absent, he should be treated as if a fracture were present. 268 FRACTURES OF THE FEMUR Prognosis and Result. — In the very aged and feeble the shock of a fracture of the neck of the femur is severe. The danger to life in these cases is great. An elderly patient may die of shock within two or three days, or within a week of hypostatic pneumonia, or he may live several weeks and die of exhaustion because of pain and the enforced confinement. If the fracture can be treated with proper immobilization, union will occur in most cases. The im- pacted cases will unite ; the unimpacted cases may unite. Slight shortening with a little deformity, some limitation in the move- ments of the hips, a limp, but a fairly useful limb, are to be hoped for (see Fig. 378). Chronic rheumatism will often prevent a frac- tured hip from ever becoming useful. Nonunion of the hip-fracture does not preclude a useful limb (see Fig. 379). Ununited fractures of the hip are greatly benefited Fig. 377. — Method of palpating tiie trochanter of the right femur. by proper ambulatory apparatus. They may be made to unite by mechanical means even several weeks and months after the injury. This is particularly true of fractures occurring in young adults. Results after Fracture of the Hip. — Of especial value in this con- nection are the conditions existing in sixteen cases of fracture of the hip, many years after the accident. These sixteen cases were treated at the Massachusetts General Hospital by gentle traction and immobilization, for periods varying from a few weeks to a few months. The patients then went about with crutches. No other treatment was used. Nearly all the cases were unimpacted either primarily or secondarily. At the time of the accident seven cases were between forty-two and forty-seven years old, the remainder — with two exceptions, whose ages are not stated — were over fifty ; three wer£ over sixty years old. These cases reported for exami- FRACTURK OF TIIF; HIP — PROGNOSIS 269 nation from two and one hall" to twenty fonr and one-half years after the accident. Thirteen of the sixteen cases have impairment of the functional usefulness of the leg; a weakness of the limb, necessitating a crutch in many instances; all movements at the hip somewhat restricted ; atrophy of the muscles of the thigh, buttock, and calf of the leg ; a decided limp, requiring a cane ; pain in the hip extending down the thigh even to the sole of the foot ; pain at night in the hip; pain in going up-stairs and in stooping Fig. 378. — Deformity following an old frac- ture of the hip. Fig. 379.— Case : Man, forty-five years old. Fracture of the neck of the femur. Union ligamentous, with displacement. Useful limb (X-ray tracing). over. In only two cases out of the sixteen could it be said that the leg was functionally useful. Treatment. — General Considerations. — Fractures of the hip or of the neck of the femur demand the greatest tact in their manage- ment. The aged respond readily to care. The patient should be made to feel as comfortable as possible while confined to his bed. Particular attention should be paid to diet and to all little comforts. The discomforts attendant upon immobilization are often very great. Let the days spent in bed be made especially attractive. 2 70 FRACTURES OF THE FEMUR Be sure that agreeable friends visit the patient, seeing to it that they do not stay so long a time as to weary him. I^et them inter- est him in the news of the day, so that he ma}^ feel that he is keep- ing up with events. Employ a skilled nurse to minister to his wants ; a bright and cheerful woman nurse is ordinarily better than a man nurse. The pulse is to be carefully watched as well as the respiration. A moderate amount of alcohol once or twice a day Fig. 380. — Case : Fracture of the neck of the femur (X-ray tracing). with meals is to be used. The courage of the aged needs bracing. Bed-sores develop with surprising rapidity. Skilled watchfulness and immediate treatment will often check the progress of a red pressure spot. The part exposed to pressure should be kept very clean with soap and warm water ; it should be bathed with alcohol, thoroughly dried, and well dusted with powder (starch and oxid of zinc, equal parts) ; and the pressure should be relieved by proper pads or cushions. If the heel is the part involved, a rubber cushion FRACTURE (IF THK HIP — TREATMENT 27 1 or a ring made of sheet wadding wound with a bandage mav be used. A certain amount of moving about in bed should be granted to old people. Asthenic hypostatic pneumonia from long-con- tinued resting in one position is not uncommon. Therefore, mov- ing about a little in bed, to the extent of sitting upon a bed- rest at varying angles, is beneficial. Deep rhythmical breathing while lying fiat on the back is a splendid stimulator of the circula- tion. In the case of a fracture of the neck of the thigh-bone occur- ring in an elderly individual treat the patient and let the fracture be of almost secondary importance. Treatment of the Fractured Hip. — The patient should be placed upon a comfortable, firm, hair mattress. Underneath the mat- tress, crossing the bedstead from side to side, should be placed several wooden slats about eight inches apart. These bed-slats prevent sagging of the mattress and much consequent discomfort. Great caution must be exercised that no sudden or forcible move- ments of the hip are made which might break up the impaction of the bone or cause, unnecessary pain. The leg should be placed in as natural a position in extension as possible. The knee should be placed upon a pillow. Extension strips of adhesive plaster should be applied to the leg and thigh as high as the perineum, and should be held to the skin by a gauze roller bandage. A weight of about five pounds should be applied to the extension while the leg is gently rotated and carefully placed approximately in the normal position. The foot of the bed should be elevated to the height of six inches in order to secure counterextension. Long and heavy sand-bags should be placed on each side of the leg and thigh to assist the light extension in afTording support and to give a sense of security. The heel, as mentioned before, should be properly protected from undue pressure. The foot should be kept at a right angle with the leg. To afford still greater immobilization, a long T-splint extending from below the foot to the axilla of the injured side may be applied by straps about the leg and a swathe about the body (see Fig. 410). After-care of the vSimple Traction Method. — The general care of the patient should be as outlined previously. He should be kept quiet in bed for about two weeks. During the second week he may be bolstered up on pillows to the half-sitting position. Ordi- 2 72 FRACTURES OF THE FEMUR narily, the extension may be removed during the third week. The patient may then be lifted to another bed or divan and be rolled into an adjoining room. In this change the thigh should be sup- ported by sand-bags. The patient may be up in a wheel-chair after the first six weeks or two months with the knee straight on a board or, if comfortable, flexed. He may use crutches and a high shoe upon the well foot, not bearing any weight upon the injured hip, after about two months or ten weeks. He should not bear weight upon the hip even with the assistance of crutches for about three or four months. At the end of a }■ ear he may be walking with one cane. The foregoing is the course of a case treated accord- ing to the old-time simple extension or partial immobilization method. It is a matter of common observation that many im- pacted hips recover with fairly useful limbs with this treatment. Impacted hips are known to have recovered with useful limbs without any medical or surgical advice or treatment, the impacted fracture having been thought at the time of the injury to be a se- vere contusion which would be all right in time. These cases have occurred both among adults and children. Greater immobilization of the impacted and unimpacted hip is demanded in most cases than can be obtained by the simple trac- tion and countertraction previously described. The simple method is far from ideal : malunion and nonunion with resulting disability too often follow its use, the period of disability is long, and the ultimate results are often most unsatisfactory. Very refractory individuals will have to be left pretty much to themselves. No great restraint can to advantage be forced upon them. The Fixation Method of Treatment. — In order to put the unim- pacted bones of the hip-joint under the very best conditions for union to take place not only must the fragments be approximated by traction, correction of eversion or inversion, and lateral pres- sure over the trochanter major, but these fragments must be firmly fixed. In order to immobilize these fragments absolutely the body or pelvis and the thigh must be fixed. The simple method already described, in spite of the fact that it has been used for many 3^ears in these cases, does not immobilize. The most com- fortable and efficient method of immobilization is by the use of the FRACTURE OF Tlllv HIP — TREATMENT 273 Thomas hip-splint. The description which follows of the Thomas hip-splint and its use is that given by Rid Ion. The Thomas hip-splint secures posterior support to the fracture, gives fixation without compression of the fractured region except posteriorly, allows the patient to be lifted with ease, does not inter- fere with the groin, favors cleanliness, admits of traction, can be applied without moving the patient and without assistance, and presents no difficulties after the initial application (see Figs. 381, 382). The splint is made of soft iron, and consists of a main stem, a Fig. 381. — Thomas' single liip-spliiit in position (Ridlon). Fig. 382.— Tliomas' double hip-splint in position (Ridlon). chest-band, a thigh-band, and a calf-band. The stem is an inch and a quarter wade and one-fourth of an inch thick, and in length reaches from the axilla to the calf of the leg— the length of the lower portion from the hip-joint to the calf of the leg being equal to that from the axilla to the hip-joint. In the part opposite the buttock tw^o gentle bends are made, the lower somewhat back- ward and the upper upward, so that the body and leg portions of the splint follow parallel lines from one-half to one inch apart, the body portion being posterior to the leg portion. The stouter 18 2 74 FRACTURES OF THE FEMUR the patient, the more nearly do these parallel lines coincide, and in some cases the main stem may be left entirely straight. To the lower end is fastened, by one rivet, the calf -band, one-six- teenth by five-eighths of an inch, and in length an inch or two less than the circumference of the leg at this point. The thigh- band is one-sixteenth bv three-fourths of an inch, and in length an inch or two less than the circumference of the thigh at its largest part; it is riveted to the main stem just below the lower bend, so that when applied to the patient, it comes well up to the perineum. The chest-band is three-thirty-seconds by one and one-fourth inches, and in length nearly equal to the circumference of the chest, being relatively longer than the other bands. It is fastened by one rivet after the upper end of the stem has been forged flat and bent back over it. This arrangement makes a fast joint, and brings the stem between the chest-band and the skin. In each end of the chest-band a round hole is forged of at least one-half of an inch in diameter. Summary of material and measurements required in making the Thomas splint : Stem, i\ inches wide, ^ inch thick, extending from the axilla to the calf of the leg. Calf -band, f inch wide, j-^ inch thick ; the length is two inches less than the circumference of the calf of the leg. Thigh-band, f inch wide, -j^ inch thick; the length is two inches less than the largest circumference of the thigh. Chest-band, ij inches wide, ^^2"^'^cli thick; the length to nearly equal the circumference of the chest. A hole is forged at each end of the chest-band, ^ inch in diam- eter. Any good blacksmith can make this splint in a very short time. The splint is now bent to fit approximately the patient, padded on the side that is to come next the skin with a quarter-inch thick- ness of felt, care being taken to leave no inequalities of surface, and then covered with basil leather put on wet and tightly drawn, so that when dry it will have shrunk sufficiently to prevent the cover from slipping on the iron. The splint is applied by opening out the wings of the bands looking to the uninjured side of the patient, and then slipping them, followed by the stem, und?r- FRACTrKIv OF THK HIP — TKRATMKNT 275 neath lla- iJatie-iU I'nmi the injured side; the wings that were straightened are bent again b\' hand and readily return to their former curves. A closer and more accurate adjustment of the wings may be made by the use of wrenches; these will be found especially serviceable in fitting the chest-band and in drawing in the other bands when the patient is very intolerant of any threat- ened movement or jarring. "The splint having been fitted, if retentive traction is not re- quired, the limb is bandaged to the stem from the calf to the upper part of the thigh, rolling the bandage in the direction the opposite to the rotary deformity that may be present ; then shoulder-straps are applied by taking a couple of yards of broad bandage or a strip of muslin, looping it round the stem where it joins the chest-band, then over the band and over the shoulders, and down to the ends of the chest-band. Here it is passed through the holes and tied ; then it is passed across the intervening space to the opposite hole and again tied. If retentive traction is desired, the shoulder- straps are omitted. To each side of the limb from the upper part of the thigh after the limb has been pulled down to the splint a broad strip of adhesive plaster is applied. The lower ends of the plaster are turned outward and upward around the wings of the calf-band, where they are fastened by a strip of plaster passed entirely around the limb ; the whole is then covered with a band- age. By this arrangement the limb is pulled upon only to the extent of correcting the actual shortening, and is held at one and the same length sleeping or w^aking, whether the muscles relapse or are spasmodically contracted. "The device aims to prevent motion in the axis of the limb ; to prevent lateral motion by bending the limb in any direction; to do this without constricting the region of the fracture; and to enable the patient to have the bed-pan adjusted without pain and without disturbing the relation of the parts. When the splint has been applied and the patient is in bed, the nurse should be instructed in certain mana^uvers. The bed-pan is adjusted by passing the arm under both limbs or below the knees and then lifting directly upward, making an incline of the W'hole patient below the chest-band. By this manoeuver it is also more easy to sraoothe out wrinkles in the bedding: and change the sheet than 276 FRACTURES OF THE P'EMUR in the usual way. The stem should be made to press upon differ- ent parts of the skin by pulling the skin night and morning first to one side and then to the other. The patient should be inspected daily for pressure sores by turning him on the sound side. In order to turn a patient upon the sound side support the fractured limb at the knee with one hand and grasp the chest-band with the other; the patient then is readily turned as a whole. The points Fig. 383.— Tracing of photograph of patient (see skiagram, Fig. 3S4) four years after fracture of the left femoral neck, showing the shortening and turning out of the leg (after Whitman). most likely to suffer from pressure are those at the junction of the thigh-band and stem, the lower bend of the stem, and the junction of the stem and chest-band. Points pressed upon should be lightly dressed with flexible collodion and protected from further pressure by padding above and below. If the pressure of the whole body portion of the stem is complained of, a small, thin mattress of hair or a sheet folded to several thicknesses may be placed between the FRACTIRK ()I- THK HIP — TREATMENT 277 splint and the patient's back. Threatened h>'postatic congestion is obviated by raising the head of the bed from one to three feet, the patient meanwhile being prevented from slipping down by tying the splint to the head of the bed. In all cases obviouslv un- impacted and in all cases when the shortening is more than three- fourths of an inch, traction should be applied. "In all cases the splint should be kept on for from six to eight weeks after all pain has ceased ; then the patient should remain in bed four weeks longer without any treatment whatever, unless there is some positive indication to the contrary, in which case the splint is cut off at the knee and the calf-band riveted at this point and the patient permitted to go about with crutches." Fig. 3S4. — Skiagram tracing of patient two and a half years of age, after the accident, illustrating the deformity of the neck and of the upper extremity of the shaft, also the eleva- tion of the pelvis on the affected side (after Whitman). In addition to the use of the Thomas splint, it may be wise to make lateral pressure, as suggested by Senn, over the trochanter of the broken hip with the expectation of more firmly fixing the broken bone. Lateral pressure may be secured by a surcingle or by a bandage applied over a graduated compress. The spot to which pressure is applied should be carefully watched and protected. The Operative Treatment. — Suturing or pegging the fragment is very properly to be reserved for fractures occurring in voung adults in whom the absolute fixation by the Thomas splint for a reasonable period has not effected union. Fracture of the Neck of the Femur in Childhood.— Whitman 278 FRACTURES OF THE FEMUR has called especial attention to this fracture. The anatomical proof of the existence of fracture of the neck of the femur in child- hood has been furnished by the specimens of Bolton, Meyers, and Starr. The fracture occurs after traumatism to the hip probably more frequently than separation of the upper femoral epiphysis. Fig. 385. — Tracing of pliotograpli of patient eiglit years old, some years after a fracture of the neck of tlie right femur, showing great projection and elevation of the trochanter, made more apparent by flexing the thigh and leg (Whitman). It is not SO uncommon an accident as has been supposed. The fracture is probably impacted or greenstick. The clinical picture of fracture of the neck of the femur in childhood differs greatly from that furnished by a similar injury in old age. In the first instance a healthy child falls from a height, and presents a shortening of the thigh of from one-half to three-quarters of an inch. There Head of fcimir. Marks iipi)er limit of head of bone. Shaft of femur, lower fragment. Fig. 386.- -Case : Girl 13 years of age. Old fracture of shaft of femur with vicious union. Fresh fracture of neck of femur. 279 2 So FRACTURES OF THE FEMUR are slight outward rotation of the leg and limitation of motion and slight discomfort in the hip. The child may walk about after a few days with but a little lameness to suggest that any injury has been received. The child recovers with a limp. Months or years later signs of coxa vara appear. In childhood a rather severe injury is followed by immediate symptoms, and later by great dis- ability. On the other hand, in old age a trivial injury is followed by immediate and complete disability. It is often overlooked in the child and is treated for a contusion or sprain of the hip. The immediate result, however, is extremely good even without more than bed treatment, but the ultimate result after several months or years may be disastrous because of the disability due to a gradually increasing bending of the femoral neck. The late result of fracture of the femoral neck in childhood resembles hip- disease in the limp, slight pain, shortening, deformity, and limita- tion of motion present. Care must be taken not to confound the cw^o conditions. These later stages of fracture are to be treated by rest to the joint. All body-weight and the jar of walking are to be removed by a properly fitting hip-splint with traction. Refrac- ture and operative measures are to be serioush^ entertained, as in other forms of coxa vara, particularly if the disability is great or is increasing (see Figs. 385-390 inclusive). The treatment of a fresh greenstick or impacted fracture of the hip in children should be by rest on the back in bed and moderate traction and immobilization of the hip and thigh and body. After a month the child may be allowed up, wearing a traction hip-splint for several months until union is so firm that the danger from coxa vara is practically eliminated. A light plaster-of-Paris spica bandage from calf to axilla will maintain immobility after the splint is omitted. FRACTURE OF THE SHAFT OF THE FEMUR Fracture of the shaft of the femur is usually oblique. It is situated either just below the lesser trochanter (subtrochanteric fracture), at the center of the shaft, or above the condyles (supra- condyloid fracture). Even in closed fractures there is sometimes great damage to the soft parts : the vessels of the thigh are at times injured. := s: - ^ o o r CJ 5. o a ■c "S c 0) < VI > ^ -a t'r. 1) V a 5 a m 4-1 IJ tj 5 V v t: < 0) D o "in s ■^ OJ CS s — i; oj = -^ = .- -i O o « o ;: X ■- aj u s >> u c CS a ■" OJ 1) -a O iC c C5 a s ■^ ~) 5" o V- .ti to ^ 4^ 7^ U _' vs — w *^ GJ li 'C o o o "^ -^ 5 57 im X — — o rt rt rt '_- > v rt >> "o rt O 5 OJ a) a; S ^ «J o o aj '" ■^ 'm :^ ^ "T 4J 3. (I) 2: bt, :j ^ O ■■", r^ V ■^ — g w hi- c! -^ 1) C£ a; o ~ = ? = rt i S -^ -^ ^7 CJ 281 2 82 FRACTURES OF THE FEMUR Symptoms. — There is often great swelling at the seat of frac- ture. The limb lies helpless. Pain, abnormal mobility, deform- ity, marked lateral rolling of the leg below the seat of the fracture, and crepitus, one or all, may be evident (see Figs. 391, 392). The limb is shortened. Measurement (see Figs. 395-398 inclusive) to determine the amount of the shortening is to be made from the anterior superior spinous process of the ilium to the internal malleolus of the same side. Great care must be exercised in taking this measurement so that the patient lies flat upon the back upon a hard and even surface, with the arms at the sides of the body and with no pillow under the head or shoulders. The long axis of the body should Fig. 391.— Fracture of the thigh at the middle. Characteristic deformity. be in the same line with the long axis between the legs as they lie with the malleoli approximated — i. e., the chin, episternal notch, umbilicus, the symphysis pubis, the midpoint between the knees, and the midpoint between the internal malleoli should all be in one straight line (see Fig. 398). The line joining the ante- rior superior spinous processes of the ilia should be at right angles to this long axis of the body and thighs. Any variations from this normal position are attended by errors in measurement, which are important. If for any reason the injured thigh can not be brought easily alongside its fellow, the two limbs should be placed as nearly symmetrical with reference to the median line as possible. THE SHAFT OF THE FEMIR 283 The- iiK'thod of measuring the lengths of the lower extremities used by Dr. Keen differs from the above in that he uses the malleo- lus as the fixed point, and measures to a line drawn at the anterior superior spinous process of the ilium. The finger and tape are not allowed to touch the skin-mark, and so do not displace it. Treatment of Fracture of the Shaft of the Femur. — The Trans- portation of a Patient : The emergency method of putting up a fracture of the thigh or hip is of very great practical importance (see Fig. 399). Limbs are fractured frequently some distance from the proper place for the application of the permanent dress- ing. It is necessary to transport such cases with the greatest de- Fig. 392. — Fracture of the right femur at the middle. Characteristic deformity. Inward rotation of leg below fracture. gree of safety and comfort. In order to accomplish this the knee- and hip- joints should be extended, the leg being held straightened in the long axis of the body. The limb should be placed upon a heavily padded board, the width of the thigh, extending from the middle of the calf to above the sacrum. The side splints of wood should be used — one on the outer side extending from the side of the foot to the axilla, the other upon the inner side extending from the side of the foot to a few inches below the perineum. Upon the front of the thigh is placed a coaptation splint extending from the groin to the patella. All of these splints are carefully padded, pref- erably with folded sheets or pillow-cases or towels ; of course, in ^'S- 393- — Fracture of the upper third of the shaft of the right femur (X-ray tracing Fig. 394. — Long oblique fracture of the shaft of the femur (Massachusetts General Hospital, 1250. X-ray tracing). 284 THE SIIAKT OF THIv I'UMIR 285 emergency wt)rk small jjillows or coats or shawls mav be utilized. It is important that the padding be evenly and intelligently ar- ranged. It will be necessary to place a wide pad between the upper end of the long outside splint, to prevent it from pressing upon the ribs and side of the chest and causing great discomfort. These splints are held in position about the le.s;-, while gentle trac- Fis- 395- — Fracture of the thigh. Correct method of measurement from the anterior superior spinous process of the ilium. Position of thumb and finger holding tape. isuiemeiu ot over L-xtrciiiil_\ . fositioii ul ihumi/.s limb. Xoie position of tion is being made upon the limb, by straps or pieces of bandage placed above the ankle, below the knee, above the knee, at the middle of the thigh, and at the level of the perineum. The upper end of the long outside splint is held to the side by a swathe about the body and splint. The patient should then be carefully placed upon a stretcher (a Bradford frame is an ideal form of stretcher) 2 86 FRACTURES OF THE FEMUR improvised for the occasion. With this apparatus snugly appHed, the patient may be securely and comfortably transported. The objects of treatment are to reduce the fracture, to maintain the reduction immobilized until union is firm, and to restore the leg to its normal usefulness. In the treatment of two of the three varieties of fracture of the femur permanent traction upon the lower fragment and permanent countertracticn upon the upper fragment are necessarv. Fig. 397. — Measurement of lower extremity. Patient lying on the back looked at from above. Position of tape, hands, and limb to be noted. The patient with a fractured thigh should always be anesthe- tized before putting the thigh up permanently. Never anesthetize the patient until all the different parts of the apparatus are ready and on a table near the bed of the patient. Always put the thigh up in temporary dressings until all is prepared for the permanent splints. About one hour will be consumed in applying the exten- sion apparatus after the patient is anesthetized. There will be no harm in letting the patient rest comfortably in the temporary TIIK SHAFT OF THE FE.MIR 28: splints over one night until all necessary arrangements have been made for the permanent dressing. Method of Examination : The patient is completely anesthetized in t)rder to secure muscular relaxation. Accurate examination is F'g- 398.— Measurement of the length of the lower extremity. Patient represented lying on back, looked at from above. The line joining the anterior superior spinous processes of ilia (C, D) should be at right angles to the long axis of the body (^, B). In this position only can comparable measurements be made. (Drawn by C. Rimmer.) now made of the fracture. If the ends of the fragments lie close to the skin, great care must be exercised, by steadying the thigh, to prevent them being pushed through the skin and thus rendering the fracture an open one. An assistant should steady the pelvis 288 FRACTURES OF THE FEMUR and upper thigh (see Fig. 400). The surgeon should grasp the thigh above the condyles with both hands, and should make trac- tion in the axis of the limb. He then determines the pull neces- sary to be exerted to hold the fragments reduced. While this pull is maintained by an assistant, the surgeon manipulates the thigh in order to learn with what ease or difficulty the fragments may be held in position. In adults in fracture of the middle of the shaft of the femur trac- tion and immobilization are best maintained by a modified Buck's Fig- 399- — Fracture of hip or thigh. Emergency apparatus. Fig. 400. — Fracture of the thigh. Method of holding leg in order to detect fracture of the thigh. Pelvis is steadied by an assistant. extension apparatus. Materials needed for a modified Buck's ex- tension : Two strips of adhesive plaster, each two inches wide and long enough to extend from the seat of fracture to the internal malleolus. Surgeon's adhesive plaster is nonirritating to the skin, and is prepared in rolls of convenient width. To each strip of plaster at the ankle end should be stitched a piece of webbing the width of the plaster and about six inches long. Prepare five other strips of adhesive plaster, all of which should be one and a half inches wide. Three of these strips should be long enough to encir- THE SHAFT OF THE FEMUR !89 cle respectively the leg above the malleoh, the knee above the con- dyles, and the thigh an inch below the seat of the fracture. The remaining two strips of plaster should be long enough to extend spirally from the malleoli around the leg and thigh to the scat of fracture. Prepare also a roller bandage of gauze or cotton cloth, a curved or straight ham-splint properly padded, and three adhe- sive straps for holding the ham-splint. In addition, three coaptation splints for surrounding the thigh are required, also six webbing straps with buckles or strips of band- age to be used as straps ; fresh sheets or pillow-cases or towels for Fig. 401.— Pulley arranged on broom-handle to be fastened at foot of bed for carrying exten- sion cord. padding; a swathe, to encircle the pelvis, made of unbleached cotton cloth or medium weight Shaker flannel ; and a long outside splint of wood, four inches wide, to extend from the axilla to six inches below the sole of the foot. To this last a cross-piece, eigh- teen inches long, should be fastened, making thus a long T-spHnt. The list is completed by two towels for perineal straps, safety-pins, a pulley, which can be bought at little cost at any hardware store (see Fig. 401). This pulley should be screwed into a broom-han- dle cut to the right height . A block with hooks above and a pulley below will sometimes be found to be more convenient than the 19 290 Till-: SHAFT oK THi: l-IvMUR 291 broom haiulk' arraiii^a-iiK-nt (sec Imr- 403). A spreader (see Fig. 404), whicli is a piece of wood two inches wide aiul a little longer than the width of the foot, perforated at its center for the exten- sion weight cord. There should be provided a cord, three feet long, size of a clothes-line; two bricks or wooden blocks for ele- vating the foot of the bed ; four siuulhac/s, twenty inches long and six inches wide ; a cradle (see h'igs. 405, 406J to keep the weight of the clothes from the thigh — the cradle may be a chair tipped up, or barrel-hoops nailed together. Application 0} the Modified Buck's Extension. — All the materials being in readiness and at hand, the patient having been etherized and the fracture examined, the thigh and leg and foot are first Fig. 403. — Pulley arranged for bed. washed with warm water and Castile soap and thoroughly dried. The long straight strips of adhesive plaster with the webbing attached are applied to the middle of the two sides of the leg and thigh up to the seat of fracture. The junction of the adhesive plaster and webbing should be brought to just above the malleoli. The two spiral and then the three circular strips should next be applied as indicated (see Fig. 407). Over the extension is placed a roller bandage, snugly and evenly inclosing the foot. The bandage steadies the adhesive plaster, prevents swelling of the foot, and affords comfort. Then the padded posterior coaptation or ham-splint is applied and held by three straps of adhesive plaster, one at each end of the splint and one below the knee (see Fig. 408). If the curved ham-splint is used, the padding (one sheet of sheet 292 FRACTURES OP THE FEMUR wadding) should be laid upon the splint evenly throughout. If a straight ham-splint is used, the padding should be applied evenly, and at the middle of the ham, behind the knee, should be placed an additional pad (see Fig. 409) in order to support the knee in its natural position. This additional pad should be placed between the splint and the layer of sheet wadding. The tendency of the padding of the ham-splint is to slip away from each end of the splint and thus leave it unduly pressing into the thigh and calf. It is wise to hold this padding in place by strips of adhesive plaster at Fig. 404. — Spreader of wood for preventing extension straps from chafing ankle and foot. Cord for attaching weight. each end of the splint. The three thigh coaptation splints should be next put in position — one anteriorly, extending the whole length of the thigh from groin to patella ; one externally, extending from trochanter to external condyle; and one internally, extending from just below the perineum to just above the adductor tubercle (see Fig. 409). The best padding for these splints is a towel folded the length of the splints and placed eventy about the thigh. These splints are held by an assistant while three or four straps are tight- ened sufficiently to hold them firmly in place. While these coap- tation splints are being applied it is vers- important that steady THK SHAFT oF THE-: FEMUR 293 traction be made iipnii llu- lower fraj,Miic-iit in order to maintain its reduction. The straps of the coai)tation sphnts are then finally tightened. The long outside splint with the T cross-piece is then padded with sheets and applied to the side of the limb and the body (see Fig. 410). The upper end of the splint is inclosed in a swathe, which passes around the body and is fastened with safety- pins. The thigh and leg are held steadily to the outside sphnt by Fig. 405.— Cradle to keep clothes from leg. Made from two barrel-hoops. Fig. 406.— Cradle to keep clothes from leg. Made from two barrel-hoops. two or three straps (see Fig. 411). The assistant, making exten- sion, exchanges his traction for that of the weight and pulley. The foot of the bed is raised upon blocks or bricks, in order to provide the counterextension by means of the weight of the body. The heel is protected from undue pressure by a ring. The foot is kept at a right angle with the leg (see Figs. 412, 413). The sand-bags are laid along the inner and outer sides of the limb to add greater Fig. 407. — Fracture of the thigh. Adhesive-plaster exttnsion strips ; long upright, ciicular, and obliquely applied strips. Fig. 408. — Fracture of the thigh. Extension strips applied , covered by bandage. Ham-splint applied ; tvi^o straps and pad in ham. Fig. 409. — Fracture of the thigh. Extension strips applied. Cotton bandage. Ham-splint, straps, pad, and coaptation splints about the seat of fracture. Straps and buckles. 294 Till- SHAFT (I I" Tin-: rHMl'R 295 steadiness to the apparatus. The cradle is placed over the foot and le.!,^ ThrouglioLiL the course oi the treatment of a fracture of the thigh it is necessary to be positive of four things : (a) The absence of shortening in the injured thigh; (b) the prevention of outward bowing of the thigh ; (c) the prevention of permanent rotation of the leg and lower thigh outward below the seat of fracture; and Fig. 410. — Fracture of the thigh. Completed apparatus as in figure 409, and in addition a long outside T-splint, straps, and swathe. Weights applied. Fig. 411.— Fracture of the thigh. Completed apparatus with bed elevated. Tlie outside splint is broad and without the T foot-piece. The swathe is very snugly applied. finally (d), the prevention of a sagging backward of the thigh at the seat of fracture, causing what appears on standing as a false genu recur\'atum. (a) The shortening of the injured leg is prevented by a suf- ficiently heavy weight for extension. This weight can be approxi- matelv but not accurately determined. Ordinarily, in an adult fifteen or twenty pounds are needed to hold the fragments in proper position. Comparative measurement of the legs from the Fig. 412. Fig. 413. Figs. 412, 413. — Forms of stirrup to prevent the foot assuming an equinus position. Fis 414. — Diagram of section of leg and splint to show how a strap carried from the back of the leg over the long side-splint can prevent eversion of the foot and leg. Fig. 415. — The more usual deformities in fracture of the shaft of the femur. Outward and posterior bowing. 296 THU SHAFT OK THK FEMUR 297 anterior superior spinous process to the malleolus should be made' regularly ever\' other day, and the measurements recorded during the first two weeks of immobilization and the extension weight correspondingly adjusted. (b) In order to prevent an\" outward bowing of the thigh, the v..: Fig. 416. — Showing the necessity of abducting the injured leg in thigh fracture. In dotted line is shown the position likely to result from neglect of this abduction. thigh and leg should be slightly abducted after the apparatus is applied, so that the extension is made with the limb in this ab- ducted position (see Fig. 416). (c) In order to prevent the thigh from rotating outward below the fracture and thus carrying the leg and foot with it, — to pre- vent, in other words, eversion of the foot, — a bandage six inches 298 FRACTURES OF THE FEMUR wide should be fastened by pins below the calf of the leg to the posterior part of the bandage or ham-splint, and brought up on the outer side of the leg and fastened to the long outside splint or to the cradle above. The leg meanwhile is held in the corrected Fig. 417. — Action of the muscular pull of the iliopsoas and of the external rotators in producing deformity in frac- ture of the femur high up. Upper frag- ment is flexed and abducted upon the trunk. Fig. 418. — Case; Oblique subtrochanteric fracture of shaft of lemur (X-ray tracing). position. If this bandage is fastened to the cradle, the latter should be fastened firmly to the bed. (d) The sagging backward of the thigh (see Fig. 415) is pre- vented by the posterior coaptation splint and its proper padding. (See Supra condyloid Fracture of the Femur.) SrHTK(»Cll.\NTi:KIC rKACTtki: 299 Subtrochanteric Fracture of the Shaft of the Femur. — I'rac- tures of the ui)])rr third nl' the shaft an- c()nii)arati\c'l\- rare. The diagnc^is oi this fracture is not ordinarily dinicult. The dispkice- nient is characteristic : The upper fragment is Hexed and abducted, and the lower fragment overrides the upper one and is shghtl}- adducted. The treatment should restore the line of the thigh. At times the ordinary extension and counterextension, as for a fracture of the middle of the femur, may prove effective. If it is Fi.£ 419. — Spiral fracture of the shaft of the femur high up (X-ray tracing). Fig. 420. — Spiral fracture of the upper half of the femur. View from in front and externally (Warren Museum, specimen 1103). not effective, — and it usually is not, — the leg and lower fragment should be elevated upon an inclined plane (see Fig. 434), so as to bring the lower fragment up to the upper one, for it will be found impossible to lower the upper fragment. Traction should then be made in the line of the elevated thigh from above the condyles of the femur. If position and traction are inefficient, — and they usually are, — then suturing of the fragments should be contem- plated. It will be found impossible to correct completely the ordinary 300 FRACTURES OF THE FEMUR deformity of abduction and flexion of the upper fragment and ad- duction and riding up of the lower fragment by traction upon the lower fragment, no matter in what position the lower fragment may be placed for traction. Rendering the closed fracture open by incision and suturing the bones in position is the onlv possible wa}' of securing a perfect result either anatomically or functionally. The surgeon must be judicious in the selection of the patients upon whom he operates. Even though old, if the patient is in excellent Fig. 421. — Same speci- men as figure 420, from be- hind. Fig. 422. — Fractured femur, base of neck driven into the shaft. Spiral frac- ture of shaft just below this (Warren Museum, 6529). Fig. 423. — Fracture of shaft of femur high up ; union with much displace- ment (Warren Museum, specimen 5993)- general health, the operation may be done with ever\' prospect of success. Supracondyloid Fracture of the Femur. — The deformity- is characteristic and fairly typical (see Figs. 426, 427) ; displacement of both fragments backward is sometimes seen (see Fig. 432). The upper end of the lower fragment is displaced backward, chiefly through the pull upon it by the gastrocnemius muscle. Treatment of this fracture in the straight and extended position is usually unsatisfactory'. It is necessars' either to flex the leg in order to relax the gastrocnemius muscle or to do a tenotomy upon SUPRACONDYUUID I'RACTURE 301 the tendo Achillis. One of lliese procedures liaving been carried out, the thigh and leg should then be placed upon a double inclined plane (see Fig. 434). Pressure by pads may be exerted upon the upper end of the lower fragment in order to lift it forward into ap- position with the upper fragment. Slight traction, if possible, should be maintained upon the lower fragment. Repeated ex- aminations with the fluoroscope will indicate when reduction is completed. The After-treatment and Progress of Fracture of the Thigh. — Inspection of the fractured limb should be made at least daily. Fig. 424. — Fractures of base of neck and trochanters of femur. View from behind and inner side (Warren Museum). Fig. 425. — Fracture well below trochan- ters, with a split running upward through great trochanter. Also fracture of neck of bone with displacement of head up and out. Recent case (Warren Museum, speci- men 1074). Measurement should be made twice a week during the first few weeks, the internal malleolus being reached through the bandage. Parts of the apparatus may need changing, and straps may re- quire tightening or loosening. The heel and sacrum will require attention because of the constant pressure from lying in one posi- tion. Ordinarily, there will be little or no pain associated with the re- pair of the fracture. After about four weeks all apparatus should be removed and the limb thoroughly inspected, to detect, if possi- ble, any uncorrected deformity, and to determine whether union is yet firm. In from four to six weeks repair in a healthy child or 302 FRACTURES OF THE FEMUR voung adult should have advanced to the stage of firm union. The apparatus should then be reapplied. At the end of the eighth week all apparatus should be finally removed. The thigh should be washed and thoroughly oiled. The patient should be permitted to lie in any position in bed without retentive apparatus for one week. After the splints are first left off and while the patient is still in bed daily systematic massage to the whole limb should be practised, together with slight passive and active motion at the knee-joint. The patient should not be allowed to bear weight upon the unprotected thigh until after the ninth week. At the ninth week he should be allowed up and about with crutches, and a mod- erately high-soled shoe (two inches) should be worn upon the foot Upper fragment of femur. Lower fragment of femur. Gastrocnemius muscle. Patella. Tibia. Fibula. Fig. 426. — Action of gastrocnemius muscle pulling distal fragment backward and downward. of the uninjured thigh. He should bear no weight upon the in- jured leg. The seat of the fracture should be protected by coapta- tion splints and straps and a light spica plaster-of-Paris bandage from the toes to above the waist. At the end of twelve weeks all support may be discarded. Of course, fractures of the femur vary considerably in the time the patient is able to get about, but the foregoing routine is that of average uncomplicated cases. It is very probable that massage without any passive motion, as early as the second week, to the region of the knee and thigh, will prevent much of the knee-joint disability and muscular atrophy that so often hinder convalescence in these cases. It is very im- portant also, in order to gain this end, to see that the extension is THE AMHlLAToRY TREATMENT 303 mack' rroin around and aboxf IIk' condxU-s of the femur and not, as so oflfu ha])]K'ns, from llic knee joint itself. It ought to be possible to avoid all knee-joint stiffness by the judicious use of massage to the whole limb and passive motion to the knee-joint. These measures in many cases should be instituted and practised regularly and persistently and always cautiously from the second week after the injury. The ambulatory trcaiiuoit of jraciiirc of the thigh by means of the long Tavlor hip traction splint, a high sole upon the shoe worn on the well foot, and crutches, is of ver\' great value, especially in children and young adults. The hip-splint, consisting of a long outside upright, pelvic, thigh, and calf bands, is applied with two Shaft of femur. Condyles and lower fra^ nient of femur. Tibia. Fig. 427. — Low fracture of the shaft of the femur. Displacement of the lower fragment backward by the gastrocnemius muscle, and of the upper fragment forward. Overlapping of fragments. perineal straps (see Figs. 435, 436). The traction is made through the windlass at the foot-piece after fastening the extension strips to it. The countertraction is made by the two perineal straps. The thigh is securely held by coaptation splints and a bandage about the thigh and splint. The patient goes about with crutches and a high sole of t\\o inches upon the shoe worn on the well foot, bearing a little weight upon the foot of the splint. As a matter of fact, the real value of this method in fracture of the thigh lies in the improvement to the general health by the early getting into the upright position and out of bed. This application of the ambula- tor}" method certainly is of great comfort to the patient. That it hastens the reparative process is yet to be fully demonstrated. If 304 FRACTURES OR THE FEMUR the Taylor hip-splint is used, it should be applied when union is found to be firm. After wearing the splint in bed for a few days the patient may get up and be about. The Prognosis. — AVhat shall be considered a satisfactory result in the treatment of a closed fracture of the shaft of the femur? The degree of restoration of function can not be determined with accuracv until about one year has elapsed after treatment is sus- pended. The following six requisites for a satisfactory result fol- lowing fracture of the femur are those reported by a committee Fig. 428.— Lateral view. Oblique fracture of the shaft of the femur low down. Little backward displacement of lower fragment. Considerable shortening of thigh from forward displacement of upper fragment. Man aged forty. Recovery. from the American Surgical Association, and generally accepted as forming a good working basis. For a result to rank as a good one, it must be established that firm bony union exists ; that the long axis of the lower fragment is either directly continuous with that of the upper fragment or is on nearly parallel lines, thus preventing angular deformity ; that the anterior surface of the lower fragment maintains nearly its normal relation to the plane of the upper fragment, thus preventing undue deviation of the foot from its normal position ; that the length of PROGNOSIS 305 Uk- limb is exacll\- equal to its fellow or that the amount of short- ening falls within the limits found to exist in ninety per cent, of healthy limbs — namely, from one-eighth to one inch ; that lame- ness, if present, is not due to more than one inch of shortening; that the conditions attending the treatment prevent other results than those obtained. Results After Fracture of the Thigh. — The prognosis as to the usefulness of the thigh after fracture deduced from the statistics available is of little value, because the details of the cases are not Fig. 429.— Same as figure 428. Anteroposterior view. presented nor is any discrimination made between the seats of fracture and the ages of the patients. Realizing these facts, I have ver\' carefully examined and classified the final results several years after treatment had ceased in thirty-five cases of uncompli- cated fracture of the shaft of the femur treated at the Massachu- setts General Hospital. The treatment in all cases was practically the same : a Buck's extension with outside T-splint, or a long De- sault apparatus, and, toward the end of treatment, a plaster spica of the thigh, groin, and trunk, with crutches. Even though this number of cases is relatively small, yet, after having most care- 20 3o6 FRACTURES OF THE FEMUR fully analyzed them, it seems highly probable that even if this number should be increased, the ultimate results would not ma- terially differ. These thirty-five cases have been arranged in three groups, according to age : (a) Those of childhood ; (b) those Sequestrum. Fig. 430. — Oblique fracture of the shaft just above the knee, with splitting apart of the two condyles. Extreme displacement ; necrosis of tip of upper fragment. Patient a man of thirty-seven years, lived for five months (Warren Museum, specimen iiiS). Fig. 431. -Same as figure 430, view from behind. Upper fragment of femur Lower fragment of femur.— Patella. - Fig. 432. — Transverse fracture of the femur in the lower third with backward displacement of both fragments. Lateral view. of adult life; and (c) those of old age. (a) Fourteen cases oc- curred in childhood, the ages averaging seven and a half years. Patients were heard from or reported for examination one and a half to seven years after the original injury. All cases were treated by bed extension, coaptation splints, and the plaster spica to thigh PROGNOSIS 307 and liip. All have perfect functional results. Four cases men- tion slight pain occasionally. Three of these four cases have a little stiffness of the knee upon the injured side one and a half years after the accident, three and a half, and three years respectively. (6) Sixteen cases occi:rred in adults whose ages ranged from eighteen to forty -eight years. These were seen or reported from one to six years after the original injur}'. Five of these have unqualifiedly perfect results, without pain or stiffness. The remaining eleven cases have limited knee-joint movements, aching in the thigh, pain Upper fragment. — Lower fragment. Fig. 433. — Same as figure 432. Anteroposterior view, showing lateral displacement. Fig. 434. — Diagram of double inclined plane for fractures near the lower end of the femur. Secures good position through relaxation of gastrocnemius muscle and pads beneath lower fragment. after exercising, pain in wet weather, weakness in the whole leg, and slight lameness in walking, (c) Five cases occurred during old age. The patients averaged fifty-eight years. These were seen or reported from two to six 3'ears after the original injury. None has functionally perfect results. There is one case of non- union of the thigh with shortening of the limb. Two cases must use a cane in walking. The knee is painful and motion is limited in all cases. Swelling of the leg is not uncommon, and pain in wet weather is vers* commonly complained of by these old people. 3o8 FRACTURES OF THE FEMUR Considering these reported cases individually and grouped according to the three age periods, it seems reasonable to conclude that they form a basis for a fairly accurate judgment as to the probable outcome of these injuries to the shaft of the femur. As the age increases the liability to impairment of the function of the limb increases. This liability is very great after fifty years are passed. Fig- 435-— Fracture of the thigh. Con- valescent ambulatory splint without trac- tion. Fig. 436. — Fracture of the thigh. Con- valescent ambulatory splint without trac- tion. Coaptation splints may be applied to the thigh and held by straps inclosing the splint. It is not very uncommon, even in closed fractures of the femur, to find gangrene of the leg developing because of laceration or pres- sure upon the great vessels of the limb. Early amputation of the thigh just above the fracture will be necessary in these cases. It should be done early in order to save life. In the aged the shock of the accident may prove fatal. In open fractures the violence, TREATMENT IN CHILDHOOD 309 usually direct, has bccMi so great that the soft parts about the knee and throughout the whole thigh have been greatly torn and lacer- ated on either side of the fractured bone. The shock in these cases is severe. Recovery is always doubtful. Fracture of the Thigh in Childhood. — This is usually caused by direct violence. The fracture is often incomplete. The symp- toms are those of the same fracture in the adult. The effusion r -y^ f ' 1 ^ffiS iM -^^ ^^^HL '**^T1 » --;?» '' «ri ^^^K flH^ ^3HH^^ F'ig. 437. — Fracture of the left thigh at the middle. Union solid. Convalescence hastened by use of hip splint with fixation of thigh by coaptation splints and straps. into the knee-joint is seen perhaps more uniformlv than in the adult. This effusion disappears from the child's knee-joint more quickly than from the adult knee-joint. Treatment. — After reducing the fracture, — making the incom- plete fracture complete if perfect reduction can not be accom- plished in any other way, — the problem of maintaining the reduc- tion arises. 3IO FRACTURES OF THE FEMUR =^ In children of ten years and older it is possible to use the Buck's extension. A plaster-of- Paris spica splint from the calf of the leg to'the axilla is also a possible method of immobilization. In children under ten years of age the Cabot posterior wire frame with coaptation splints and extension is the very best method of conveniently and efficiently treating a fractured thigh or fractured hip. The Cabot Posterior Wire Sphnt (see Fig. 438) : The splint con- sists of two portions — a body part and a leg part. The patient lies upon the body part with the thigh and leg resting upon the leg part, as upon a coaptation sphnt. Having A D a, vise and simple iron wire the size of an or- dinary lead-pencil, this splint can be made in a few moments ; the bending of the wire ac- cording to the diagram and fastening the free ends by a strip of small-sized wire being all that are required. It is necessary to make the fol- lowing measurements before bending the wire to the general shape shown in the diagram — namely, D E, the distance from the axilla to the calf of the leg ; A D, the width of the trunk ; A B, from the axilla to a point midway between the crest of the ilium and the top of the great trochanter; F E, the width of the leg, usualty from two to two and a half inches. A D and B C are bent to the curve of the back. B C is so bent that it jumps over the sacrum and does not touch posteriorly excepting at B and C. The long rods are so bent as to adapt them to the posterior curves of the buttock, thigh, popliteal space, and leg (see Fig. 439). The sphnt is covered, as in the posterior wire splint for the leg, by layers of sheet wadding and cotton bandages. A swathe is at- tached to the two sides A B and D H of the body part (see Figs. 438 and 440). The child is carefully laid upon this splint, the body swathes adjusted, the extension strips applied, traction made by weight and pulley with the foot of the bed elevated, coaptation sphnts apphed and held in position by straps that include the pos- terior wire sphnt. If it is necessary to move the child for the Fig. 438. — Cabot wire splint for fracture of the hip and thigh. TREAT.MKNT IX CHILDHOOD 3 II making of the bed, for the use of the bed-pan, or for bathing, the extension may be unfastened temporarily without any injury to the fracture, particularly if the coaptation splints are then tem- porarily tightened to secure a firmer hold on the thigh. The child Fig. 439.— The Cabot wire splint ready for use. Lateral view, showing curves of splint cor- responding to small of back, buttock, and knee. Fig. 440. — The Cabot wire splint ready for use. Front view, showing covering of Canton flannel and Canton-flannel double swathe for fixation to chest. should be, of course, clean from both urine and feces, and the fracture immobilized. After four weeks of bed-treatment the child may be up, with crutches and a high shoe with the Cabot splint applied. Shoulder- 312 FRACTURES OF THE FEMUR straps should be attached to the sphnt when it is worn in the erect position. This is one of the simplest, cleanest, and most efficient methods of treating fracture of the thigh in young children. The child can be moved with freedom and without pain. A light plaster-of- Paris spica bandage may be used in convalescence with crutches and a high shoe on the uninjured side. Fig. 441.— Bradford bed-frame for fixation of trunk in fracture of the thigh. Fig. 442.— Fracture of thigh in a child. Bradford frame. Vertical suspension of leg with weight and pulley. Coaptation splints to thigh and fixation of pelvis by towel swathe about frame. In verv^ small children it is sometimes wise to use the Bradford (see Fig. 441) frame and vertical suspension (see Fig. 442) of one or both thighs. This is an efficient, comfortable, and clean method of treatment. The Bradford frame is an iron, frame-hke stretcher, on which the child lies and to which the shoulders and hips are fastened to prevent the child's moving about. Counterextension TRKATMUNT IN CHILDHOOD 313 is then secured by the imniobihzation (jf the pelvis and hip. The extension is appUed to the thigh and leg as usual. The limb is flexed on the body to a right angle, coaptation splints being ap- plied to the thigh. After the novelty of the position passes away, the child is perfectly contented. As soon as union is firm, the permanent plaster spica dressing may be applied, and the patient may be up and about with high shoe upon the well foot and with crutches. The use of the long hip-splint will be of great service Fig. 443. — Old fracture of the ihi,:;li with ^lelorniit\-. Due to use of unprotected thigh before complete consolidation of fracture (Warren). in these cases either with or without the extension foot-piece (see Figs. 435, 436). After fracture of the shaft of the femur in chil- dren there should be no shortening and no special difficulty in con- valescence. It is wase to guard the thigh a sufficient time after union is firm to insure absolute solidity and freedom from bowing in any direction (see Fig. 443). The Making of the Bradford Frame. — It is most easily made from f- to ^-inch gas piping. It should be one inch wider than 314 FRACTURES OF THE FEMUR the width of the hips, and six inches longer than the height of the child. It should be covered with canvas, so as to leave a space under the buttocks for the use of the bed-pan. SEPARATION OF THE LOWER EPIPH- YSIS OF THE FEMUR Anatomy. — The lower epiphysis of the femur is the largest of the epiphyses. It unites with the shaft of the bone at or about the twenty-first year. The epiph- ysis includes the whole of the articular surface of the lower end of the femur. The points of origin of the gastrocnemii mus- cles are situated upon the epiphysis; a few fibers only arise from the diaphysis. The inner condylar line of the femur is continuous with the inner lip of the linea aspera, and terminates at the adductor tubercle, which can be palpated upon the inner side of the thigh near the knee- joint. The upper and outer angle of the trochlear surface of the femur can be pal- pated best with the knee flexed. A line drawn from this angle of the trochlear to the adductor tubercle marks the level of the lower epiphysis of the femur (see Fig. 444). In no position of the knee-joint are the bones in more than partial contact. This is one of the superficial joints of the body. The strength of the joint lies in the ligaments and fasciae about it. Un- like the elbow- and hip-joints, it does not depend upon the contour of the bones for strength. An attempt to overextend and to bend the knee laterally brings very great strain to bear upon the ligaments that are attached to the lower femoral epiphysis. If this strain is Fig. 444. — Femoral epiph- yses at fifteen years. Note re- lations of lower epiphyseal line to inferior articular surface. SEPAKATIUN UF THE LOWER EPIPHYSIS 3^5 of sufficient force, the epiphyseal cartilage gives way, and the epiphysis separates from the shaft of the femur. The common cause of the accident is the catching of the leg or thigh in the spokes of a revolving wheel. The accident most often occurs to boys about ten years old (see Figs. 445, 446). The epiphysis usually separates without splintering the diaph- ysis. The periosteum is stripped for a considerable distance. Fig. 445. — Case : Boy, eleven years of age. Separation of the lower femoral epiphysis. Photograph taken four hours after the injury. Note inversion of the limb ; fullness of lower third of thigh posteriorly ; fullness over head of tibia ; fullness in popliteal space (X-ray tracing. Fig. 447, explains the evident deformity). Fig. 446. — Case same as figure ^4.5. ^epilation of the lower femoral epiphysis of the left le Contrast two knees (see X-ray tracing, Fig. 447). About half the cases are open, the end of the diaphysis projecting through the skin of the popliteal space. The knee-joint is usually unopened. There may be almost no displacement of the frag- ments. A lateral sliding of the epiphysis has often been observed. One condyle has been found in the popliteal space, but commonly the epiphysis lies in front of the shaft of the femur with its sepa- rated surface in contact with the shaft (see Figs. 447, 448, 449). The diaphysis is displaced backward and downward into the popli- 3i6 FRACTURES OF THE FEMUR teal space, because of the possible high attachment of the gastroc- nemii and the fracturing force. The nerves of this region may be pressed upon or lacerated, and this may be the cause of great pain attending the accident. The popliteal vessels may be compressed, stretched, or even ruptured. Consequently, interference with the circulation may result. This may be moderate and tempor- ary, or extreme and result in gangrene of the leg. The shock attending this accident is often great. Suppuration may appear in closed separations, although it is infrequent ; it is much more Diaphjsis of femur. \ Lower femoral epiphysis. --Condyle of femur. .. .Upper epiphysis of tibia. ,Diaphysis of tibia. .Fibula. Fig. 447. — Lateral view. Case of iigure 445. Boy, aged eleven years. Separation of the lower femoral epiphysis. Displacement forward of epiphysis and backward of lower end of shaft (see Figs. 445, 446. X-ray tracing). likely to appear in open lesions. Sloughing of the skin is not un- usual from the bony pressure. Gangrene of the leg sometimes occurs. Necrosis of bone is not unlikely to result, particularly if the separation of the periosteum is great (see Fig. 450). Diagnosis. — After severe trauma to the region of the knee there are three injuries that should be considered possible : a dis- location of the knee-joint, a supracondyloid fracture of the femur, or a separation of the lower epiphysis of the femur. There may be so much swelling that a satisfactory examination is impossible. Ordinarily, careful palpation will detect the bony SEPARATION OF THH LoWKK HPIPHYSIS 317 outlines of a dislocation. This is txtrcnicly raix- in children. The crepitus of a supracondyloid fracture is bony and hard, and the displacement of the distal fragment into the popliteal space evi- Epiphyseal line. Lower femoral epiphysis. Epiphyseal line of tibia.- — Epiphyseal line of fibula. Fig. 448.— Same case as figure 447. Anteroposterior view of uninjured knee in a child eleven vears of age, showing epiphysis in position (X-ray tracing). 7 Lower femoral epiphysis. Epiphyseal line of tibia. Epiphyseal line of fibula. Fig. 449. — Same case as figure 447. Anteroposterior view of displaced lower femoral epiphysis in a boy eleven years old. dent. All fractures at the knee are not necessarily supracondy- loid. Several cases of fracture of one condyle of the femur into the joint are reported. The separated epiphysis itself may be split 3i8 FRACTURES OF THE FEMUR through into the joint. A severe trauma to the knee, a cart-wheel accident to a young boy, attended by considerable shock, followed by great swelling of the knee, a fullness in the popliteal space, feeble or absent pulsation in the dorsalis pedis and posterior tibial arteries, increased lateral and anteroposterior mobility at the knee, and soft crepitus form the picture characteristic of a separation of the lower femoral epiphysis. Prognosis. — It is impossible to state positively that in any given case there will or will not be shortening of the leg upon the injured Lower femoral epiphysis. /' Patella. Diaphysis of femur.— — • —Upper epiphysis of tibia. — — Diaphysis of tibia. Fig. 450. — Separation of lower epiphysis of the femur with displacement forward and upward between femoral diaphysis and patella (Warren Museum, 8116-1). side because of a cessation of growth in the femoral epiphysis. If the epiphysis is separated without great laceration and periosteal denudation and is replaced soon after the injury, the chances are that there will be a minimum amount of shortening of the affected leg. After open incision and replacing of the epiphysis in closed fractures good results are to be expected as far as the usefulness of the joint is concerned. Slight necrosis of bone may attend con- valescence. If the separation is closed and reduction is impossible by manipulation alone, open incision should be made. Treatment. — If the vessels are torn; if there is great laceration SEPARATION OF THE LOWER EPIPHYSIS 319 of the soft ])arts, ainpulalion should be performed. If the sepa- ration is open and the shaft of the femur protrudes through the wound, and much of the diaphysis is seen to be denuded of perios- teum, the diaphysis should be resected to the limit of periosteal separation, and then the bone reduced. It may be necessary to enlarge the opening in the soft parts before it is possible to reduce the bone. If the separation is closed, reduction by manipulation should be attempted; if successful, the leg should be flexed to a Fig. 451. — Method of grasping knee to reduce a displaced femoral epiphysis. Note thumbs at anterior border of epiphysis and fingers upon the lower end of the femoral diaphysis. right angle or an acute angle and immobilized in a plaster-of-Paris splint. Reduction by Manipulation When the Fragment is Displaced Forward. — While an assistant makes traction upon the leg, the surgeon, grasping the thigh above the condyles with the fingers in the popliteal space, making pressure on the upper fragment, pushes with his two thumbs upon the upper border of the displaced epiph- ysis (see Fig. 451 ). The leg is gradually flexed. If the reduction is achieved, a soft grating sensation will have been felt, and the shortening of the leg that existed previous to reduction will disap- 320 FRACTURES OF THE FEMUR pear. The contour of the knee will assume a somewhat normal appearance. The Operative Method of Reduction. — The obstacle to reduction is no single band or obstruction, it is the retraction and tension maintained by the fasciae, ligaments, and muscles of the thigh upon the tibia. This retraction is so great that the tibia is held crowded against the lower end of the upper fragment, and prevents the replacing of the epiphysis. An incision is best made over the Fig. 452. — Diagram to show method of reduction of separated femoral epiphysis by incision. Retractors are upon diaphysis and epiphysis, and lines of traction are shown by arrows. Fig. 453. — Cabot splint arranged as double inclined plane for epiphyseal separation at the lower end of femur. B, The part behind the knee-joint, may be bent to a more acute angle ; C, the body portion, is to be molded to the trunk ; A, the foot-piece. With the angle at B obliterated, the splint may be used for fracture of the leg in childhood. denuded shaft of the femur on the outer side of the leg. The shaft and the epiphysis are exposed in the wound. Traction should be made by means of periosteal retractors upon the epiphysis, and countertraction upon the diaphysis while the leg is slow^ly flexed from the completely extended position, as indicated in the figure (see Fig. 450). This w411 result in the reduction of the displace- ment. Suture of the bones may be needed to retain the replaced epiphysis in position. The flexed position of the leg wall assist SEPARATION OF THE LOWER EPIPHYSIS 321 materially in retaining the fragment in position. The application of a light-weight plaster-of- Paris circular bandage from the toes to the groin, with the leg Hexed to a right angle, will immobilize the parts. After-union is firm between the epiphysis and shaft. After three or four weeks the leg may be gradually extended. The foot of the injured leg may be touched to the floor while the plaster splint is in place about five weeks after the injury. Slight weight may be borne upon it. The plaster should be removed after about six weeks, and gentle active and passive motion made at the knee- Fig. 454. — Case : Boy, aged eleven years. Separation of left lower femoral epiphysis ; in- cision, reduction. Recovery. After six months, useful leg. Knee motion in flexion beyond a right angle as shown (see frontispiece and Figs. 445-4.50 inclusive). joint. Massage to the calf of the leg and the thigh should be given daily. A flannel bandage applied to the foot, ankle, leg, and thigh will be all the support that is needed. After about ten weeks the boy should be allowed to step on the foot all he chooses. At first he will do this with fear, but soon with confidence. There will usually be a little limitation of motion in the knee-joint (see Figs. 454, 455)- Traumatic Gangrene, Septicemia, Malignant Edema. — Fractures complicated with laceration of the large vessels are a frequent cause of gangrene. If an acute infectious process starts in a limb with traumatic gangrene, the gangrene spreads with frightful 322 FRACTURES OF THE FEMUR rapidity. The general disturbance is very great. A septicemia of grave type results. To such cases in which there is much gas formation, associated with edema, and which results in rapid de- struction of tissue, the name malignant edema is given. The specific bacillus of malignant edema will be discovered in the blood and tissues far above the wound of the soft parts. Fig. 455. — Case same as that in figure 454. Separation of lower femoral epiphysis. Note degree of extension possible and cicatrix of incision six months after operation. Note also absence of deformity. The proper treatment is early high amputation with stimulation of the heart by strychnin and alcohol. Fat Eynholism. — Fat embolism, to a greater or less degree, ex- ists in every case of fracture. It is most evidently present in those cases associated with great laceration of tissue and in open frac- SEPARATION OK THE LOWER EPIPHYSIS 323 tures. The soft fat of the medullary tissue is the source of the fat- drops that, getting into the venous circulation, are carried directly to the pulmonary capillaries, where they lodge unless the blood pressure is sufficient to force them out of the lung capillaries on into the systemic circulation. They then lodge in the brain, kid- neys, or other organs. The danger in fat embolism is that the patient may die from asphyxiation, due to the imperfect oxy- genation of the blood because of the rapid occlusion of the pul- monary' capillaries with fat globules. Symptoms. — Symptoms develop within twenty -four to seventy- two hours after the accident. In fatal cases facial pallor and dis- tress are followed by cyanosis. The patient is first excitable, rest- less, then somnolent and comatose. Death occurs from asphyxia. The temperature is usually not elevated. Respiration is rapid. Hemoptysis may exist, associated with pulmonar\' edema. Fat globules will be found in the urine usually upon the second and fourth days after the accident, for they are eliminated by the kidney. A difficulty in breathing, cyanosis, and fat found in the urine may be the only evidences of a fat embolism. The prognosis is, of course, dependent upon the extent of the embolism and the strength of the heart. The occurrence of fat embolism is not un- common. Death from fat embolism is rare. Treatment. — Stimulation of the heart for its extra work is indicated. Immobilization of the fractured part to prevent more fat from getting into the circulation and the administration of ox}-gen to relieve asphyxia are important in the treatment. CHAPTER XIII FRACTURES OF THE PATELLA Anatomy. — A knowledge of the anatomical relations of the patella is necessary to a perfect understanding of the fractures to which it is liable (see Fig. 456). Attached to the patella upon its Fig. 456.— Normal patella: i, From in front; 2, from behind; 3, from inner side; 4, from outer side ; 5, anteroposterior section ; a, b, usual seat of fracture. Patella. Synovial membrane, cavity of joint. Fig. 457.— Horizontal frozen section of the knee-joint, shovi'ing lateral extent of synovial membrane (Professor Dwight's specimen). upper border is the tendon of the quadriceps extensor muscle. Upon each side of the bone are attached the vastus internus and vastus externus respectively. Below the insertions of the vasti is a portion of the low attachment of the fascia lata of the thigh. 324 ANATOMY 325 At the lower border of the patella is the patellar tendon. This tendon is inserted into the tubercle of the tibia, and it is separated Fig. 45S. — Anteroposterior frozen section of the knee-joint, showing extent of synovial mem- brane superiorly and inferiorly (Professor Dwight's specimen). Fig. 459. — Ligamentous preparation of the knee, the patellar tendon cut just below the patella, dissected out, and reflected downward. Shows the lateral expansions of the quadri- ceps tendon extending to the tibia (from dissection by Professor Dwight). from the head of the tibia by a bursa and a pad of fat tissue. The tendon of the quadriceps, the insertions of the vasti muscles, and Fig. 460.— Skiagraph of normal right knee-joint in an adult. 326 ANATOMY 327 the paU-llar U'lidon aiv all rdUliniK ms with ihc slroiiK fascia lata surrounding the thigh. Tht- fascia lata is attached below to the condyles of the femur, the sides of the patella, the tubenjsities of the tibia, the head of the fibula, and to the deep fascia of the leg in the popliteal space. The patella is seen, therefore, to lie in a strong fibrous sheath that encircles the knee and is attached to Fig. 4.61.— A, Nearly median section of the knee-joint, the convex surfaces of the femur and of the patella in contact. B, Diagrammatic view, showing position in which the patella is subjected to a strain on contraction of the quadriceps, the probable mechanism of many patellar fractures. various bony prominences (see Figs. 457, 45S, 459). The synovial membrane of the knee-joint lies directly beneath and attached to the posterior surface of the patella. Laterally and posteriorly the synovial membrane lies next to the encircling fascia of the joint. The deep bursa of the femur lies in front of the lower end of the femur beneath the quadriceps muscles, and often communicates with the knee-joint. The tubercle of the tibia is on a level with 32 8 FRACTURES OF THE PATELLA the head of the fibula. The outHne and anterior surface of the pa- tella can be palpated throughout. When the leg is completely ex- tended and is at rest, the patella can be removed from side to side. The numerous longitudinal striae on the anterior surface of the patella can be detected. In these the tendinous bundles of inser- tion of the rectus are embedded. It is these fibers that fold in over the broken patella and prevent the approximation of the frag- ments. The ligament of the patella is parallel with the axis of the leg- Fracture of the patella occurs through either muscular contrac- tion (see Fig. 461) and strain or through direct \dolence. The form of the fracture is not altogether dependent upon the causative Skin. Quadriceps fascia. Synovial membrane with under- lying fat tissue. Skin. ri^ ' Joint surface of patella. — Point of reflexion of synovial Ligamentum patellse. .^_J^f^'-'^| membrane. Skin. Fig. 462.— Diagram of anteroposterior section of patella and tendons, showing the small extrasynovial portion of posterior surface of the bone. force. The fracture wih be either transverse and clean cut or comminuted and irregular. The knee-joint is generally opened: i. e., the svnovial membrane is generally torn. The synovial mem- brane is reflected from the posterior surface of the patella some distance from the most inferior tip of the bone. It is possible, therefore, for a fracture to occur at the lower portion of the bone for some considerable distance from the lower edge without open- ing the knee-joint (see Fig. 462 ). Symptoms.— There are pain in the knee and immediate dis- abihty, var\4ng from partial to complete loss of power in extension and in flexion. The patient may be unable to rise or, if he can stand, he can not move except backward, and then only by drag- EXPECTANT TREATMENT 329 ging the foot of the injured liiiil) upon the ground. The patient is often unable to raise the heel from the bed when lying upon the back. Swelling of the knee, which at first is slight, after three or four hours may become very great (see Fig. 463). The swelling is due to the accumulation of blood and synovial fluid in the knee- joint. A traumatic synovitis exists. The immediate swelling of the knee may become great enough to demand an incision to re- lieve the tension upon the skin, to prevent sloughing of the skin above the broken patella. Immediately after the accident crepitus mav be elicited by pressing the two fragments together. When the knee-joint is distended by fluid, it is often impossible even to detect the fragments of the patella, but as the fluid subsides and 463.— Case: Right knee normal; left knee, fracture of patella. Two days after accident. Observe swelling of whole knee. Joint filled with fluid. the sulcus between the bones is felt, crepitus can again be detected. The degree of the separation of the fragments is dependent upon the amount of distention of the joint and upon the extent of the tearing of the lateral aponeurosis (fascia lata) of the knee, per- mitting muscular contraction and retraction. If the causative violence is associated with a wound of the soft parts, there will be evident a contusion or an abrasion of the skin or a lacerated wound opening the knee-joint, making the fracture an open one. Treatment. — The indications to be met are the limitation and removal of the eftusion, the reduction of the fragments, the main- tenance of the reduction until union is satisfactor\-, and the res- toration of the functions of the joint to its normal condition. The Limitation and Removal of the Effusion. — If the fracture is 330 FRACTURES OF THE PATELLA seen before there is great swelling, limitation of the swelling may be effected by immobilization of the knee and the accurate appli- Fig. 464. — Fracture of patella ; fibrous union. Broadening of lower fragment (Warren Museum, specimen 3652). Fig. 465. — Fracture of patella. Fi- brous union with moderate separation ; marked tilting forward of fragments : no enlargement of fragments. View from side, a, Fibrous union; b. extent of ar- ticular surface which is now concave (War- ren Museum, specimen 1129). Fig. 466.— Fracture of patella ; union with long fibrous band ; separation of fragments 3K inches (Warren Museum, specimen 5253). cation of an elastic rubber bandage. If the bandage is not at hand, sponge compresses may be used— viz., two slightly moist- EXPIvCTANT TRKATMKNT 331 ened bath or carriage sponges are allowed to dry under pressure sufficient to llatten them. These are placed upon each side of the knee and over it, and are held by a few turns of a roller bandage. Cool water is the poured over the whole. As the sponges absorb the water they enlarge, causing equable and firm pressure on the knee, thus verv materially hindering the accumulation of fluid Fig. 467. — Fracture of patella ; bony union ; some elongation of bone as a whole. View from side (Warren Museum, specimen 6707). Fig. 46S.— Recent fracture of patella with comminution. Probably from direct violence (Warren Museum, specimen 1130;. Fig. 469. — Ham-splint without strap, showing proper length and relation to thigh and leg posteriorly. and favoring its absorption. These wet sponge compresses should be left in position for from twelve to twenty-four hours, and then a fresh set used. ^Massage skilfully applied to the whole limb, irrespective of the method of treatment eventually instituted, will not only assist in the absorption of the fluid, but will preser\-e intact the muscles of the limb. Massage to be effective should be applied at least twice 332 Fractures of the patella daily, and from fifteen minutes to half an hour at a time. Slight pain will be felt, but after a time massage will be painless and give great comfort. The Reduction of the Fragments. — No attempt should be made to reduce the fragments until nearly all the fluid is removed from the knee-joint. Reduction is accomplished by immobilization of the knee-joint, by fixation of the lower fragment, and by trac- Fig. 470. — Improper method of applying a ham-splint. The knee-joint is not immobilized. Flexion is possible. Straps i and 2 are insufficient. ^1( j^BHI J^ ^^^^j HI ^^^^^^H 1^^ Fig. 471. — Proper method of applying a ham-splint. The third adhesive-plaster strap (3) prevents flexion of the knee. tion upon and fixation of the upper fragment. The leg should be extended completely and the knee immobilized either upon ham- splint (see Figs. 469, 470, 471) or upon a Cabot posterior wire splint. The ham-splint is preferably made from a plaster-of- Paris bandage. The lower fragment is held fixed by a strap, preferably of adhesive plaster, placed obliquely about the leg and splint, and fastened to the splint above the fragment (see Figs. 472, 473, 474, EXPECTANT TREATMENT 333 475). The upper fragment is drawn down first by elevation of the leg upon an inclined plane, which relaxes the quadriceps extensor muscle, then by traction obtained by a strap passed obliquely above the upper fragment and fastened to the splint below^ the Fig. 472.— Expectant method of treating fracture of the patella. Leg extended on pos- terior wire splint. Fragments held by two straps. Fluid has left the joint. ^, Side splints; B, coaptation splints reflected. Fig. 473.-Expectant method of treating fracture of the patella. Same as figure 472, with the addition of coaptation splints to the thigh, padding, and straps. fragment. The upper strap will need repeated adjustment as the plaster sHps and as the fluid disappears from the joint. To facili- tate traction by this upper strap, the quadriceps muscle should be held firmly by coaptation splints and straps encircHng the poste- 334 FRACTURES OF THE PATELLA rior splint. The quadriceps can not then actively pull upon the upper fragment. The tendency of these two straps thus applied will be to tilt the broken surfaces of the two fragments upward and apart, particularly if there is fluid in the joint. It is important, therefore, to place a third strap over the two broken edges of the fragments, in order to hold them down to their proper level and to assist in bringing them into apposition. The coaptation splints should be removed at every massage treatment, the upper frag- ment being steadied by an assistant. The straps about the patella need not be removed during the massage. They will be of no in- Fig. 474. — Expectant method of treating fracture of the patella. Same as figure 473, with the addition of two lateral splints, padding, and straps. A posterior wooden splint, seen better in figure 473, and elevation of the limb. convenience. As soon as the effusion has left the joint, all will have been gained in the reduction of the fracture that can be gained by this method. Aspiration of the knee-joint by means of a narrow knife incision or by means of a large-sized trocar is, if done under strictly anti- septic precautions, and forty -eight hours after the fracture, often satisfactory in immediately removing the bulk of the effusion; if firm compression is then made, it effectually prevents the reac- cumulation of fluid. Maintenance of Reduction until Union is Satisfactory. — At the end of about four or six weeks from the injury union will be found. EXPECTANT TREATMENT 335 All lluid will have left Uic joint. The releiitive straps and coapta- tion splints may now he removed. The leg should be immobilized by means of a plaster-of- Paris splint extending from just below the swell of the calf to the groin. This splint is split on the side or Fig. 475. — Expectant method of treating fracture of the patella. Anterior view of apparatus com- plete. The padding of the side splints is shown. Fig. 476.— Extent of flannel bandage to knee, applied after all immobilizing apparatus is re- moved. The bandage is started at I. posteriorly and arranged as a removable dressing. Proper bath- ing is facilitated. This enables the masseur to work. The removable splint is made thus : A light weight plaster-of- Paris roller bandage is applied to the properly protected leg from above the ankle to the groin. It is split in the median line its whole length before the plaster has quite hardened. It is sprung off the leg. After it is hard a narrow strip of leather, upon which 336 FRACTURES OF THE PATELLA are fastened lacing hooks, is stitched to each cut edge. This spHnt may now be sprung on the limb and laced snugly in position. A leather splint may be similar!}^ made from a plaster cast and mold of the limb. As soon as union is firm, the patient should be up and about with the light removable fixation splint applied, walking with the aid of crutches. Fixation (prevention of flexion and extension) on walking is to be maintained for at least six months after the injury. Protecting the knee thus when walking for this period of six months does not preclude active movements of the knee when not bearing weight upon the limb. At the end of that time the patient may be al- Fig. 4 77. —Old fracture of patella ; great separation of fragments. Condyles of the femur are prominent in between fragments. Leg was useful, but weak. A, The lower fragment ; B, the condyles of the femur ; C, the upper fragment. lowed to go about with a cane and a snugly fitting roller bandage (see Fig. 476). This bandage should be made of medium weight flannel, cut straight with the weave and not on the bias. The bandage should be applied from the middle of the calf of the leg to the middle of the thigh when the leg is completely extended. As the patient becomes confident of his strength, the cane need not be carried. Sudden movements are to be avoided. At the end of eight or ten months, varying with the individual case, all support may be omitted from the knee. The Restoration of the Function of the Joint. — From the day of the injur}^ daily massage to the whole limb is important. It maintains HXPKCTAXT TKHATMKNT 337 the muscles in good lone. It prevents adhesion of the fragments to the tissues about the condyles of the femur, a not uncommon cause of ankylosis of the joint. It facilitates the absorption of the effusion of blood and synovial fluid. After the fourth week daily passive motion is to be instituted: at first ver>- slight indeed, barelv two or three degrees. If the relative position of the frag- ments is not altered perceptibly by this passive motion and lasting pain is absent, it may be persisted in with regularly increasing Fig. 478.— Case : Fracture of the patellae. Moderate separation of the fragments of each knee-joint. Useful legs. amounts. At the expiration of eight or ten weeks active motion at the knee-joint may cautiously be allowed. The appearance of persistent and increasing tenderness, sensitiveness, or pain, and increasing separation of the fragments are the indications to dimin- ish or cease passive and active motions. Summary of the Treatment of Fracture of the Patella by the Expectant or Xonoperative Method. — During four w-eeks fixation of the knee, elastic compression, douching, massage, the thigh 338 FRACTURES OF THE PATELLA flexed slightly on pelvis, the leg extended, retentive straps, coapta- tion splints, are the measures employed. At the fourth or sixth week, remove all apparatus, apply removable splint, allow walking with crutches, and use daily passive motion. At the eighth week, discard crutches, use cane, and permit limited daily active motion. At the sixth month, discard splint, apply flannel bandages, and dis- card cane. At the eighth to the tenth month, remove all support. Open Fracture of the Patella. — This is a Yery serious injury, because one of the largest synovial cavities of the body is exposed Fig. 479. — Fracture of upper third of patella, showing separation of fragments. Tilting of the upper fragment through rotation upon its transverse axis (X-ray tracing). to infection. It is safest and wisest to lay open the knee-joint, to thoroughly irrigate it with a solution of corrosive sublimate (i : 10,000), and then with a sterilized normal salt solution. All blood-clots should be carefully wiped away. All loosely attached fragments of bone should be removed. Particular attention should be paid to the posterior parts of the joint, behind the condyles of the femur. It will be found convenient in cleaning these parts first to flush the joint with sterile salt solution and to flex and to extend the knee. All parts of the joint posteriorly are thus likely to be thoroughly flushed. The fragments should be approxi- PROGNOSIS AFTlvK ICXPKCTANT TREATMENT 339 mated and sutured by some absorbable suture. The skin-wound should be closed. The knee-joint should be immobilized in a pos- terior wire splint and side splints or in a plaster-of-Paris splint. Prognosis. — Ordinarily, an individual should not follow his occupation for about six weeks to two months after a fracture of the patella — i. e., unless the occupation can be conducted with a leg held stiffly at the knee. The functional usefulness of the limb and not anatomical considerations should be the chief crite- Fig. 480. — Fracture of the patella in the lower third, showing tilting of lower fragment through rotation on its trans- verse axis (X-ray tracing). Fig. 481. — Fracture of lower edge of patella. Little separation of fragments. Indirect violence (X-ray tracing). rion in determining the result following fracture of the patella. If a man can earn his living as before the accident without local discomfort or hindrance, he possesses a useful limb. It makes little difference if there is a slight separation of the fragments or a suggestion of a limp or slight atrophy of the thigh and calf muscles ; these conditions are all to be accepted as part of the irreparable damage, and are trivial. In nonoperative cases the union is usually fibrous, although it may be bony. The interval between the fragments may amount to five or six inches. The approxi- 340 FRACTURES OF THE PATELLA mation of the fragments of the patella is not evidence of strength, for the fibrous bond of union may be much narrower than the frac- tured surface and ver}' thin, and thus easily ruptured. The use- fulness of the limb after fracture of the patella is not dependent upon any one factor, either the kind of union or the extent of the separation of the fragments of bone. There are usually no adhe- sions of the upper fragment to the femur; but injury to the bursa under the quadriceps may cause troublesome adhesions upon the Fig. 482. — Double fracture of patella without great separation of fragments (X-ray tracing). Fig. 4S3. — Transverse fracture of patella, showing straps in position to hold fragments (X-ray tracing). anterior surface of the thigh. Full flexion is a common result, but there is often limitation of active extension. There almost always remains a little joint stiffness, despite both massage and active and passive motion; this, unless due to fibrous adhesions, disappears gradually. The majority of cases of fracture of the patella under careful nonoperative treatment will secure a useful limb. A patella once fractured and having united by fibrous or bony union may be broken through the callus of the healed fracture or in an entirely different fracture from the first break. RESITLTS AFTHR I'RACTliRE OF THIi PATELLA 34 1 Results after Fracture of the Patella. — In a series of forty- seven cases of fracture of the patella treated at the Massachusetts General Hospital, occurring between the ages of eleven and sixty- five years, four were over fifty years, thirteen were under twenty - five years, twenty-nine were between twenty-five and forty-five years, one was forty-seven years old; practically, a young adult series. Of this series of forty-seven cases ten were treated by opera- tion and the remainder by the expectant method. These cases are not mentioned in this connection to compare methods of treatment, but to determine the condition of the knee a long time after the \ \ \ \ \ • \ \ \ I I I Fig. 484. — Comminuted stellate fracture of patella through direct violence (X-ray tracing) injur\'. As a matter of fact, there appeared no greater freedom from the symptoms complained of among the cases operated on than among those unoperated. The results, as carefully recorded in these forty -seven cases, suggest some of the difficulties that patients experience after fracture of the patella. The detailed reports of these cases, from one and one-half to ten and one-half years after treatment ceased, show that about twenty have as good a leg as before the accident. The remaining twenty -seven cases complain of limitation of motion at the knee-joint, that the knee creaks in walking, that it feels stiff, aches, and burns at times. The leg is said to be weak, and is troublesome in going up and 342 FRACTURES OF THE PATELLA down stairs — stepping up is especially difficult ; kneeling is pain- ful ; stepping upon irregular surfaces is painful ; running with the same freedom as before the accident is impossible ; the knee often gives way in walking and causes a fall; the patient can not jump as before the accident, and walks with a slight limp. Pain is present in or about the knee in damp weather and after unusual exertion. Fie^. 485. — Old fracture of patella. Much separation of fragments. Small nodules of bone seen in the band of union (X-ray tracing). Fig. 486. — Old fracture of patella. Wide separation of fragments. Dimp- ling of skin. A useful but not a strong leg (Massachusetts General Hospital, 847. X-ray tracing). Operative Interference in Recent Closed Fractures of the Patella. — In deciding whether a given case should be treated by operation or not the following considerations should be carefully weighed : A closed fracture of the patella does not in itself endan- ger life. It may be treated by the conservative method without added risk. If properly treated, the result will ordinarily be satis- factory as far as the functional usefulness of the knee is concerned. The operative method consumes less time in convalescence and an OPERATIVE TRKATMIiNT 343 excellent result is achieved, but operation exposes to the danger of sepsis; If sepsis results, the following conditions are imminent : A stiff knee, amputation of the thigh, and possibly death from Quadriceps tendon Upper fragment of patella. Periosteum. Interposing tissues. Lower fragment of patella. Patellar tend — Joint surface. Cartilage. Fig. 4S7.— Median section of patella and tendons (diagrammatic), showing interposition of fascia and periosteal shreds between the fragments. Fig. 488.— Fracture of patella; fragment approximated and sutured with silver wire. Wire seen in situ (X-ray tracing. C. B. Porter). septic infection. Whether operation shall be done or not, there- fore, depends upon the degree of safety \vith which it can be per- formed. It is the surest method of securing perfect apposition 344 FRACTURES OF THE PATELLA and bony union. It should be undertaken only by surgeons of exceptional judgment and great skill, who have at command skilled assistants, and who can work under the most rigid aseptic conditions. The acute symptoms should be allowed to subside before operation. The tissues require time to recover themselves from the acute trauma. The operative treatment should be con- fined to healthy individuals under sixty years of age ; to fractures with a separation of an inch or more of the bony fragments and extensive lateral fascial tears (the fascial tears may be recognized Fig. 489.— Case: Freshly fractured right patella sutured with chromicized catgut. Result after eight weeks. Note flexion of leg to a right angle ; line of incision (Warren). by;joint distention and locahzed bulging) ; to cases presenting great joint distention that does not disappear quickly. It should be seriously considered if the individual's occupation is arduous and necessitates much standing or walking. The patient should be informed as to the probable outcome by the two methods of treat- ment. The danger to life and limb should be fairly stated. It should be remembered that the power of extension of the leg is not materially limited by a transverse fracture of the patella in which the tearing of the lateral fascia is absent. Only in direct OPKkATIVE TREATMENT 345 proportion to the extent of the lateral fascial tear is there limita- tion of the power of extending the leg upon the thigh. In open fractures, in rcfracture, and in cases of impaired function from long fibrous union or from adhesions of the patella or from badly united patellaMuechanicalh- impeding the movements of the joint, operation is always indicated. The working-man who wants to get to work should, under the conditions previously stated, have his patella sutured, for he will go to work quicker and have a better knee-joint than by any method of treatment. Method of Operation. — The joint and the fractured bones are to be thoroughly exposed by a transverse or longitudinal incision. All clots should be thoroughly washed or sponged out. Any loose small fragments of bone should be removed. In almost all cases a rather dense fascia will be found overlapping the broken surfaces of the two fragments (especially is this seen in a transverse frac- ture). These bits of overlapping tissue or curtains of tissue should be retracted and removed or utilized in suturing the fragments (see Fig. 487). Whether silver wire is employed to suture the bone directly or whether an absorbable material is used to suture the soft parts seems of little consequence as long as all fascial tears are sutured and the bony fragments are approximated (see Fig. 488). The weight of opinion to-day is in favor of absorbable sutures. Closure of the joint without drainage and immobilization in the extended position followed by the treatment already mentioned are indicated (see Fig. 489). The Restoration of the Function of the Joint Following the Opera- tive Treatment. — After suture of the patella, massage and gentle passive motion should be begun at the end of two weeks. At the end of three weeks the patient may go about with the knee pro- tected by a light stiff dressing. After about six weeks to two months a flannel bandage and a cane will be all the protection needed to the knee. At the end of three months the knee should be functionally perfect. HhsU> CHAPTER XIV FRACTURES OF THE LEG Anatomy. — The followin g structures may be palpated: The internal and external tuberosities of the tilDia, the whole of the external tuberosity being subcutaneous; the broad anterior and Fig. 490. — Middle of the patella, tubercle of the tibia, and midpoint between the malleoli all lie in the same straight line as the leg rests naturally. inner surface of the tibia, which forms the shin, downward to the internal malleolus; the sharp crest of the tibia throughout its whole length ; the head of the fibula, an inch below the top of the 346 ANATOMY OF THE TIBIA AND FIBULA 347 tibia; a little of the shaft of the fibula below the head and the at- tachment of the biceps tendon ; the lower third of the fibula which is subcutaneous. The tubercle of the tibia is distinctly felt on the anterior surface of the upper end of the tibia. It is one inch from Fig. 491. — Fracture of the tibia; union with displacement forward and outward (Warren Museum, specimen 1140). Fig. 492. — Fracture of the tibia low down; marked outward bowing;; union (Warren Museum, specimen 1146). the articular surface, and marks the lowest limit of the upper epiphysis of the tibia. Into it is inserted the patellar tendon. The shaft of the tibia arches slightly forward. The shaft of the fibula arches slightly backward. The broad inner malleolus is higher than the outer malleolus, and more to the front of the leg. The 348 FRACTURES OF THE LEG outer malleolus is narrow. The posterior edges of the two malle- oli are in about the same plane. The anterior edge of the external malleolus is about an inch behind the anterior edge of the internal Fig. 493. — Fracture of the left fibula near the lower end ; united. View from outer side (Warren Museum, specimen 1150). Fig. 494. — Fracture of the tip of the lower end of the left fibula ; united. View from inner side (Warren Museum, speci- men 1151). Fig. 495. — Fracture of the tibia low down ; displacement of the upper fragment backward ; union (Warren Museum, specimen 7723). malleolus. The narrowest part and the weakest place in the tibia is at the junction of the lower and middle thirds of the bone. In the normal leg the middle of the patella, the tendon of the patella, ^iit o i" 2 1) - — 349 350 FRACTURES OF THE) LEG and the midpoint of the ankle are in the same straight Hne (see Fig. 490). General Observations. — Fractures of the tibia and fibula mav occur at any point, depending upon the seat and direction of the fracturing force. If the force is indirect, the fracture of the two bones will be at different levels. If the fracture is high up, the Fig. 497. — Fracture of both bones of the leg ; union with considerable displace- in&UiU.cross union of the two bones (War- ren Museum, specimen 5265). Fig. 498.— Fracture of both bones of the leg; displacement of upper fragments downward and inward ; union (Warren Museum, specimen S303). knee-joint may be involved or the popliteal vessels and peroneal n erve may be implicated. If the fracture is low down, the ankle- joint may be involved. The high fracture of the tibia is usually transverse. The low fracture of the tibia is usually oblique. The common seat of fracture is at about the junction of the middle and lower thirds of the leg. The line of the fracture is an oblique METHOD OF EXAMINATION 35 1 one, extending from above and bcliiiid downward and forward through the tibia. The llbula is fraetnred a Httle higher than the tibia. If the force is considerable and the sharpness of the frag- ments great, the overlying skin may be lacerated, an open or in- fected fracture resulting. The upper and lower epiphyses of the tibia may be separated; these are, however, rare injuries. The tibia and fibula may be fractured separately. In such cases the unbroken bone serves as a splint for the fractured one. The dis- placement in these latter fractures is slight. It is not very unusual to find a starting of the upper epiphysis of Fig. 499. — Method of measuring the length of the tibia rom the internal tuberosity to the internal malleolus. the tibia as illustrated in figure 496. Dr. Robert Osgood has demonstrated recentlv that manv apparentlv trivial injuries to the region of the tubercle o f the tibia are in realitv partial separations , with or without some displacement of the tongue-shaped portion of the upper epiphysis of the tibia, or actual separation of an inde- pendent bony center for the tubercle of the tibia. Clinicalh^ slight swelling and tenderness in the region of the tibial tubercle and pain upon extension are the chief sign s. Examination of a Fractured Leg. — It is sometimes extremely difficult to detect a fracture of the leg. It is, therefore, important that a systematic examination should be made immediatelv after 352 FRACTURES OF THE LEG the injun.-. Deformitv As'ill ordinarih" be apparent upon inspec- tion (see Fig. 501 j. Gentle manipulation will suffice to satisfy one of the existence of a fracture, particularly if both bones are broken. An open fracture will be eA-ident if a wound exists in the skin near the seat of fracture. In taking hold of the leg for examination or for moving the leg it should not be grasped lightly bv a few fingers but bv the whole hand firmly, as one grasps an ax handle in chop- 'i^^-^ Fig. 500. — Fracture of both bones of the left leg. Comparative height of knees to show shortening of leg. The patient is sitting with knees ilexed to a right angle (after Van Lennep). ping wood; n ot as one lifts a lead-pencil from the table . The leg should be so raised in naaking the examination that there is abso- lutely no risk of converting the closed fracture into an open one. In order to guard against this the assistant should grasp the foot at the ankle and make gentle but strong traction in the long axis of the leg as the whole leg is raised. This care in examination will cause the patient a minimum amount of pain. Crepitus is not the onlv thing that is to be sought at the examination. The freedom SYMPTOMS 353 of anv abnormal moMlilv should be noticed, as well as the direc- tion of the motion, the ease with which reduction is possible, and the liability to recurrence of the deformity. If there is any doubt as to the seat or extent of the fracture, the examination should be made with the assistance of an anesthetic. The temporary dress- ing may be applied at this time. The bones should be palpated. While an assistant steadies the knee-joint the surgeon, grasping the lower part of the leg, attempts motion in each direction. vSim- ply raising the leg and attempting motion in an anteroposterior direction is not sufficient ; a fracture of the tibia, if transverse, might remain completely locked except upon lateral movement. The tibia should be measured (see Fig. 499) from the knee-joint line, at the upper border of the internal tuberosity, to the lower 1\IS >f>\ Fig. 501. — Case: Fresh fracture of the leg (both bones). Characteristic deforrnity. Note normal position of patella, with the foot lying on its outer side. Prominence of upper frag- ment. Compare this with figure 391 of a fracture of the thigh in which the patella does not look upward. edge of the internal malleolus to determine shortening. Shorten- ing of the leg may be roughly estimated after union of the bones by comparing the height of the two knees while the soles of the feet rest upon the floor (see Fig. 500). The measurement should be compared with that of the uninjured tibia. It is often difficult in fractures near the ankle to palpate the internal malleolus, on account of swelling. Deep pressure with the thumb will detect it. Inquiry should be made as to whether either tibia has ever been fractured previously. The pulse should be felt for in the posterior tibial and dorsalis pedis arteries to be sure that the large vessels of the leg are intact. Symptoms. — Ordinarily, the presence of pain, deformity, abnor- mal mobility, crepitus, and loss of use of the leg will be the evi- 23 354 FRACTURES OF THE LEG dences of fracture. If the fracture is of the tibia or hbula alone and transverse without much displacement, localized tenderness upon pressure and swelling will be the only signs. It is important Fig. 502. — Fracture of the tibia, oblique and high up. Almost no displacement (Massachusetts General Hospital, 1235. X-ray tracing). Patella. Tibia. Fibula. Fig- 503- — Fracture of the external tuberosity of the tibia (Massachusetts General Hospital, 1242. X-ray tracing). t o remember the backward bowing of the fibula iiL attempting to locali ze by palpation the tender point of the fracture of that bone. The deformity is due to the displacement of the upper fragment SYMPTOMS 355 forward and of the lower fragment upward and backward. If the fracture is oblique, this displacement will be considerable. The lower fragment is often rotated upon its longitudinal axis, so that the foot rests upon its side, while the upper fragment remains un- disturbed by rotation, the patella looking directly upward (see Fig. 501). The swelling will var\\ It may be extremely slight and limited to the seat of the fracture or it may extend over the entire leg. The maximum swelling of the leg is usually reached three or four days Fig. 504. — Longitudinal Assuring of tibia from blasting accident. Front view (X-ray tracing). Fig. 505. — Longitudinal Assuring of tibia from blasting accident. Lateral view. Same as figure 504 (X-ray tracing). after the accident. If the fracture was caused by direct violence and the fragments of bone are sharp, the soft parts will be dam- aged and the resulting hemorrhage and swelHng will be ver\' con- siderable. Ecchymosis of the skin appears in from twentv-four to forty- eight hours after the accident ; it may extend over the whole leg. Ecchymosis Jm m^a sprain is localiz ed more or less about the sea t ofjhe sprain; that from a fracture is often extensive. Blebs or vesicles may appear near the fracture during the fiirst week if the 356 FRACTURES OF THE LEG swelling is great. It is necessary* to exercise great caution in the care of these blebs, that they do not become infected. Fracture of the shaft of the fibula may be very obscure, but pressure upon the fibula toward the tibia will elicit pain and crepi- tus. In s eparation of t he lower epiphysis of the tibia t he preserva - tio.n^ fjth e^normal relations between the malleoli is of considerable diagnostic importance. Fig. 5o5. — Oblique fracture of the tibia low down , and oblique fracture of the fibula at its middle (X-ray tracing). Fig. 507. — Fracture of both bones of the leg at the middle; slightly spiral of tibia (Massachusetts General Hospital, 1134. X-ray tracing). Treatment. — For purposes of treatment fractures of the leg are arranged into scA^eral distinct groups — viz. : 1. Fractures with little or no swelling or displacement. 2. Fractures with considerable swelling. 3. Fractures with a displacement of fragments difficult to hold corrected. 4. Open fractures. The indications to be met bv treatment in each of these groups TREATMENT 357 are corrcclion of dcfoniiily, inimobilization of fragments, and res- toration of the limb to its normal condition. Fractures with Little or No Displacement or Swelling. — Fractures of the tibia alone or the fibula alone are properly placed in this group. Fractures of both bones occasionally occur with little or no displacement and with but a trifling amount of swelling. In H\i^m ^ NT:-/ Fig. 508. — Oblique fracture of both bones of the leg. Displacement of the upper fragments in the same inward direc- tion (Massachusetts General Hospital, 749. X-ray tracing). Fig. 509. — Transverse fracture of both bones of the leg at the middle; slight displacement and considerable bowing (Massachusetts General Hospital, 1215. X-ray tracing). these cases the l e^ should be elevated for ten minutes in order to lessen the swelling. The foot, leg, and lower thigh are then bathed with soap and water, and thoroughly dried and powdered . The leg being properly protected, a light plaster-of -Paris roller bandage is applied from the toes to the middle of the thigh. (See Details of Plaster Work.) Thejeg jsjo be^£LelevatedJor^the first week bv at least t\yii_,ox..tlu:&fc,,piUGm:;a. If good judgment is 358 FRACTURES OF THE LEG exercised in the subsequent care of the case, the placing of such a fracture, as previously indicated, immediately in a plaster-of- Paris splint is attended b}' no risk. The danger lies in too great pressure upon the circulation, caused by the increasing swelling of the leg within the unyielding plaster splint. Pressure sores and gangrene are liable to result. In applying the splint a liberal amount of sheet wadding should be used. The condition of the circulation should be noted immediately after the application of the splint and at regular intervals thereafter until all danger from undue pressure has ceased. E vidences of Jtoo_ great pressure are persistent or Fig. 510. — Double fracture of the tibia. Single fractureof the fibula (Massachusetts General Hospital, 1055. X-ray tracing). Fig. 511. — Fracture of the fibula with- out injury to the tibia (Massachusetts General Hospital, 1230. X-ray tracing). increasing swelling of the toes, blueness of the toes, and pain. It is well, in order to avoid undue pressure upon the leg, to split the plaster the entire length of the splint before it has quite hardened. The splint loses by this procedure none of its immobilizing quali- ties, for it can be bandaged or strapped tightly together again. Too great pressure upon the circulation can then be immediately relieved by loosening the retaining straps or bandage and thus opening the splint. After the splint has been on the leg for about a week and a half or two weeks, the swelHng having begun to sub- side, the plaster splint will become loose and will cease to hold the TREATMENT 359 fragments ririiil>-. Unless a new and snug splint is now applied, it will be necessary to cut out a strip of plaster an inch or more wide from the old splint to admit of tightening. Duringf the changing of the plaster splint the log should be steadied bv an assistant while it is thoroughly washed with so^p and yator and bathed with a lcohol . Fractures with Considerable Immediate Spelling. — Many fractures are not seen by the surgeon until two or three hours after they have occurred, when considerable swelling is present. Associated 12. — Fracture of the fibula low down without fracture of the tibia (X-ray tracitig). Fig. 513. — Oblique fracture of both bones of the leg low down. Fracture difficult to hold in good position (Massa- chusetts General Hospital, 1024. X-ray tracing). with such primary swelling there will be laceration of the soft parts and possible extensive injur}' to the bone. Blebs filled with clear or bloody serum may be present about the seat of fracture. These should be evacuated after the part has been rendered surgically clean by washing with soap and water and corrosive sublimate solution, and then dressed with a drs' antiseptic powder, powdered dermatol, or aristol. Infection _.may .^ take^ 2lace_th.ia as b b i p h.'i ■ Ver\' great care should be exercised in their treatment. Obvi- ously, it is unwise immediately to apply a plaster-of-Paris sphnt to cases in which there are many blebs and much swelling. The 36o FRACTURES OF THE LEG swelling of the leg may become so_ g reat^th at the life of the limb ma^be at 5take, the danger from impending gangrene becoming imminent. In^such cases the skin of the leg becomes tense and shiny, the leg feels hard and board-like, pain may be extreme, and the toes and foot become slightly blue. The hemorrhage, being confined beneath the fascia and skin, causes pressure upon the Fig. 514. — Fracture of both bones of the leg from bullet-wound. Characteristic comminution of the bones. Bullet not re- moved. Recovery with a useful leg (X-ray tracing) (Warren). \ Fig. 515. — Transverse fracture of the tibia, high. Direct violence. Great swell- ing of leg. Threatening gangrene. Free incisions. Leg saved. Result good. Same case as figure 516 (Massachusetts General Hospital, 1064. X-ray tracing) (Scudder). circulation. The circulation in the leg is thus impeded. Under such circumstances operation is necessary- in order to relieve ten- sion and to check hemorrhage. Incisions in the long axis of the limb through skin and fascia will be followed by a rapid decrease in the swelling of the leg and a cessation of the pain. After inci- sion^the bleeding vessels found should be ligated. The bones may TREATMENT 361 be sutured at this tiiiie if it is thought wise. If these wounds remain aseptic, they may be closed after a few days by suture or niav be allowed to heal openly. This method of treatment will usually result in saving the leg (see Figs. 515, 516). If the circu - lation does not return and gangrene is imminent, immediate am- liJjW Fig. 516. — Case : Closed fracture of the left tibia. Hematoma. Imijairnieiit of the circu- lation. Free incisions. Evacuation of blood. Relief of pressure. Leg saved. Recovery (Scudder). r /^H ■ ^1% -Fracture of the leg. Temporary or emergency dressing. Application of the pillow with straps. Open end of the pillow-case at the foot. putation of the limb well above the fracture at the, lower^Q£,ffljxldk third of the thigh is the onlv Drocedure . Traumatic gangrene is often rapidly followed by general septic infection. It is best to use a temporary- dressing in cases in which there is great initial swelling of the leg. 362 FRACTURES OF THE LEG The Temporary Dressing. — The Pillow and vSide Splints. — The leg is placed on a pillow covered with a pillow-case; straps are placed under the pillow and drawn snugly up about the leg (see I^i&- 517)- The edges of the pillow are rolled in against the leg for firmness. Narrowly folded towels are placed between the leg and the straps. The straps are then drawn tighter. The open end of the pillow-case is folded and pinned under the sole of the foot. 1^ ■i M 1 1 1 1 1 "" ""' ^" Fig. 518. — Fracture of the leg Pillow and side splints with straps and towels. Compare figure 519. -Fracture of the leg. Temporary or emergency dressing, straps. Pillow held by shield-pins. Pillow, side splintF, and // Three pieces of sp lint wood are introduced between the pillojwand straps — one is slipped underneath and one upon each side of the pillow. The pillow thus serves as a padding for the box formed by the splint wood fsee Fig. 518). Ice-bags niay be conveniently place c^ala ng the anterior surface of the leg Ijctween tlie edges of the pillow. They relieve pain and are said to check hemorrhage immediately after the fracture. If greater security is thought necessary, the pillow-case, instead of having its sides rolled in, TREATMENT 363 may be pinned with shield-pins up over the anterior surface of the leg (see Fig. 519). This temporary dressing is left in place for a week or a week and a Fig. 520.— Diagram of oblique fracture of the leg. Displacement upward and forward of the lower fragment. Fig. 521. — Diagram illustrating a frequent method of apparently correcting the displacement, which results in producing a backward bowing. Fig. 522. — Diagram illustrating the pioper direction in which, combined with traction, force should be exerted in order to correct the displacement. half. The swelling will then have partly subsided. If at this time there is little or no swelling and the displacement is slight, a plaster- of-Paris splint may be apphed as a permanent dressing; it is split 364 FRACTURES OF THE EEG or not as circumstances indicate. If, on the other hand, at the end of a week or a week and a half it is desired to have the fracture open to inspection and more directly accessible and under the eye of the surgeon, then the posterior wire and side splints should be applied. The Permanent Dressing for Fracture of the Leg. — Several im - porta ntthings are to be kept constantly in mind in placing a frac- tured leg in a permanent splint. They are as follows : The aline- nient of the bones of the leg is to be maintained ; rotation of either fragment upon its long axis is to be avoided ; the foot is to be kept extended to a right angle with the leg; lateral deviation is to be avoided ; the inner side of the great toe, the middle of the patella, and the anterior superior spine_ of the ilium should be in one straight line ; anteroposterior deformity is to be avoided (the con- Fig. 523. — Padding the Cabot poni ihv tors to the knee substi- tuted, and the patient l)e allowed to loueli the foot to the floor, bearing a little weight. As soon as the j^lasler is removed and the bandage substituted, a shoe, preferably laced, should be worn on that foot. From the tenth to the twelfth week after the injury the patient should be walking with a cane. According to present methods, a fractured le.^- woidd recjuire from three to five months of treatment before restoration to normal function is completed. The after-care of a ease of fraetnre of the k\i;- is attended with no little anxiety on the part of the surgeon. The general health of the patient is a matter of considerable concern. The loss of exer- cise entailed by the cramped and unnatural position causes loss of Fig- 543.— Case : Open Pott's fracture. Wound in soft parts and protruding tibia to be seen. appetite, headache, constipation, dyspeptic ills, etc. The pain through the whole limb, due undoubtedly to the sprain and wrenching at the time of the injury, the aching at night at the seat of the fracture, combine to render the patient thoroughly uncom- fortable, unhappy, and even melancholy. Pressure spots will appear about the most carefully applied bandage, and they must receive attention. Itching of the skin inside the splints is some- times almost unendurable. To every patient daily general and local massage and bathing will be found to be of unspeakable com- fort. The average hospital patient is far less sensitive to all the pettv annoyances of an immovable and closely fitting dressing than is the private patient. 38o FRACTURKS OF THE LEG The Prognosis. — In children and young people the minimum time is consumed by the process of repair. The restoration of the leg to its normal function is more rapid than in the cases of adults, and there are fewer complications. In adults a chronic arthritis may appear in the neighboring knee- or ankle-joints. Fig. 544.— Normal leg and foot at a right angle. Note the relative position of heel and leg Fig. 545.— Pott's fracture. Posterior displacement of the foot on the leg. Note the short- ening of the foot from the toe to the front of the ankle. Compare the relative position of the heel and leg with the same in figure 544. Swelling of the leg and ankle may persist for some time. Non- union of the bones may result, and necessitate operative measures (see Fig. 538). IJ^^^Jxa^XmS^M:^^^^ shortening may occur even after union takes place if the unsupported leg isu^ To o soon and too much. If the wound of an open fracture heals quickly, RESULTS AFTER TK1:aTMKNT 381 and there is liulr ciinninut ion <.l hone, repair will lake place as in a closed fraelnre. Otherwise, an open fracture will unite more slowly than a closed fracture. Persistent swelling of the leg, par- ticularly about the ankle, is associated with the convalescence from an open fracture. Necrosis of bone at the seat of fracture may occur in cases of open fracture even many months or years after the original injury. Abscesses and sinuses may form, neces- sitating operation for the removal of the necrosed bone (see Figs. 539^ 540). If the fract ure is near the knee- or ankle-joints, the prognosis is inore uncer tain than if the fracture is at the. center of ^UsU Fig. 546.-Line of measurement to detect backward displacement of the foot on the leg. thejhaft, A comminuted fracture is more likely to be longer in uniting and to give rise to trouble after repair than is a single transverse fracture. Results after Fracture of the Leg.— Of value in this connection are the results following fracture of the leg in thirty-five cases treated at the Massachusetts General Hospital, and examined one and a half to ten years after the accident. In the detailed report of these cases the exact lesion and its seat will be stated. In thirteen cases— in ten of which the age w^as forty-two, the rest under thirty— the result reported was that the injured leg was "as good as the other leg." In twenty-two cases the result was a leg Fig- 547 •■ -Pott's fracture of left ankle. Method of examining ankle. Lateral mobility shown. Note the grasp of the foot and the leg. Fig. 548. — Case : Fracture of the internal and external malleoli and displacement of the foot inward and backward. 382 RESULTS AFTER TREATMENT 383 permanently ini])aii-e-d in some parlicular. Some cases had Hat- foot, dcforniily of llie leg, limited motion at the knee-joint, lame- ness, necrosis of bone, pain in the fracture when the weather was damp. Other cases had pain in the leg upon standing, stiffness of the ankle, pain upon stepping on uneven surfaces, weakness of the leg,, swelling of the leg and foot, cramps at night in the calf of the leg. or some combination of these symptoms. Fig. 549.— Same as figure 54S. Lateral displacement of foot inward (see X-ray tracing, Fig. 550) ■ Thrombosis and Embolism. — Thrombosis of the veins about a fracture, and particularly about a fracture in which there is some laceration of the soft parts, is not at all uncommon. At times, and rather more frequently than is generally supposed, emboli are detached from these thrombi and cause almost immediate death, with symptoms of pulmonar\- embolism — namely, a sudden cyano- sis and great difficulty in breathing associated with intense precor- dial distress. 1 i^'Wh 384 FRACTURES OF THE LEG Thrombosis of the veins of the leg or thigh is undoubtedly one of the causes of the great edema seen after fracture of these parts. Rejractnre of the Bones of the Lower Extremity. — It is not an un- common experience to find that a patient with a fracture of the thigh, leg, or patella refractures the partially united bone. This refracture is due to either muscular violence or a slight fall. There is ordinarily little displacement of the fragments. The callus of the original injury holds the bones quite securely. The leg is usually bent at the seat of the fracture. Re^acture is,_therefOTe^ practically a fracture of callus. This accident has even occurred while the patient is wearing a protective splint of plaster-of- Paris. Union in these cases is much more rapid than after the original injury. About one-half the time required for union of the original fracture is necessary for union of the refracture. The patient may, therefore, be much encouraged, for though the accident of refracture is a disheartening one, yet he will not be obliged to look forward to a long confinement. POTT'S FRACTURE ^"^V iO Anatomy. — The anatomical relations of the lower ends of the ilbilO fibula and tibia and the astragalus and os calcis should be kept constantly in mind. The os calcis and astragalus are held firmly together, forming the posterior portion of the foot. The astraga- lus rests mortise-like between the internal and external malleoli (see Fig. 541). The strength of the inferior tibiofibular articula- tion depends upon the strong inferior tibiofibular ligaments, par- ticularly upon the interosseous ligament. By Pott's fracture of the ankle is understood the injury caused by forcible eversion and abduction of the foot upon the leg. The lesions which may be present in this fracture are a rupture of the internal lateral ligament, a fracture of the tip of the internal malleolus, a separation of the lower tibiofibular articulation, an oblique fracture of the fibula two or three inches above the tip of the external malleolus, a fracture of the outer edge of the lower end of the tibia. Ordinarily, the mechanism of the fracture is some- what as follows : As the foot is abducted, the strain is felt at the internal lateral ligament and at the inferior tibiofibular interosse- I'oTT S I-KACTIKK 385 oiis liij^aniciil, and these give way- H the force continues, the f' -' '^ fibula breaks (see V\%. 542). If the force still continues, the inter- 'j''*']/* nal nuilkolus is pushed th^)u,^]l the skin, and an open fracture re- svilts (see h'ig. 54,1). If the internal lateral ligament holds against this lateral force, the tip of the internal malleolus may be pulled off. Symptoms. — The ankle presents a very constant appearance after this fracture. A traumatic synovitis exists. Great swelling appears, at first chiefly upon the inner side of the ankle. The ankle-joint becomes distended with blood and serum. All the Internal malleolus. / / ■sJ-,' ' Internal malleoli. 1 > Fig. 550. — Fracture of both malleoli (anteroposterior view). Inversion of foot (X-ray tracing). natural hollows about the joint are obliterated. The foot is everted, appearing to have been pushed bodily outward. The internal malleolus is undtdy prominent. Some of this prominence is masked by the swelling. The bonv connections and natural support of the foot having been removed, the foot drops back- ward, partly because of the pull of the calf -muscles, but chiefly because of its own weight (see Figs. 544, 545). The deformity, therefore, is a double one, a lateral sliding of the foot outward and an anteroposterior dropping of the foot backward. The malleoli -5 386 FRACTURES OF THE LEG are spread apart : the measured distance between them is increased over the normal. Palpation close above the anterior articular edge of the tibia and the astragalus reveals tenderness over the ruptured tibiofibula ligament. The backward displacement is best measured by the length of the line from the front of the ankle to the cleft between the first and second toes (see Fig. 546) . This line will be found shortened upon the injured side. There is ten- derness over the fracture of the fibula. If the internal malleolus is fractured, the sharp ridge at the broken edge can be distinctly Os calcis. — Astragalus. Cuboid. ■ Tibia. Fibula. Scaphoid. ' Os calcis. Fig. 551. — Fracture of the tip of each malleolus. Dislocation of the foot backward. Note the prominence in front of the ankle. Same case as figure 550 (X-ray tracing). felt. Grasping the posterior part of the foot firmly with the whole hand while the other hand steadies the lower leg just above the ankle, abnormal lateral mobility of the foot may be detected (see Fig. 547). The foot will be felt to move inward to its natural posi- tion. The moment inward pressure is removed the foot will be seen and felt to slump outward again. Figures 548-551 inclusive illustrate a reversed Pott's deformity, the foot having moved inward instead of outward as w ell as having fallen backward. Treatment. — The indications for treatment are to place the parts POTT S FRACTURE 387 in their normal rt-lations, and to maintain them so nntil repair is completed, guarding against both the lateral and the posterior deformities. If for any reason, such as the presence of very great swelling of the ankle, it is expedient to delay reduction, the leg should be placed temporarily in a pillow and side splints (see Figs. 517, 51S, 519). An anesthetic should always be administered before the reduction of this fracture. The reduction is thus ren- dered painless and, through relaxation of the muscles, is made far easier. The principles of the old Dupuytren splint are the ones to be applied in the reduction of this fracture whatever the apparatus in which the leg is permanently placed. These consist of the Diaphysis of fibula. Epiphysis. Diaphysis of tibia. Epiphysis. Astragalus. oi/oi/D Fig. 552. — Normal ankle-joint, showing epiphyses (anteroposterior view) making of lateral outward pressure upon the internal malleolus, lateral inward pressure upon the foot, and a forward lift upon the posterior part of the foot or heel. The practitioner may very properly use the Dupuytren splint. It is thought to be uncom- fortable, but it is not if properly applied. It is ver^- efficient in holding the fracture reduced. The Dupuyiren Splint. — This is a board from one-quarter to one-half of an inch thick, long enough to extend from the middle of the thigh to six inches below the sole of the foot, and as wide as the calf of the leg from front to back (see Fig. 560). At its lower or foot end it is serrated with three or four teeth, as seen in the Upper end of lower frag- ment of fibula. '- Tibia. Astragalus. / C?-" ternal malleolus. F'g- 553-— Pott's fracture (anteroposterior view). Notice sliding of astragalus outward. Fracture of internal malleolus. Fracture of fibula. Extreme deformity (X-ray tracing). I Lower fragment of fibula. 1 Fibula. ' Tibia. \ Os calcis. Fig. 554. — Pott's fracture. Same as figure 553 (lateral view). pott's FRACTTKIv 389 illustration. It is padded with folded sheets, so that when it is J iiLJjw applied to the inner surface of the limb, the padding extends to just ajTjho above the level of the internal malleolus, the serrated end of the Fracture of fibula. Fracture of internal malleolus. Fig. 555. — Pott's fracture. Almost no displacement. Compare with figure 553 (Massachusetts General Hospital, 82S. X-ray tracing). -Unusual space. "Internal malleolus. Fig. 556. — Pott's fracture. Notice sliding of astragalus outward. Fractures of internal mal- leolus and fibula (Massachusetts General Hospital, 54S. X-ray tracing). splint projecting six inches below the sole of the foot. The pad- ding, as seen in the illustration, is so thick at the lower end over the internal malleolus that sufficient room is left for inversion and o Astragalus — Fracture of fibula. Fig. 557. — Pott's fracture, showing fracture of the fibula and but slight sliding of the astra- galus, a sufficient distance, however, to have made a rupture of the internal lateral ligament highly probable (X-ray tracing). Fig. 558. — Splintering of the lower end of fibula (Massachu- setts General Hospital, 1105. X-ray tracing). Seat of fracture. Fig. 559. — Fracture of the internal malleolusJ( Massa- chusetts General Hospital, 1084. X-ray tracing). 390 POTT S FRACTURIC 391 rotation of the foot upon its anteroposterior axis without its im- pinging upon the splint in the least. The splint is held in place by straps and buckles : one is placed above the ankle, one above the knee, and a third is placed at the upper end of the splint. For the proper application of the splint an assistant is needed. The splint is applied while the leg rests upon the bed. An assistant steadies Fig. 560. — Pott's fracture. Diipuytreii's splint. Note length of splint ; position of straps ; arrangement of padding ; space between foot and splint. the splint and the leg so that they both project clear of the foot of the bed. A roller bandage is then applied in circular turns about the ankle and splint from the splint toward the leg. After two circular turns are made, the assistant adducts and inverts the ankle and foot, and this position is held by the third turn of the bandage, which is passed around the forward part of the foot and over one 392 FRACTURES OF THE LEG of the serrations of the splint (see Fig. 561). In order to hold this firmly a turn is then taken around the ankle. A figure of eight is then applied for several turns about the foot and ankle, crossing the ankle in front of the instep at each turn. Each suc- ceeding turn is caught by the succeeding serration of the splint. Fig. 561. — Pott's fracture. Dupuytren's splint. Note serrations of splint and turns of bandage adducting foot. Fig. 562. — Cabot posterior wire splint bent at the ankle for a Pott's fracture of the right leg. To be used to assist in maintaining adduction of the foot. At the same time the foot is lifted forward by pressure from be- hind, and this forward lift is maintained by circular turns of the bandage. The whole limb is placed upon pillows. Thus, the eversion and posterior dropping of the foot are corrected. This splint forms a good temporary' or emergency dressing for Pott's TREAT.MIvXT oF I'OTT"s FKACTURK 393 fracture. This dressing corrects the eversion, but there is great ' danger that the foot may slump backward unless most carefully }^jzj\\i. watched. This failure to hold the posterior displacement cor- ' rected is the defect of the Dupuytren splint. The Posterior Wire Sfy/int with Curved Foot-piece (see Figs. 562, 563, 564). — The posterior wire splint extending to the middle of the thigh is another apparatus used in treating Pott's fracture. Fig. 563.— Pott's fracture. Cabot posterior wire splint and side splints. Note position of lateral pads and twisted foot-piece. Side splints are shown unpadded (diagram). The foot-piece should be twisted at the ankle, so as to hold the foot when inverted fsee Fig. 562 j. The splint is covered and padded in the usual way (see p. 365). The patient is anesthetized. The leg is placed upon the splint. The foot is strongly inverted bv great lateral pressure put upon the posterior part of the foot. This inversion of the foot can not be made too stronglv, for the deform- ity can not be overcorrected. The position of extreme inversion is not a painful one to maintain. Ordinarily, the lateral pressure 394 FRACTURES OF THE LEG applied is too slight entirety to correct the deformity. The foot is held to the inverted foot-piece by straps of adhesive plaster, pads, and side splints (see Fig. 563). A pad is applied to the sole of the foot, andso placed_as to_niai ntainth e lQng^anteropostoior.JaSh of the foot. It is found that if this is not done, there is consider- able flattening of this arch upon recoven,\ The forward lift upon the foot is made and maintained by proper padding posteriorly to the lower leg and just above the heel (see Fig. 564). The lift may be reinforced by smoothly applied strips of adhesive plaster placed laterally on the foot and carried under the heel and up and over the end of the foot-piece. These adhesive-plaster strips serve as a sling for the foot. There is one other way to avoid pressure upon the point of the heel, and that is by placing beneath the heel a ring Fig. 564. — Pott's fracture. Cabot posterior wire splint, adapted to the adducting of the foot. See figure 530 for method of slinging foot and preventing its backward displacement (diagram). of sheet wadding covered with a tightly wound bandage (see Fig. 530). These methods of protecting the heel from pressure may all be used at one time to advantage. The side splints are applied with great care, being so padded as to maintain the outward pressm-e upon the inner surface of the lower end of the tibia, and the inward pressure upon the outer surface of the foot. Ver}' great care must be exercised that there is no recurrence of the deformity. Frequent readjustments are necessary-. The Lateral and Posterior Plaster-of-Paris Splints (Stinison's Splint). — The posterior splint (see Fig. 565) extends from the toes along the sole of the foot around the back of the heel and up the back of the leg to the knee or to the middle of the thigh. The lateral splint (see Fig. 566) begins at the external malleolus, passes TRKATMHNT OF I'UTTS FKACTURK 395 over the dorsum of the foot to the inner side under the sole, and up- ward alons the outer side of the leg to the same height as the poste- rior splint. Kach of Hk-sl- splints is made of about six or eight strips of washed erinoline, four inches wide and long enough to ex- tend from around the foot to the bend of the knee or middle of the thigh. The leg is protected by roller bandages of sheet wadding. Plaster cream is rubbed into the crinoline strips one after the other Fig- 565.— Pott's fracture. Stimson's splint. Posterior plaster (represented two inches too long at the upper end). until all the strips have been used. The posterior splint is applied first, and held snugly by a gauze bandage to the leg and foot. Then the remaining crinoline strips are likewise covered wdth plaster cream and applied as the lateral splint (see Fig. 567). This is also held snugly by a gauze bandage to the leg and foot. During the application of the splint and until the plaster-of- Paris has set, the foot should be held in a corrected position by an assistant. 396 FRACTURES OF THE LEG These two plaster-of- Paris splints are preferable to the encircling plaster splint, the ordinary "plaster leg," for by their use the ankle can be inspected. Less judgment is requisite in its application to insure the correction of the deformity than by the use of the ordi- nary "plaster splint." As the swelling subsides and the plaster Fig. 566. — Pott's fracture. Stims m's splint completed. Lateral plaster and posterior plaster. becomes loose, if the splints are kept tight by bandaging, the de- formity can not possibly recur. Care of the Fracture after the Permanent Dressing is Applied. — If the posterior and side splints are used : After the initial swelling has subsided — i. e., after the first week — the leg may be placed in a plaster-of- Paris splint (circular bandage), and the patient allowed TKl'ATMIC.NT oF PoTT's 1"KACTI'RE 397 up and about willi crutclKS. TIk- i)lasler should be split after application and held in i)lace by straps or a bandage. If the Stimsoii splint is used, the patient may be allowed up and about with crutches at the end of the first week. Massage may be applied to the exposed parts of the leg and foot dailv. At the third week all dressings should be removed, and gentle massage applied to the whole leg from toes to groin, especial attention being paid to the region of the ankle. Massage and gentle passive motion in an anteroposterior direction only should be ap- plied at least once or twice daily after the second week. All lateral motion is to be avoided. After the fifth or sixth week a flannel Pig. 567.— Foil's fracture. Stimson's splint lenioved. Lateral and posterior plasters. bandage will be all the support needed, although comfort may demand a thin, stiff, retentive splint at times. At the end of two months some weight may be borne upon the foot. Of the three methods of dressing a Pott's fracture the posterior and lateral plaster splint of Stimson is by far the simplest, and it is efficient in ever>' way. Moreover, it allows of massage being insti- tuted early with the least disturbance to the ankle. The posterior wire spli-t is more difficult of application, and needs careful watch- ing end frequent readjustment. \\'ith the posterior wire splint in use the foot or leg is easily accessible to early massage by simply loosening the side splints. 398 FRACTURES OF THE LEG Prognosis and Results. — In young adults there should be no deformity and almost no permanent disability. In adults there will be some stiffness for a time. If the lateral deformity has not been completely corrected, a traumatic pronation of the foot will result. The longitudinal arch of the foot should be supported always by a suitable pad under the instep for at least six months following this fracture, whether there is deformity or not. If there is deformity, it will relieve the pain. An insole of leather with a pad stitched to it for support to the arch of the foot is often of great service. If there is no pain or deformity, it will strengthen the foot until walking is easy again, and will prevent deformity appearing. If the anteroposterior deformity has not been cor- rected, pain may be experienced upon using the foot. The foot is shortened and dorsal flexion is much hindered, so that the gait is decidedly impaired. The patient will walk with a more or less stiff ankle. In those cases in which there is great deformity asso- ciated with extensive laceration of the soft parts, the foot and ankle may for many weeks subsequent to union be painful, stiff, and swollen. Pain, stiffness, and swelling increase with the age of the patient — i. e., the younger the patient, the less discomfort will there be following this fracture. The Operative Treatment of Old Pott's Fractures. — The in- dications for operation will be persisting lateral or backward dis- placements. The only method for the relief of these deformities is by osteotomy of the tibia and fibula. The results following this operation are satisfactory. Open Pott's Fracture (see Fig. 543). — The ankle-joint is in- volved. Two things are to be considered in deciding upon the treatment of the injury — the extent of the laceration of the soft parts and the amount of injury to the bones. If the laceration is so great that the foot is useless, amputation is indicated. Ampu- tation is indicated in only two other instances — old age and sepsis. If the laceration is not great, and any existing dislocation can be reduced, it should be reduced without excision, proper drainage being provided, both anteriorly and posteriorly, to the joint. If the laceration is not great and reduction of the deformity is im- possible, then either partial or complete excision should be done. OPEN POTTS FRACTURE 399 If there is great injur)- to bone, whether the dislocation can or can not be reduced, a partial or complete excision should be done. In every open Pott's fracture, no matter how small the wound of the soft parts, in order to insure an aseptic wound it should be en- larged sufficiently for thorough cleansing with antiseptic solutions in ever\' part. Extreme conservatism should characterize the treatment of recent open Pott's fracture. In the large majority of cases treated upon the conservative or expectant plan a useful ankle-joint and foot will result. The older the adult patient is, the more radical must be the treatment. <^XXi,0 CHAPTER XV FRACTURES OF THE BONES OF THE FOOT Fracture of the astragalus is caused by a blow on the sole of the foot, as in a fall from a height (see Fig. 568). Fracture of the os calcis is often present in the same foot with fracture of the astraga- lus. The ankle-joint may or may not be involved. The diagnosis is difficult without the use of the Rontgen ray. Crepitus may be elicited. Great swelling may appear in the region of the fracture. Tibia. Line of fracture. Head and neck n^ of astragalus. / \ Cuneiform. Scaphoid. \/ ' External I" ' malleolus. ■ Body of astrag- - Os calcis. J Cuboid. Fig. 568. — Fracture of the neck of the astragalus (X-ray tracing). It is highly probable that many cases of sprained ankle have been cases of fracture of the astragalus. If there is no displacement, treatment will consist in immobilizing the ankle-joint with the foot held at a right angle with the leg. As soon as the swelling has begun to subside, massage may be used to advantage and con- valescence be thus hastened. The most satisfactory- dressing is a plaster-of- Paris splint extending from the toes to below the knee, applied and immediately split open, so as to form a removable splint. This may be taken off for massage and passive motion. 40 D FRACTURK OF THK OS CALCIS 401 Recovery takes place with fair movement at the ankle-joint, so that after from two months and a half to three months the patient can walk without support. After this time complete recover)- is External malleolus. f ^^ / Posterior fragment "^v of OS calcls. / -. Inferior fragment "^ / of OS calcis. \ • / Tibia. Anterior fragment of OS calcis. Fig. 569. — Fracture of the os calcis in the body of the bone (X-ray tracing). Line of fracture. Fig. 570. — Fracture of the os calcis, almost transversely across the junction of the body and neck (X-ray tracing). slow. More or less stiffness and pain may exist for four or six months after the accident. Fracture of the Os Calcis. — The os calcis is fractured by a fall on the sole of the foot, as well as by a powerful contraction of the gastrocnemius muscle and strong tension upon the tendo Achillis. 26 402 FRACTURES OF THE BONES OF THE FOOT It may be crushed, fractured transversely or longitudinally, or a piece may be torn off from its posterior portion near the insertion Fig. 571.— Fracture of the left os calcis through the body of the bone (X-ray tracing). Astragalus. Line of fracture. Fig. 572.— Fracture of the os calcis. The part torn off is that to which is attached the tendo Achillis. Notice displacement (Massachusetts General Hospital, 1652. X-ray tracing). of the tendo Achillis (see Figs. 569, 570 inclusive). The symp- toms of fracture will be the usual ones of crepitus, swelling, pain, abnormal mobility. The heel is seen, by comparison with its unin- TRlvATMUNT 403 jiirccl follow, to be cnlart,a^d. This fracture is sometimes associ- ated with fracture of the astragalus (see Fig. 575). The treatment Body of astragalus. I Neck of astragalu.s. >—A- / ■^ External malleolus. \ -\ — ^ Os calcis. I . Os calcis, posterior I fragment. -1 — Os calcis, anterior / fragment. Fig. 573. — Fracture of the right os calcis. Same patient as figure 568. Upper border of os calcis. Os calcis. . — / \ Pig- 574- — Fracture of the os calcis without great displacement (Massachusetts General Hospital, 102. X-ray tracing). is to immobilize the foot at the angle that will best hold the frag- ment approximately in apposition. Complete plantar flexion of the foot may be needed to bring the fragments well into position. 404 FRACTURES OF THE BOXES OF THE FOOT The pull upon the tendo Achillis is in this position remoA'ed from the posterior fragment. Massage should be instituted early — during the first week. The removable plaster-of- Paris dressing is the best form of splint. After three weeks the splint should be removed, and a close fitting flannel bandage applied, with small pads under the malleoli and on each side of the tendo Achillis. The pads, if applied with considerable pressure, will assist ver}^ materially in reducing the swelling and in restoring form to the ankle. It will be about two months before the patient should bear much weight upon the foot. After three to four months walking w^ill be comparatively easy. It is often the case after fracture of the OS calcis and also after fracture of the astragalus that there is Fig. 575. — Case: Posterior viewof fracture of right os calcis and of left astragalus. Deformity. Note fullness each side of the tendo Achillis (see X-ray tracings 568 and 573). considerable disturbance of the normal mechanism of the foot. A traumatic flat-foot results from the accident. This can be greatly relieved by the introduction into the shoe of a leather pad, to raise the instep and take the strain off the injured part. The patient may find that for a period of six months or more the wear- ing of this pad is a great support and comfort. The hot-air baking is verv^ satisfactory- for the relief of the pain and stiffness felt throughout the ankle and foot. The hot-air treatment, combined with massage, helps to hasten convalescence. This treatment should be used once daily until the pain in the foot has disap- peared. Open fracture of the astragalus and os calcis, if treated anti- FRACTURE OF THK METATARSUS 405 septically, recovers with a useful ankle and foot even though the ankle-joint is ankylosed. The mediotarsal joint becomes more flexible than it ordinarily is. The loss of motion at the ankle-joint is compensated for by the mediotarsal joint motion, and the indi- vidual may walk with hardly a perceptible limp. Removal by operation of the fractured bone is attended by good functional results, and if the bone is much comminuted or dislocated, opera- tion is indicated. Fracture of the Metatarsal Bones (see Fig. 576). — This fracture F'g- 576. — Metatarsus and phalanges, showing epiphyses at fifteen years (Warren Museum, specimen 537). \ Seat of fracture. s / " TT ~ri !■ Sesamoid bones. Fig- 577- — Fracture across the first metatarsal of the right foot (X-ray tracing). is caused by direct violence. There is evidence to show that indirect violence may cause a fracture of metatarsal bones. The first and fifth bones are the ones most often broken (see Fig. 577). The symptoms are swelling, pain, crepitus, and abnormal mobility. The weight can not be borne upon the foot without pain. There is never great displacement. In order to avoid trouble in walking after union has occurred, it is wise to make the approximation of the fragments as nearly accurate as possible. A closed or simple fracture is ordinarily imcom- plicated. Union takes place in from three to four weeks. It 4o6 FRACTURES OF THE BONKS OF THE FOOT will be at least from two to four months before the foot can be used without thought of the injury received. If the fracture is open, repair will be slower than after a closed fracture. If the wound is kept clean and free from infection, no complications will arise. If, on the other hand, the wound be- comes infected, necrosis of bone, abscess formation, burrowing of pus, and great swelling of the foot may occur, all of which will greatly delay the healing process. The foot should be immobilized by a lateral molded splint of plaster-of- Paris. This should be placed upon either the outer or inner side of the ankle, according as the outer or inner metatarsals are broken. The splint should Fig. 578.— Fracture of the first phalanx of the little toe (Massachusetts General Hospital, 115. X-ray tracing). extend from the middle of the calf of the leg to the tips of the toes. It is held in position by a roller bandage of gauze. Fracture of the Phalanges of the Foot.— These fractures are rather unusual, except from a crush of the foot (see Fig. 578). They are sometimes open. The same general rules of treatment applv to fractures of these bones as to fractures of the phalanges of the hand. A simple plantar splint of splint wood, padding of the toes, and adhesive-plaster straps will be sufficient to hold the fracture. If the plantar splint covers the entire sole of the foot, it will prove of great comfort. It is sometimes wise to immobilize the ankle-joint by the thin plaster side splint, particularly if there is swelling of the leg and ankle. CHAPTER XVI ANATOMICAL FACTS REGARDING THE EPIPHYSES HiTiiHRTO our knowledge of injuries to the epiphyses has been obtained mainly through clinical and pathological observation. This knowledge is only approximately correct. \\"ith the assist- Fig. 5S0. — Relation of the capsule of the shoulder-joint to the upper epiphyses of the humerus (diagram). Fig. 579. — Epiphyses of humerus at eight years (Warren Museum, specimeti 334). Fig. 581. — Relation of the capsule of the knee-joint to the patella, femur, and tibia (diagram). ance of the Rontgen ray a ver\" great advance is being made in the accuracy of our knowledge of the epiphyses. Whereas there will, perhaps, always exist differences in the times of the appearance of the ossification centers and the times of union of the epiphyses, the 407 408 ANATOMICAL FACTS REGARDING THE EPIPHYSES discrepancies in each observer's series of cases will grow less and less. The importance of an exact knowledge of the epiphyses to those having to do with injuries in the neighborhood of joints is un- doubted. The diagnosis, prognosis, and treatment of joint inju- ries and injuries in the immediate vicinity of joints is far more satisfactory than ever before. The book by John Poland upon "Traumatic Separation of the Epiphyses," from which the follow- ing data are largety taken, marks an era in this branch of surgery. Only those facts that are considered especially important for practical everyday use are here mentioned. THE DATE OF THE APPEARANCE OF OSSIFICATION IN THE CHIEF EPIPHYSES OF THE LONG BONES (After Poland) At birth f Lower end of femur. I Upper end of tibia. At one year j Upper end of femur. t- Upper end of humerus. At one and one-half years J Lower end of tibia. I Lower end of humerus. At two years i Lower end of radius. t- Lower end of fibula. At three years j Great trochanter of femur. I Great tuberosity of humerus. At four years / Upper end of ulna. I Upper end of fibula. From five to six years j ^pper end of radius. A , • , . ' ( Lower end of ulna. At eight years J 1 Lesser trochanter of femur. After a most exhaustive study of pathological and clinical material, both of his own and that of other observers, Poland con- cludes that the order of frequency of separation of the epiphyses is about as follows: 1. The upper epiphysis of the humerus. 2. The lower epiphysis of the femur. 3. The lower epiphysis of the radius. 4. The lower epiphysis of the humerus. 5. The lower epiphysis of the tibia. 6. The upper epiphysis of the tibia. THE l.oWIvK IvPIl'HYSIS oK TIIIv I'lvMUR 409 The upper epiphysis of the humerus is composed of three sepa- rate centers of ossification: That for the head, appearing at two years; that for the great tuberosity, appearing at three years; that for the lesser tuberosity, appearing at four years. These three centers coalesce to form the upper epiphysis, and it unites, at from tlie twentieth to the twenty-fourth year, to the diaphysis of the humerus (see iMg. 579). (For Separation of this Epiphysis see p. 132.) Fig. 582.— Relation of the capsule of the knee-joint to the lower epiphysis of the femur and the upper epiphysis of the tibia (diagram) . ^4)- The lower epiphysis of the humerus is formed from three sepa- rate centers of ossification — viz., the capitellum, which appears at three years; the trochlea, which appears at eleven years; the external epicondyle, which appears at thirteen years (see Fig. Fig. 586.— Tibia showing epiphyses (War- ren Museum, specimen 417). Fig. 587.— Fibula, showing epiphyses (Warren Museum specimen). 585). These three centers coalesce at about the fifteenth year, to form the lower humeral epiphysis. The epiphysis unites to the diaphysis at about the seventeenth year. The epiphysis for the internal epicondyle forms no part of the lower humeral epiphysis. It appears at about the fifth year, and joins the diaphysis at from the eighteenth to the twentieth year. (For Separation of this Epiphysis see p. 175.) The svnovial membrane at about the fifteenth year and after- 412 ANATOMICAL FACTS REGARDING THE EPIPHYSES ward overlaps the epiphyseal line. The epiphyseal line is a little higher on the outer side than on the inner. It inclines obliquely downward and inward. The epiphysis is thinner internally than externally. The epiphysis of the lower end of the tibia appears about the second year, and unites to the diaphysis about the eighteenth or nineteenth year. Neither anteriorly nor posteriorly does the synovial membrane come in contact with the epiph3'Seal line, so that, unless great violence is exercised or the epiphysis is fractured, the ankle-joint is imopened in separation of this epiphysis (see Figs. 586, 587). Fig. 5S8. — Right scapula from above and behind: a. Epiphysis of acromion; b, epiphysis of coracoid process; c, epiphysis of g-lenoid cavity (from speci- mens in Warren Museum). Fig. 589. — Relation of the cap- sule of the hip-joint to the upper epiphysis of the femur. The epiphysis of the upper end of the tibia (see Fig. 586) ap- pears at about the first year, and unites to the shaft at the twen- tieth or twenty -second ^^ear. The synovial membrane is quite a little distance from the line of the epiphysis. The epiphyseal line runs quite close to the superior tibiofibular articulation. The acromion process of the scapula (see Fig. 5S8) presents an epiphysis that appears at from the fourteenth to the sixteenth year, and unites at from the twenty-second to the twenty-fifth year. The epiphysis includes the oval articular facet for the clavicle. The coracohumeral and acromioclavicular ligaments are attached to it. The epiphysis joins the acromion behind the acromioclavicular joint. CHAPTKR XVII GUNSHOT FRACTURES OF BONE The civil surgeon rarely has opportunity to study the effect upon bone of bullet wounds. He may see in his practice a few gunshot fractures. His experience is necessarily limited. The facts contained in this brief chapter are taken from the experience of such militarv' surgeons as Kocher, Treves, Nancrede, Makins, Senn, Borden, La Garde, and others who have during the past few years studied scientifically this important class of w'ounds. In the construction of the modern military rifle several impor- tant changes have been made. The bore of the rifle has been re- duced. The caliber of the bullet has been lessened. The velocity of the bullet at the muzzle has been increased. The trajectors' is more flat. The revolution of the bullet upon its long axis is in- creased. As a general result of these various changes the modern military' rifle has a great range and great accuracy. The effect of the modern bullet upon bone is described as concisely as is possible in the following paragraphs. The amount of the damage done to bone is dependent upon several factors : The greater the velocit}' of the bullet when the bone is struck, the greater will be the destruction of the bone. The nmzzle velocity of the modern bullet is ordinarily about two thousand feet a second. The less the velocity, the less will be the destructive effects. The velocity may be just sufficient to break the bone and not to carr\' the bullet through the limb. The severity of the injurs- therefore decreases in proportion to the dis- tance which interA'enes between the rifle and the object struck. The trained military- surgeon may read the range in the character of the damage done. The more pointed bullet secures for itself greater penetration and perforation. The bullet acts like a steel wedge driven with great velocity through the soft and hard parts. 413 414 GUNSHOT FRACTURES OF BONK The primary collision area is small. The only indisputable evi- dence of a low velocity is the lodgment of an undeformed bullet. The resistance offered by the tissues is lessened and the resulting Fig. 590.— Sections of bullets to show relative shape and thickness ot mantles : i, Geudes : regular dome-shaped tip ; mild steel mantle ; thickness at tip, 0.8 mm. ; at sides of body, 0.3 mm.; 2, Lee- Met ford : ogival tip; cupro-nickel mantle; thickness at tip, 0.8 mm. ; gradual decrease at sides to 0.4 mm. ; 3, Mauser : pointed dome tip ; steel mantle plated with copper alloy; thickness at tip, 0.8 mm. ; gradual decrease at sides to 0.4 mm.; 4, Krag-Jorgensen : ogival tip as in Lee-Metford ; steel mantle plated with cupro-nickel; thickness at tip, 0.6 mm.; gradual decrease at sides to 0.4 mm. Note the more gradual thinning in the Lee- Metford (from Makins' "Surgical Experiences," etc.). Fig. 591. — Four common types of lateral Mauser ricochet bullets (from Makins' " Surgical Experiences," etc.). wounds are neat. Important parts are seemingly miraculously avoided by the bullet. The revolution of the bullet on its long axis facilitates a neat wound of entrance through the skin. The GUNSHOT FKACTl'RHS OF BONE 4'5 Mauser bullet revolves on its own axis once in 8} I inches, or about half of a full revolution in the perforation of a limb. The amount of deslruction sulTered by any ])art of a bone depends primarily upon the amount of resistance which it opposes to a bullet. There is more resistance offered by the cortex found in the shaft than by the spongy tissue of the ends of the long bones. When the hard shaft or cortical bone is hit, the force of the bullet is expended in breaking this dense and resistant bone into minute pieces. The explosive effect of a bullet is dependent upon the velocity remaining to be expended upon the small particles of bone broken off by the initial impact. The carrying of these particles of bone Fig. 592. — Five types of fracture : a, Primary lines of stellate fracture ; 6, development of the same lines by a bullet traveling at a low degree of velocity; the two left-hand limbs seen in (a) absent ; in their places is seen a transverse line ; c, typical complete wedge ; d, incom- plete wedge; e, oblique single line (from Makins' " Surgical Experiences," etc.). forward into and through the tissues causes the laceration and tearing so characteristic of the so-called explosive effect of a bullet. The detached bony particles become really secondar\- missiles. Kocher has classified the parts of the long bones injured as the diaphysis, the epiphysis, and the part between the two, the meta- phvsis. The cortical layer of the metaphysis is thin and the spong}' tissue is in evidence. Uncomplicated injuries of these three parts of the bone are usually quite characteristic (see Figs. 594, 595, 602). The flat bones show a clean perforating wound similar to that seen in the short bones. The cancellous or spongA- tissue of bone is ordinarily perforated completely and the wound of the bone is usually pretty clean-cut. Clean-cut perforations wdth- 4i6 GUNSHOT FRACTURES OF BONE out fracture are the rule in the neighborhood of the joints and epiphyses. Makins noticed in South Africa, among the wounds he studied, "the striking contrast of clean perforation and extreme comminution in different cases " ; "the occasional occurrence of fracture of a very high degree of longitudinal obliquity"; "the rarity of any that could be termed transverse fractures"; "the general tendency of longitudinal fissuring, when it occurred, to Fig. 593. — Diagrammatic view of a type of fracture of the femur, the bullet entering on the anterior surface of tlie bone caus- ing extensive longitudinal fissuring of the shaft. The articular ends of the same have not been involved in the fracture (after Kocher). Fig. 594. — Diagram of a type of frac- ture. The entrance wound clean-cut, the exit wound lacerated and larger than the wound of entrance (after Kocher). stop short of the articular extremities of the bones." If explosive effects are but slightly marked it is probably because the velocity remaining was insufficient to impart enough motion to the de- tached particles to convert them into secondary missiles. The greater the distance between the rifle and the bone struck, the lower will be the velocity of the bullet. Consequent^ the splin- ters of bone will be fewer, longer, and more adherent. On the con- GUNSHOT FRACTlKIvS oF IJONlv 417 trarv, the iK-arcr the 1)()1K' to tlic rilk-. the sijlintcrs will be more numerous, shorter, uualtaehed, and puU eriz.ed with bone sand. A small skin wound may eonceal a serious injurs- to the bone beneath. The llesh wounds of entranee inllieted by the modern rifle are mostly trivial. The missile with its great velocity, in face of slight resistance, will retain nearly all its energ\', imparting little or none to the tissues. The exit wound may be small or large, depending upon the presence or absence of the explosive effect and Fig. 595.— Diagram of a bullet wound of the metaphysis of the femur. The smaller en- trance wound contrasts with the larger e.xit wound. The absence of Assuring is rather char- acteristic of bullet wounds in this region of the ends of the bones (after Kocher). also Upon the deflection of the bullet. Deflection of the bullet at the distance at which many wounds are received, as pointed out by Xancrede, occurs more commonly than is taught. Between the discharge of a bullet and its arrival at the mark many things may happen to it, resulting in a complicated w^ound of the soft parts and an extensive comminution of bone. The turning of a bullet by impact with an obstacle in its course is spoken of as ricochet. The bullet which ricochets may enter the body not necessarily end on, but in any position and wobbling 27 4i8 GUNSHOT FRACTURES OF BONE about. Under these circumstances the wound of entrance is greatly increased, and, the velocity being impaired, a lodged bullet often results. However, if great velocity remains, a ricocheting bullet may cause very great damage. A ricochet bullet is dangerous because its penetrative power is diminished, it is liable to be retained in the tissue, serious damage results to the bone if it is struck, and a badly lacerated wound may result in the soft parts. These facts are perhaps of interest : The old flint-lock ball was Y^Q inch in diameter. The Minie rifle (Crimean) ball was -^-^ Fig. 596. — Gutter fracture ot second degree, perforating the skull in the center of its course. The external table alone carried away at either end (from Makins' " Surgical Ex- periences," etc.). ■ inch in diameter. Martini Henry ball was -^^ inch in diameter. The modern small bore Lee-Metford is -^-q inch in diameter. The Mauser is slightly smaller than the latter. The latter two bullets have the new cupro-nickel case. The others were the old lead bullets. The Mauser' bullet is 1.2 1 inches long, weighs 172.8 grains, is 0.275 inch in diameter, has a muzzle velocity of 238 feet per second, and makes i turn to the left every 9 inches. The English Lee-Metford is 1.25 inches long, weighs 215 grains, is 0.303 inch in diameter, and has a muzzle velocity of 2000 feet per second. As Ta Garde has justly remarked, the employment of smokeless TRlCATMIvNT 419 powder, a flatter trajectory and greater penetration, and the change to the smaller jacketed projectiles will increase the number of the wounded in war, but the woiuuls, as a whole, will be less grave — more humane. Soldiers will be more often restored to the State useful members of the community, instead of cripples and pensioners. In point of economy the new projectiles confer a great advantage. Treatment. — The principles underlying the treatment of closed fractures are to be followed in the case of gunshot fractures. But there are a few considerations worthy of note. Avoid exploration of a fresh gunshot fracture upon the field. IvOcal Fig. 597. — Diagrammatic transverse section of complete gutter fracture: A, External table destroyed, large fragment of internal table depressed (low velocity or dense bone) ; £, pulverization and comminution of both tables at the center of the track; C, depression of iimer table (low velocity) (from Makins' " Surgical Experiences," etc.). examination to determine the number, size, and position of fragments is unwise. The modern bullet is usually aseptic, smooth, and not heated. There is no urgency for its removal. It appears (Borden) that neither ricochet passage through other objects nor, lowered velocit}^ markedly increases the proneness of the jacketed missile to produce infection. The lodgment of a bullet does not necessitate the treatment of the wound as if it were an infected one. The dictum of von Nussbaum — "The fate of the wounded rests in the hands of the one who applies the first dress- ing" — applies nowhere with as much force as to the wounded in battle. The first field dressing is of the greatest importance. 420 GUNSHOT FRACTURES OF BONE Consideration of gunshot traumatism of the shaft of long bones, as shown by the Rontgen ray in connection with the ultimate out- come of the cases, points indubitably to the conclusion that infec- tion or noninfection of the wound should influence treatment, rather than the amount or extent of bone damaged (Borden). In noninfected wounds extensive comminution is not, as a rule, an indication for operative interference of any kind. Occlusive Fig. 598. — Clean gutter fracture of the ilium (range about 300 yards). The gutter was clean-cut and admitted the forefinger. The inner and outer tables of the bone were in part blown out of a large, irregularly' circular exit opening about 1% inches above the crest of the ilium. The cancellous tissue was probably entirely blown out. Plates of the outer and inner tables still remained connected by their periosteum to that deep aspect of the iliacus and gluteus medius muscles. The peritoneal cavity was not opened. The patient did well. Compare with gutter fracture of the skull, seen in figure 596 (from Makins' "Surgical Ex- periences," etc.). dressings and immobilization give assurance of the best possible results. Where there is considerable comminution shortening of the limb will probably occur as a result of the comminution and the displacement of the bone fragments. But excellent functional use of the limb may be restored, unless the lesion of the soft parts is extensive and motion is restricted by the formation of cicatricial connective tissue in the traumatic spaces (Borden). TKIvATMUXT 42 1 Where infection exists removal of the cause under aseptic or antiseptic precautions is indicated. In such cases complete cleansing of the wound and removal of all loose bone fragments, followed by drainage and antiseptic dressings and irrigation, will usually suffice, and excision or amputation will only have to be resorted to in extreme cases (Borden). Amputation for extensive fracturing of the long bones is almost unknown (N'ancrede). As to the disinfection of the limb, primary cleansing, mainly by soap and water, of course should precede the exploration; and when the latter has been carried out, a second cleansing, prefer- ably with corrosive sublimate, is imperative. Fig. 599. — Superficial perforating fracture, illustrating lifting of the root at both entry and exit openings (from Makins' "Surgical Experiences," etc.). Immobilization is a more difficult problem. Makins' remarks : A question of constant difficulty is that of frequency of dressing. In a stationar\^ or base hospital this is not difficult. When the patient is, however, being moved from the field to the stationary- hospital, and thence to the base, the movements during transport disturb the fixity of the dressing. No fractures of the thigh or leg, and few of the arm, can be transported for any distance without material disadvantage. If possible, all fractures of the arm, thigh, or leg should be kept at a stationar}^ hospital for a period of three or more weeks. The necessity for primary- amputation chiefly depends on the nature of the injury to the soft parts, less commonly on the extent 422 GUNSHOT FRACTURES OF BONE of the injury to the bones, and should be decided on exactly the same lines as in civil practice. So-called intermediate amputa- tions are always to be avoided if possible. The results have been bad and the operation should only be undertaken in cases of severe sepsis where little can be hoped from it, or for secondary hemorrhage. When the operation could be tided over until the septic process had settled down and localized itself, sec- ondary amputation gave very fair results. In either intermediate or secondary amputation for suppurating fractures it was neces- sary to bear in mind the special likelihood of an extensive osteo- myelitis (Makins). The very great mortality attending gunshot fracture of the femur previous to the introduction of the small-bore rifle makes it important to consider this fracture in some detail. I quote Fig. 600.— Diagrammatic longitudinal section of fracture shown in figure 599 (from Makins' "Surgical Experiences," etc.). Makins as having had the best recorded clinical experience in these cases. First with regard to the primary signs and symptoms. A very considerable degree of general or constitutional shock usually accompanied them, and this was perhaps more constant than in the case of any other injury in the body. Tocal shock to the part was also a prominent feature. Abnormal mobility was very free in the badly comminuted cases. Crepitus was often loose, and of the "bag-of -bones" variety. The result of local shock and conse- quent flaccidity of the muscles was to reduce the development of primary shortening; in some cases of severe comminution this w^as practically nil during the first day or two, when, with return of tone in the muscles, it sometimes became very considerable. The long and difficult transport is the most unsatisfactory ele- ment to contend with in the treatment of fractures of bone in the field. There are advantages in having a field hospital behind the firing line. Sir Wm. MacCormac has said that the ideal treatment TKICATMIvXT 423 of a gunshot fracture of the femur would be to erect a tent over the man where he fell and not to transport him at all. The plaster-of- Paris splint {niller bandage) spica to both thighs, with a long outside splint from axilla to below the foot, is the most satisfactory immobilization apparatus for these cases of compound thigh fracture. The operative mortality following compound or open fractures of the femur during the Crimean war was about 73 per cent. Dur- Fig. 601. — Perforation of lower third of tibia, showing lifting and Assuring of the compact roof of the tunnel. Compare with figure 599, of a fracture of the cranial vaults (from Makins' " Surgical Experi- ences," etc.). Fig. 602. — Oblique perforation, implicating both epiphysis and diaphysis. Large fragment detached at exit aperture. Caused by a bullet traveling at a low rate of velocity. The dotted lines indicate the course of the track (from Makins' "Surgical Experiences," etc.). ing the American w^ar it was about 53 per cent. During the Franco-German war it was 65 per cent, among the Germans and 90 per cent, among the French. The conser^^ative mortality — i. e., in the unoperated cases — was, under these same conditions : Crimean war, 72 per cent. ; American war, 49 per cent. ; Franco- German: German, 28 per cent.; French, 9 per cent. In the re- cent war with Spain in Cuba, although the results are not all tabulated, during 1898-99 the general mortality in operated and unoperated cases together was but 10 per cent, in this serious 424 GUNSHOT FRACTURES OF BONE injury. Modern surgical methods used upon wounds of bone caused by modern military weapons will bring the mortality-rate ver}' low indeed. All those interested in this department of surgerv will await final statistics with hopeful expectation. Prognosis in Fractures of the Femur. — From Makins' " Surgi- cal Experiences " : "As regards mortality, fractures in the upper third of the bone proved one of the most formidable injuries which came under treatment. Suppuration was common, at least 60 per cent, of the wounds becoming infected. This depended on several reasons, often inseparable from the injuries, or, from their treatment in field hospitals; such as (i) the exit wound being situated in the dangerous region of the thigh; (2) ineffective dressing and fixation; (3) the impossibility of insuring primary cleansing and removal of detached fragments of bone; (4) the necessity of the early transport of patients to the stationary or base hospitals, often for great distances; (5) the comparativ^ely long period that often had to elapse before the opportunity of doing the first efficient dressing arrived. Fractures in the middle and lower thirds of the bone were more easy to treat successfully, but these also added to the list both of amputation and fatalities. Punctured fractures of the lower articular extremity were usually of little importance, as they progressed without exception, as far as my experience went, favorably." CHAPTER X\'I II THE RONTGEN RAY AND ITS RELATION TO FRACTURES BV E. A. CODMAN, M.D. On Januar}' 23, 1896, Rontgen read his announcement of the discoven- of the X-rays before the Physico-medical Society at Wurzburg. The extraordinary- news fled over the world in an incredibly short time. AA'ithin a few months skiagraphs of the bones of the hands appeared in every newspaper that could afltord an illustration, and the reporters indulged their imaginations and dwelt on the advantages the new discover^' would bring to medi- cine and surgerA'. The strangeness of the subject offered an un- usuallv brilliant field for the imaginative and humorous, and in consequence it will undoubtedly be years before the public is dis- abused of its first erroneous impressions. Perhaps more people err now on the side of incredulity than credulity, and are inclined to regard the wonders they heard of at first as "newspaper talk." Medical men are particularly subject to this criticism, and there are manv who seem to feel a disappointment in the results. It is unfortunate that Rontgen 's original article was not widely pub- lished in the first place, for it is a model of scientific accuracy, and contains not a single statement that has not been substantiated again and again. To those men who understood the limitations of the X-ray that this article pointed out, the results have not been disappointing. On the contrary', the improvements in appa- ratus and technic have enlarged the scope of its use and increased the importance of the information it gives us. The X-ray depart- ment has become a necessity in ever}- large general hospital. In discussing the value of Rontgen's discover}^ in a book on the treatment of fractures it has seemed wise to point out some of the mistakes that are commonly made in the interpretation of skia- graphs. To those who have done practical work with the X-rays 425 42 6 the; rontgen ray and its relation to fractures this chapter will be valueless; but those who have not may find in it some assistance in their effort to learn what real value the new science is to this branch of surgery. Among other misconceptions the Crooke's tube was supposed to emit a very powerful light. It is not a powerful light, but merely a faint one of such quality that it is able to penetrate sub- stances that ordinary light does not. It is its peculiar quality, not its intensity, that enables it to penetrate opaque objects. It is invisible to our eyes, but has the quality of causing chemical action on a photographic plate or of affecting crystals of certain sub- stances so as to make them emit a faint light. A sort of sand- paper made of these crystals, finely ground, forms a fluorescent screen. A fluoroscope is made by inclosing such a screen in a light tight box with an eyepiece to allow the observer to see the crystal side of the sand -paper. When this instrument is brought near a Crooke's tube in action, the cr\'stals become luminous and any substance that is not easily penetrated by these rays, when placed between the source of light and the screen, will cut off the rays and cast a shadow on the sand-paper that can be seen on the side away from the object. This shadow will be more or less deep, according to whether the substance cuts off more or less rays. Thus, iron casts a darker shadow than wood; bone, a darker shadow than flesh. In general the opacity of different substances varies directly with their atomic weights. In the same way the substance placed between the source of light and a photographic plate will cut off some of the rays from the plate. Where these are cut off, chemical action does not occur ; where some of the rays go through, it occurs slightly; where the object does not interfere at all and the ra5^s strike the plate directly, the action is greatest. When the plate is developed, we get a picture of the shadow of the object with its most dense parts most deeply shaded. Many people confuse an X-ray picture with a photograph They take it to be a photograph by X-ray light. It is not a pho~ tograph, but a shadow-picture, a compound silhouette, a projec- tion of the parts of an object. A photograph of the hand is made by the light reflected from the hand to the photographic plate, and shows the surface of the skin. A skiagraph of the hand is made by the light that has passed through the hand, and shows a chart of MISTAKES I.\ IXTKRI'KlvTATlON OF SKIAGKArilS 427 the dilTcrent densities of tlK- dilTerent eonslitiients of the hand, as bone, muscle, fat, and skin. As the other parts of the hand are of about equal density and this density is much less than that of bone, the bones appear prominently on the chart. The thickest portions and most dense portions of the bone appear more deeply marked than the lighter and spong)^ portions. As evers- little gradation of density is registered, the whole forms a picture. As far as we know, the effects of the X-rays are only obtainable in the immediate neighborhood of their course; that is, a small point on the platinum reflector in the Crooke's tube. From this point they radiate in all directions, their power gradually dimin- ishing until at a distance of about a hundred feet or a little more they are not appreciable by any means now at our command. Practically, they are only strong enough for skiagraphic pvu-poses within a few feet of the tube. Since they proceed from a point, and are not approximately parallel like the sun's rays, their shadows are necessarily distorted. We are all familiar with the distorted shadows thrown on the wall by a candle. The same distortion takes place in an X-ray pictiure in a lesser degree. vSince the rays proceed from a point, all parts of an object can not stand in the same relation to that point and the surface of a plate at the same time. The least distortion will take place when the object is in contact with the plate, and as far from the light as is consistent with obtaining sufficient effect to take the picture : that is, to have the ra^'S penetrate the less dense portions of the object. Let the distance from the point to the plate remain the same. It follows that : (a) Shadows will be enlarged in proportion to the distance of the object from the plate, toward the light. (b) Shadows are distorted of any object or part of an object not in a perpendicular line from the point of light to the surface of the plate, and that distortion takes place in a line drawn from the base of such perpendicular through that object or part of an object. As an illustration of these distortions, we have represented in figure 603 the projection of a cubical block of wood (a). For con- venience of drawing, the shadow (b) is represented at an angle. The outside square of b represents the upper surface of the block, while the inner square represents the lower. The density of the 42 8 THE RONTGEN RAY AND ITS RELATION TO FRACTURES shadow is greatest at the edges of the lower square, for they repre- sent the longest paths of the ra3's through the block. From the consideration of figures 604, 605, 606, and 607 the reader will read- ily observe that any change in the tilt of the plane of the plate (Fig. 605, a) in the shape or densit}^ of the object, or in the distance of the point of light (Fig. 606), will produce a definite alteration of the shadow or picture. It is, therefore, necessary^ in looking at a skiagraph to know how the plane of the plate lay, how far distant T'-tA-r Fig. 603. the light was, and, in general, what the shape and density of the different parts of the object were. Just as it is true that the shadow of any object increases in size as it is moved from the plate toward the light, so also it is true that the density of the shadow decreases as its size increases. Each object that is translucent to the X-rays seems to have the ability to cut off a certain amount of X-ray light. In other words, it contains a certain amount of shadow-casting material. As it is THE INTERPRETATION OK SKIAGRAPHS 429 moved from the plate toward the light its shadow increases in size, but diminishes in density, since only a certain amount of light can be obstructed by that object. k—?iaXe TLate Fig. 605. Putting it in another way, we see that the object .v y (Fig. 604) in the angle ah c interferes with three times as much light as if in the position oiade, but since it can only cut off a certain quantity 430 the; rontgen ray and its relation to fractures of rays in either position, the shadow in d e will be darker, though smaller than h c. Of course, if x y were not penetrated at all by the rays, the shadow would be at a maximum in both cases. In ah c there are three times as many rays to go through, but x y can only subtract a certain number. It can subtract that number from a d e where there will be a smaller remainder and hence a deeper shadow. This is an especially important point to keep in mind, for the range of variation of density of different bones is very small, and a very slight change in position in relation to the Fig. 606. Fig. 607. plate may make an enormous difference in the resulting picttu-e. For example, figure 608, a skiagraph of the knee taken from be- hind, — i. e., with the plate behind, — C shows little or no sign of the patella. While with the plate in front {B) and the tube behind, the outline of the patella is distinguishable through the shadow of the femur. This is the more decided if the tube is brought quite near to the back of the knee {A), for then the size of the shadow of the femur is increased and its density diminished, while that of the patella remains nearly the same in both size and density. Another point that, though simple, seems to cause misunder- THK IXTERPRKTATION OF SKIAGRAPHS 431 standinj^ is illustrated in figure 607, representing the shadow of a section of one of the cylindrical bones. It is intended to show why a long bone appears like a longitudinal section in a skiagraph. Though the whole circumference may be of the same thickness, the rays that pass through the sides, x-y, meet more resistance than those through the center; hence the medullary cavity appears on the plate. It is often of great assistance to plot out on paper a projection of the salient points of the subject, as in figure 603, at the same time bearing in mind that variations occur in densitv as well as in size. TVaii PUt< Fig. 60S. We should like to go into the question of the deceptiveness of skia- graphs at greater length, because we regard it as of the utmost importance that ever}- physician who uses this means of diagnosis should fully understand the wa}' in which any conclusion should be drawn from one of these pictures. Though the pictures themselves are inaccurate as pictures of the object, they are accurate pictures of the shadows of the different parts of the object, and the reasoning of conclusions drawn from them should be exact. In answer to the question of what help the X-ray has been in increasing our knowledge of the pathology- and treatment of frac- tures, we may mention first the general points and then the par- 432 THE RONTGEN RAY AND ITS RELATION TO FRACTURES ticular fractures in which we find it to be of benefit. Although surgeons have alwavs realized very nearly accurately the position of the displaced fragments in the common fractures, there can be no doubt that the production of pictures of the exact condition in individual cases gives more reliable information of the condition and relation of the broken ends than can possibly be obtained by palpation. A more definite knowledge of the pathology" brings greater exactness of treatment. When the splints are applied, it can be ascertained whether the position is good without removing the bandages. Little details that otherwise would escape notice are brought out. The patient is spared painful manipulation or etherization and the bruising and laceration of the tissues from unnecessary handling. The question of a cutting operation to reduce otherwise intractable fragments may be decided by an exact knowledge of the positions of the parts. This subject of the advisability of interference by making a simple fracture compound is one that is attracting more and more attention, and will lead to its being made the rule in cases where a good result can not be expected by the simple method. When asepsis can be practised, there is little danger of making an incision, and the time saved in cases where approximation of the fragments is prevented by loose bits of bone or soft parts is well worth this slight risk. At present w^e find the X-rays of more assistance in the study of the pathology of fractures than w-e do in their treatment. For though we believe that in each individual case of fracture a skia- graph is of decided assistance, yet it nmst be confessed that the cases where it leads us to modify the treatment to any considera- ble extent are few in number. An exact diagnosis of fracture without skiagraphs is always open to doubt, while with a careful X-ray examination there is seldom a doubt. We appreciate the X-ray, too, when, after applying our splints, even if plaster, we assure ourselves of the correct alinement of the bones. As a means of demonstrating to students the pathology- of frac- tures, a series of lantern-slides of skiagraphs is of the greatest assistance. The knowledge that the pictures are of actual cases and not theoretic diagrams gives a practical interest that is akin to clinical instruction. The plates when shown at the same time ITS PRACTICAL VALUE 433 as the case at a hospital clinic also serve to illustrate the pathology and indications for treatment. A not unimportant result of the use of Rontgen's discover)- is the exactness it offers as a method of record in the rarer fractures. Heretofore statistics on the uncommon forms of fracture have always been open to the doubt of mistaken diagnoses, and we have Vjeen dependent on the chance of securing postmortem specimens in order to obtain accuracy. In future the recorded cases of this kind can be illustrated by skiagraphs, and we may look forward to not only greater accuracy, but to a much greater number of cases that were formerly considered rare. Ever}- large hospital will be able to turn to its records and say definitely in what percentage anv given fracture occurred. At the same time, each individual case has the benefit of a definite record, and the result can be com- pared with the extent of injur}'. The reader will now ask in what forms of fractiu-e can we say the X-rav is of great assistance. In general, those bones that can be brought near the plate or that are not overshadowed by other bones give the most satisfactory- skiagraphs. Therefore, little can be expected of skiagraphs of the bones of the head or vertebrae, while those of the extremities come out with great precision. The pelvic and shoulder-bones stand midway between these, but with a good apparatus and care in the choice of the relative positions of the plate, tube, and the particular portion of the bone to be taken, we may expect a definite picture. Even in the case of the skull and vertebrae we occasionally find a skiagraph of advantage. The entire contour of the lower jaw can be easily investigated; the nasal, alveolar, and mastoid processes and malar bones come out sharply ; the cervical vertebrae, both from behind and from the side, can be brought out with great detail, while the dorsal and lumbar, though not appearing clearly, sometimes show the rough outlines of bodies and articular, transverse, and spinous processes. Any particular portion of any particular rib, except the necks, can be taken w^ith great accuracy; since the plate can be laid almost directly upon it. The clavicle, too, comes out clearly. The ster- num is too much overshadowed by the dense dorsal vertebrae to show definite outlines. Fractures in the shoulder-joint are often impossible to recognize 28 434 THE RONTGEN RAY AND ITS RELATION TO FRACTURES without the X-ray, particularly in those cases where the swelling and effusion about the joint prevent manipulation. Fractures of the tuberosities of the humerus, of the surgical and anatomical necks, can be differentiated with great certainty. When separa- tion and dislocation of the epiphysis have occurred, we may decide the question of operation ; and the same question may be answered in those puzzling cases in which fracture of the neck has occurred with dislocation. Separation of the tuberosities we now find is a much more common accident than we had supposed. Even in breaks of the shaft of the humerus and the other long bones we gain much information. The extent, direction, and plane of cleav- age, with the exact amount of displacement, are guides for the application of padding and splints. It is in fractures of the long bones particularly that a second series of skiagraphs with the splints in position is of value. The amount of shortening is shown more accurately than by measuring the landmarks, for the overlapping can be distinctly seen. If necessary, the approxima- tion of the fragments can be aided by proper pads. It is not out of place here to refer again to the question of distor- tion, for in these cases one must remember that not only may the bones be magnified, but also the interspace between them. Two or more pictures must be taken, for a view from the side will often show a displacement that is not brought out in the shadow from in front or behind. The fluoroscope is particularly useful in this sort of work, for, while it does not give the detail that can be seen in a plate, it is clear enough to assure one of the alinement of the parts and avoids the trouble of taking and developing the plates. In general work, however, we place less reliance on the fluoroscope than on the skiagraph. As will be pointed out later, the use of the fluoroscope, also, is not without danger of dermatitis. It is in injuries about the elbow-joint that we must be more than ever upon our guard to avoid false conclusions from the distortions that we have endeavored to point out. It will be most useful to any practitioner who intends to do X-ray work to take a series of skiagraphs of the normal elbow-joint from different positions and in different positions, and to study most carefully the projections of the parts in each. Such a series of injuries occur in this region that the diagnoses are most difficult, and the skiagraph correctly ITS PRACTICAL VALUE 435 interprclfd is of the grcatcsl help. Cases lluil. formerly appeared in hospital records as "injury to elbow" arc now divided into "fractures of head of radius," "neck of radius," "separation of coronoid process," etc. A feature which is now thoroughly brought out is the common occurrence of fracture with dislocation. Injuries to the elbow are particularly puzzling in children, since the ossification of the epiphyses is found in different stages, and the cartilaginous portions do not show in our plates. We may expect better results in this field when, by stud}^ and experience, we learn more of the time and mode of formation of the epiphyses. In the wrist Rontgen's discovers- has taught us much. We find in the fracture of the lower end of the radius a variety of types. Breaking of the styloid of the ulna is found to exist much more often than was supposed. The styloid of the ulna was fractured in 80 per cent, of 140 cases of Colles' fracture. Fracture of the scaph- oid is also not uncommon both alone and in conjunction with Colles' fracture. Fractures of the semilunar and os magnum are also reported. The metacarpals and phalanges offer a less inter- esting field, but in the former, when impaction into the distal ex- tremity has occmred and it is impossible to obtain crepitus or mobility, a skiagraph shows clearly the condition. Improvements in apparatus and technique have enabled us to get, as a rule, clear pictures of the upper extremity of the femur when normal or recently broken. When diseased or surrounded by much infiammator\^ thickening or calcareous deposit, the out- lines are blurred and unsatisfactory', but yet throw light on the diagnosis. There are often puzzling cases when fracture, disloca- tion, tuberculosis, and coxa vara all have to be considered, and in which a skiagraph is of the greatest assistance. Anv portion of the shaft of the femur can be taken, and, since portable X-ray apparatus have come into use, the picture may be obtained with- out disturbing the patient or his dressings. Of the knee we get very clear plates. Of the method of taking the patella we have already spoken. \A'e can compare the results of the traction treat- ment with those of suture and wiring. It is of assistance in deter- mining whether the fragments are not too much shattered to admit of wiring. In injuries of the lower leg we may appl}- what has already been 436 THE RONTGEN RAY AND ITS RELATION TO FRACTURES said of the other long bones, and in addition mention a case in which a fragment from the external malleolus lodged back of the astragalus under the tendo Achillis. In the foot, as in the wrist, the X-ray has taught us much. Numerous cases of breaks in the OS calcis, astragalus, and scaphoid have been reported, and, though fractures of the other tarsal bones have not fallen within our experience, their occurrence might easily be recognized. Gocht points out that many swollen feet of uncertain diagnosis prove to be fractures of the metatarsals. He also reports frac- tmre of one of the sesamoid bones of the great toe. It is commonly said that the X-ray is dangerous to the patient and burns the skin and destroys the hair. This is true as a possi- bility, but nowadays is only to be feared in connection with gross ignorance and carelessness. It is a fact that Crooke's tube in action is capable of causing an effect on the tissues similar in many respects to a brun. But this action does not take place unless the tissues are exposed to the tube for a considerable period of time and at a very short distance : For instance, eight inches from the tube for an exposure of five minutes we should consider perfectly safe ; one inch from the tube and five minutes, dangerous. Danger in- creases as we prolong the time of exposure or diminish the dis- tance of the tube from the skin. Repeated exposures at short intervals are approximately equivalent in time to one exposure equal to the sum of all. Probably the skins of different people vary in susceptibility to this influence, but we doubt if injury ever occurred unless the tube was within a foot of the patient. Danger to the hands of the operator of the apparatus is quite another matter, for repeated exposure may produce the same con- dition. The most severe cases occur when, in the use of the fluoro- scope, the operator puts his hand near the tube, either to hold the patient's limb in place or to demonstrate the bones of his hand to an audience. Physicians who are called upon to use the fluoro- scope often should wear rubber gloves to protect the hands, or cover the tube with a grounded aluminium screen. Most of the recorded cases of severe injury took place when the new light was first used, and experience had not pointed out these cautions. To-day, with our improved apparatus, the penetration and defini- tion render a closer approach to the tube than twelve inches un- THE LOCAL liFKECT OF THE RONTGEN RAY 437 necessan-. The cause of these burns has been a subject of much discussion, and it may still be considered an open question. There are many who believe it to be due to an electrostatic efTect, while others, among whom is Professor Elihu Thomson, affirm that the Rontgen rays themselves are responsible. Professor Thomson certainly should be an authority on this point, for he has not only the advantages of his electrical knowledge, but also of experimen- tal experience. The following is a quotation from a personal letter from him in November, 1896, describing a somewhat heroic ex- periment. ' ' Hearing of the effects of the X-rays on the tissues, especially on the skin, I determined to find out what foundation the state- ments had by exposing a single finger to the rays. I used for this the little finger of the left hand, exposing it close up to the tube, about one and one-quarter inches from the platinum source of the rays, for one-half an hour. For about nine days ver\' little effect was noticed ; then the finger became hypersensitive to the touch, dark red, somewhat swollen, stiff ; and soon after, the finger began to blister. The blister started at the maximum point of action of the rays, spread in all directions covering the area exposed, so that now the epidermis is nearly detached from the skin ; underneath and between the two there is a formation of pirrulent matter that escapes through a crack in the blister. It will be three weeks to- day since the exposure was made, and the healing process seems to be as slow^ as the original coming on of the trouble." Foiu" days later: "The whole epidermis is off the back of the finger and off the sides of it also, while the tissue even iinder the nail is whitened and probably dead, ready to be cast oft'. The back of the finger for a considerable extent, where it received the strongest radiation, is raw and will not recover its epidermis, ap- parently, except from the sides of the wound." Xot entirely satisfied with this experiment, Professor Thomson shortly afterward repeated it on another finger, which he covered with some aluminium foil in such a way as to convince him that the tissue, while still exposed to the X-ray, was shielded from the brush discharge. As he obtained the same result, he concluded in favor of the Rontgen ray itself. In a recent article on the subject he shows that this effect is due to those of the rays that are less 438 THE RONTGEN RAY AND ITS RELATION TO FRACTURES readily transmitted by the tissues and are less valuable for skia- graphic purposes. This quotation is made not only from its value as an experiment, but also because it is so clear a description of this form of dermati- tis. The long period before the effects become evident is quite characteristic, although in many cases they have appeared sooner. It seems probable that the direct effect is on the vasomotor or trophic nerve supply, which eventually affects the nutrition of the part. This chapter has been mainly devoted to warnings of the dan- gers of the Rontgen ray, and may in a measure discourage practi- tioners from its use. It should be stated, however, that when the limits of error are kept clearly in mind, the actual value of the dis- covery to surgical science is very great. When there is doubt of the diagnosis of a fracture, no physician has done his full duty by his patient if he can command skiagraphic examination and has not used it. This is particularly true in medicolegal cases where there is a question of liability. Conclusions Expressing the Views oe the American Sur- gical Association upon the Medicolegal Relations of X-rays; Adopted in May, 1900. 1. The routine employment of the X-ray in cases of fracture is not at present (1900) of sufficient definite advantage to justify the teaching that it should be used in every case. If the surgeon is in doubt as to his diagnosis, he should make use of this as of every other available means to add to his knowledge of the case, but even then he should not forget the grave possibilities of misinter- pretation. There is evidence that in competent hands plates may be made that will fail to reveal the presence of existing fractures or will appear to show a fracture that does not exist. 2. In the regions of the base of the skull, the spine, the pelvis, and the hips, the X-ray results have not as yet been thoroughly satis- factory, although good skiagraphs have been made of lesions in the last three localities. On account of the rarity of such skiagraphs of these parts, special caution should be observed, when they are MEDICOLKGAL RKLATIONS OF X-KAYS 439 afTected, in basing upon X-ray testimony any important diagnosis or line of treatment. 3. As to questions of deformity, skiagraphs alone, without ex- pert surgical interpretation, arc generally useless and frequently misleading. The appearance of deformity may be produced in any normal bone, and existing deformity may be grossly exaggerated. 4. It is not possible to distinguish after recent fractures between cases in which perfectly satisfactory' callus has formed and cases which will go on to nonunion. Neither can fibrous union be dis- tinguished from union by callus in which lime-salts have not yet been deposited. There is abundant evidence to show that the use of the X-ray in these cases should be regarded as merely the ad- junct to other surgical methods, and that its testimony is espe- cially fallible. 5. The evidence as to X-ray burns seems to show that in the ma- jority of cases they are easily and certainly preventable. The essential cause is still a matter of dispute. It seems not unlikely, when the strange susceptibilities due to idiosyncrasy are remem- bered, that in a small number of cases it may make a given indi- vidual especially liable to this form of injury. 6. In the recognition of foreign bodies the skiagraph is of the very greatest value; in their localization it has occasionally failed. The mistakes recorded in the former case should easily have been avoided; in the latter, they are becoming less and less frequent, and by the employment of accurate mathematical methods can probably in time be eliminated. In the mean while, however, the surgeon who bases an important operation on the localization of a foreign body buried in the tissues should remember the possibility of error that still exists. 7. It has not seemed w^orth while to attempt a review of the situation from the strictly legal standpoint. It would var}^ in different States and with different judges to interpret the law. The evidence shows, however, that in many places and under many differing circumstances the skiagraph will undoubtedly be a factor in medicolegal cases. 8. The technicalities of its production, the manipulation of the apparatus, etc., are already in the hands of specialists, and with that subject also it has not seemed worth while to deal. But it is 440 THE RONTGEN RAY AND ITS RELATION TO FRACTURES earnestly recommended that the surgeon should so familiarize himself with the appearance of skiagraphs, with their distortions, with the relative values of their shadows and outlines, as to be him- self the judge of their teachings, and not to depend upon the inter- pretation of others, who may lack the wide experience with surgi- cal injury and disease necessary for the correct reading of these pictures. CHAPTER XIX THE EMPLOYMENT OF PLASTER-OF-PARIS Many fractures of the upper and lower extremities may, at some period, ver^- properly be treated by the plaster-of-Paris splint. The plaster-of-Paris should be of the best quality and dry. Crinoline is used for bandages. Commercially it is called Arrow- wanna Crinoline Lining. It is a lining material that is coarser meshed than the cheese-cloth used for gauze bandages, and is also stififer than cheese-cloth. It should be cut into four -yard lengths, folded, and stitched together. Crinoline contains considerable sizing or glue. This is detrimental to its use as a plaster bandage. It should, therefore, be washed of the sizing in lukewarm water, thoroughly rinsed, and rough dried. The stitching holds the material firmly together dtiring the washing. It should then be cut into strips the widths of the desired bandages. Three widths are ordinarily useful — namely, widths of two inches, three inches, and five and one-half inches. These fotur-yard strips are made into roller bandages. A fine-meshed gauze bandage is being used quite commonly in place of crinoline. Rolling the Plaster. — It is a simple matter to make one's own plaster roller bandages. It is possible to purchase plaster band- ages in sealed packages. These are ordinarily made with un- washed crinoline and are less desirable. A shallow box or tray is needed to hold the plaster. Two persons can roll the bandage with facility. "A" manages the roll of crinoline, straightens it as it unwinds, spreads the plaster with a light piece of board, the size of the hand, while "B" draws the crinoline across the tray from imder the board held by "A," and rolls up the bandage loosely and evenly. "A" w4th the board held still and plaster heaped upon the bandage behind it, regulates, by more or less presstue upon the bandage, the amount of plaster distributed over the crinoline. It requires but ten or fifteen minutes to make enough 441 ^llbU n -a p Cfl CS T) 1^ rt -a bb o Ix, rt ^ 442 443 444 THK EMPLOYMENT OF PLASTER-OF-PARIS bandages for a plaster splint for the leg or thigh. An advantage in making one's own bandages is that they are made of the desired width and have the proper amount of plaster. They are fresh and more likely, therefore, to set readily upon being wet. If many bandages are made at a time, they may be kept in a tin cracker box. If the closed box is put in a dry place, these band- Fig. 614. — Fracture of the elbow or orearm. Application ot sheet wadding tor protection. Method of holding the arm at a right angle. ages will keep indefinitely. Should the plaster become damp, the bandages should be placed in a warm oven until dry. It is im- portant in making the plaster rollers to put just enough plaster into the bandage and to distribute the plaster evenly through the meshes of the crinoline. The proper amount of plaster to put into a bandage can only be learned by experience in making and using the bandages. It is a common error to spread the plaster too MAKING THK PLASTER BANDAGE 445 thicklv. The water in wliicli the bandages are dipped should be r^Sj^ lukewarm and of sufficient depth to cover the bandages when set > up on end. The water working its way into the meshes of the bandages displaces the air in the bandage, which is indicated by the bubbles rising to the surface of the water. As soon as the bubbles have stopped rising the plaster is thoroughly wet throughout the bandage. Table salt, two teaspoonfuls to four quarts of water, Fig. 615.— Fracture of the elbow or forearm. Application of plasterof-Paris bandage. Method of holding the arm. hastens the setting of the plaster. Its use, how^ever, is to be dep- recated, because the plaster has to be applied too quickly for the best results in plaster work, and the brittleness of the plaster re- sulting from the use of salt is undesirable. The plaster bandage should be lifted from the w-ater carefully with both hands holding the two ends so as to retain as much plaster as possible within the roll. The bandage should then be wrung free from water while Fig. 616. — Fracture of the elbow or forearm. Plaster-of-Paris splint being applied. Elbow at a right angle. Fig. 617. — Anterior and posterior splints being applied after having become firm upon the forearm. For fracture of forearm bones. 446 Fig. 6i8. — Anterior and posterior splints in position. To be held in place by adhesive-plaster strips and a bandage. A light, durable, cheap, efficient splint. Fig. 619. — A posterior splint for elbow, forearm, and upper arm. It is most comfortable. 447 Fig. 620. — Posterior elbow splint in position. Fig. 621. — Posterior and anterior splints for elbow. Anterior splint being applied. w Fig. 622. — Anterior and posterior splints for the elbow. Note the additional plaster wedge being put in place to strengthen the anterior splint at the bend of the elbow. Fig. 623.— Anterior and posterior plaster splints applied. Most comfortable and efficient in injuries high up the orearm and at the elbow and lower part of upper arm. 29 449 Fig. 624.— Lateral or side splint of plaster-of-Paris for the foot, ankle, and lower leg. Note shape of crinoline. The plaster cream is being poured from pitcher and evenly rubbed into the layers of crinoline. Foot Portion. Leg Portion. Fig. 625.— Lateral or side splint of plaster-of-Paris ready for application to leg, ankle, and foot. Plaster cream has been thoroughly rubbed into the meshes of the crinoline. 450 Fig. 626.— Lateral or side splint of plaster-of-Paris applied to the inner side of leg, ankle, and foot. Held in position ready for bandage. Note the perforated tin strip at the ankle for greater strength. Foot at right angle with leg. Fig. 627. — Lateral or side splint of plaster-of-Paris. Retentive bandage being applied. Tin reinforcing strip seen at the ankle. 451 Fig. 628. — Plaster gutter to posterior surface of leg and foot, held in place by a few turns of a cheese-cloth bandage. This plaster posterior splint is made much as is the lateral plaster splint for the leg and foot. Fig. 629.- -Anterior and posterior plaster splints for injuries to the leg below the knee and about the ankle and foot. Anterior splint being applied. 452 Fig. 530.— Anterior and posterior leg splints applied. Note application of the half cuff 01 plaster to reinforce the ankle. Fig. 631.— Fracture of the patella. The leg covered with sheet wadding. The application of the plaster-of-Paris roller. 45: Fig. 632. — Fracture of the patella. Application of the plaster-of-Paris 1 oiler. finished. Bandage being Fig. 633. — Fracture of the leg. Plaster-ofParis splint applied from the toes to the Foot at aright angle]withjhe leg. Toes padded to prevent chafing. 454 Fig. 634.— Fracture of the leg. Plaster cast of leg from toes to below the knee removed. Fig- 635.— Fracture of the leg. Removable plaster cast of leg. Same as figure 6J4. Anterior view, showing cut in plaster. 455 Fig. 636. — Open fracture of the leg. Plaster-of-Paris splint. Window cut in plaster, through which wound is dressed. Window surrounded by oiled silk. Fig. 637. — Open fracture of the ankle. Window in plaster-of-Paris splint, through which wound is dressed. Gauze seen in the window. Oiled silk about the window. 456 APPLYING THE PLASTER BANDAGE 457 the hands still grasp its ends. The bandage should be wrung until it does not drip. In the application of the plaster splint to frac- tures of any part of the body it is ini]ic)rtant that all deformity should be corrected and that the part should be thoroughly immo- bilized. This necessitates the presence of one or two assistants. In applying a plaster splint with the roller bandage the surgeon Fig. 638.— Ham splint of plaster-of-Paris. The splint is slightly thicker at the ham underneath the region touched by the thumb in the plate. It is thus strengthened. More comfortable than ordinary wooden ham splint. should do his work so carefully that he scatters no plaster any- where but upon the splint and in the pail of water. The surgeon should work neatly. The patient should be protected by a sheet. The floor should be protected by a sheet spread under the patient and under the chair of the smgeon. The surgeon should remove his coat, roll up his sleeves, and be protected from unexpected spattering of plaster by an apron or sheet over his body. 458 THE EMPLOYMENT OF PLASTER-OF-PARIS One thickness of sheet wadding torn into strips, from three to five inches wide, and rolled into roller bandages and then applied to the limb forms the best protection to the skin in applying the plaster splint. The sheet wadding is purchased at any of the dry- goods stores. It may be purchased by the quarter bale or by the single sheet. The plaster bandage should be applied to the pro- tected part slowly, deliberately, and accurately. The bandage should be applied smoothly, and should have no wrinkles or thick awkward places an^^where. It is well to rub the bandage as fast as Fig. 639.— Fracture of the patella. Leather knee-cap with hooks for lacing. Made from plaster cast. Worn as a protection to knee after fracture. it is laid upon the part with the palm of the hand slightly wet to distribute the plaster cream thoroughly and evenly. Over bony prominences the bandage should be very carefully molded. This will insure a good fit and less likelihood of slipping upon change of position. It is well to carry the first roll of plaster as far as it will go, one or two layers thick, completing the whole splint once, and then to go over it again from beginning to end. A sufficient num- ber of layers should be applied to make a firm enough splint for the support of the part when the plaster has set. The splint should be as light as is compatible with strength. Light splints, if accu- APPLYING THE PLASTER BANDAGE 459 rately fitted, accomplish more good than heavy, ill-fitting ones. It is better to use too few rolls of plaster bandage rather than so many that a heavy and cumbersome splint is made. Immediately after the plaster has set, if it is found to be too weak at any spot, an additional bandage may be used to reinforce at that point. The part bandaged should be held in perfect position until the plaster has set firmly enough to support it. This will ordinarily occur in about ten or fifteen minutes. The weight of the splint may be materially reduced by using tin strips incorporated in the layers of Fig. 640. — Fracture of the leg. Removable dextrin splint with hooks and lacing. Fig. 641. — Fracture of the leg. Same as figure 640. Anterior view. the plaster bandage. These strips should be perforated by holes so as to offer rough places to catch in the plaster bandage. The two ends of the splint should be so finished that pressure and con- sequent deformity can not occur — for instance, the plaster of the forearm should stop just short of the bend of the elbow. The plaster of the thigh should be so far below- the perineum and groin as to permit of flexion of the thigh upon the trunk without excoriat- ing the skin of the groin. The toes and fingers should be left uncovered to admit of inspection. A certain degree of skill is demanded upon the part of the surgeon 460 THE EMPLOYMENT OF PLASTER-OF-PARIS for the proper application of the plaster-of- Paris splint. Plaster- of-Paris, when used for fractured bones, is applied either before or after the swelling has taken place : if applied before, it constricts the seat of fracture, prevents swelling, and may cause great pain ; if applied after the swelling has taken place, it becomes loose as soon as the swelling of the soft parts subsides, and motion of the limb in the splint and of the fragments of the fractured bone one upon the other is possible. It is important, therefore, to split the plaster soon after it has been applied, and thus obviate these dan- gers of too light and too loose a splint. The tightness of the splint should be regulated by straps and a bandage of cheese-cloth. The Removal of the Plaster Splint. — The removal of the plaster splint is difficult. No instrument has been devised that is more efficient than an ordinary sharp jack-knife. If the plaster splint is split immediately after its application, — i. e., as soon as it is hard, — it will be far easier than if it is cut after it is thoroughly dry. A strip of tin an inch wide laid upon the protected leg and covered by the plaster in its application will often be of great ser- vice upon removing the plaster. The tin will serve as a protection to the skin, and the cutting may be done more quickly and easily. After removing mos t of the p laster from his hands the surgeon^ should wash his hands with a little water and granulated sugar or molasses. The sugar assists in removing all traces of plaster and leaves the skin soft and clean. Bandages of plaster-of- Paris are so readily obtained, so efficient, so safe from interference upon the part of the patient, and so easy to apply, that it is surprising they are not applied more often than they are. The dextrin bandage is much slower in becoming firm than the plaster bandage, and yet is very light and serviceable. It is applied exactly as is the plaster-of- Paris bandage. The roller bandage of cotton cloth is first unrolled and rerolled in a basin containing a watery solution of powdered dextrin. Formula for making the solution of dextrin : Add about fourteen ounces of powdered dex- trin to a pint of water, boil until dissolved, strain, and add one ounce of alcohol. The bandage is, therefore, thoroughly saturated with the dextrin solution. After covering the part bandaged once, dextrin is painted, with a small paint-brush, over the bandage. This is allowed to dry before a second and a third layer of the band- THE DEXTRIN BANDAGE 46 1 age are applied. After each bandage a coating of dextrin is ap- '^1^^^ plied. After the final bandage several coatings of dextrin are ap- jji^iD plied, until a shiny, smooth surface results. This bandage may be cut, and, by the addition of strips of leather along the cut edge upon which are hooks, may be laced and unlaced as necessary j (see Figs. 615, 616) CHAPTER XX THE AMBULATORY TREATMENT OF FRACTURES By the ambulatory treatment of fractures of the lower extrem- ity is understood a method of treatment that permits the imme- diate and continued use of the injured limb as a means of locomo- tion. Medical literature contains many references to this method. It has been in use for some ten years. It has not met with general acceptance even among hospital surgeons. It is a radical method and open to criticism. It contains, however, several important suggestions. It will prove instructive to follow the adoption of this method by its advocates, and to discover, if possible, what there is in it of permanent value. Orthopedic surgeons as early as 1878 conceived the idea of allowing a patient with a fracture of the thigh or of the leg to walk about by means of apparatus. Thomas, of Liverpool, and Dow- browski used the Thomas knee-splint in the treatment of fractures certainly as early as the year 1881 or 1882. Krause, a German surgeon, published, in 1891, the first account of the treatment of fractures of the bones of the leg in walking patients. Krause demonstrated that plaster-of- Paris could be used as a splint in fractures of the leg and in transverse fractures of the thigh. Korsch, in 1894, presented a paper to the German Surgical Con- gress demonstrating that compound fractures of the leg and frac- tures of the thigh may be treated with plaster-of- Paris splints and early use. Korsch makes permanent extension in a thigh frac- ture, while traction is maintained by an assistant, by applying the plaster directly to the skin, snugly to the malleoli, the dorsum of the foot, and the heel. A padded ring is incorporated into the upper limit of the plaster splint around the thigh, which presses against the tuberosity of the ischium, and thus accomplishes coun- terextension. Korsch's cases were treated in Bardeleben's clinic. 462 HISTORICAL CONSIDERATIONS 463 Bruns, of Tubingen, in 1893, described a splint for use in these cases of fracture of the leg and thigh. Dollinger, of Budapest, in 1893, described a splint for the ambulators' treatment of fractures of both bones of the leg, and reported three cases. Bollinger's method of applying the plaster-of-Paris splint is the one generally used whenever the ambulators' treatment is employed. The method is described later. Warbasse, at the Methodist Episcopal Hospital of Brooklyn, N. Y., in 1893, was the first in this countrx' to adopt systematically Bollinger's method. Warbasse reports six cases — all in young adults. Bardeleben reported, in 1894, one hundred and sixteen cases treated with walking splints. There were eighty-nine frac- tures of the leg, complicated and uncomplicated ; five fractures of the patella ; twenty -two fractures of the thigh, five of which were compound ; three cases of osteotomy for genu valgum. Bardele- ben lays down the following law : " It is of the greatest advantage to the patient that such a dressing can be applied to the broken leg that he can bear the weight of the body upon it and walk about; but such a method of treatment should be applied only under medi- cal supervision, and with the most careful consideration of compli- cations that might arise." Korsch presented to the German Sur- gical Congress, in 1894, seven cases — ^three of the thigh and four of the leg. Albers, in 1894, reported seventy-eight cases (fifty -six of the leg, five of the patella, sixteen of the thigh, and one of the leg and thigh) treated by the ambulatory method. He seems to be a little more cautious than other German surgeons in this matter. He savs that when great pain is present, it is best to employ injec- tions of morphin. Elevation of the limb will often reduce the swelling ; when this does not suffice, the bandage must be removed. Severe local pain from presstu-e indicates the necessity for cutting a fenestrum. The first attempt at walking should be made on the day following the application of the cast. A crutch and cane are used at first ; later, two canes are emplo^'ed ; and, finally, some patients walk without any support at all. Krause, in 1894, reported seventy-two cases treated. He is of the opinion that the ambulatory treatment in plaster splints must be limited principally to fractures and osteot- omies in the region of the malleoli, the leg, and the lower end of 464 THE AMBULATORY TREATMENT OF FRACTURES the thigh. He does not employ the method in the handHng of obhque fracture of the femur and fractures of the neck of the femiur. Bardeleben writes again in 1895, reporting up to that date one hundred and eighty-one cases treated by the ambulatory treatment. This last report, of course, included the one hundred and sixteen cases of the previous record. Dr. Edwin Martin, be- fore the Surgical Section of the College of Physicians of Philadel- phia, in December, 1895, reported twenty cases of fracture of the leg treated by this method. Dr. E- S. Pilcher, of Brooklyn, N. Y., in whose wards Marbasse worked, reported to the American Sur- gical Association the twenty or more cases treated by him in which the results were satisfactory. N. P. Dandridge, of Cincin- nati, Ohio, has used the method in eight cases. In most of the cases pain was complained of when weight was borne on the foot. In a feeble woman it was necessary to remove the cast in the third week. In the case of a man, — a compound fracture of the leg, — after walking two weeks he had so much pain that the plaster was removed. Redness and swelling were great at the seat of fracture, and there was much swelling over the internal malleolus. Wood- bury introduced the method at Roosevelt Hospital, New York city, and Fiske has reported cases treated at that clinic. Roberts, of Philadelphia, and Woolsey, of New York, have used the method in selected cases with satisfaction. A. T. Cabot, of Boston, has used, in several fractures of the femur, Taylor's long hip-splint. E. H. Bradford, of Boston, has treated cases of fracture at the Children's Hospital by a modified Thomas knee splint, with and without plaster-of- Paris splinting (Fig. 642). Those advocating the ambulator}' treatment suggest its appli- cation to fractures of the leg below the knee, both simple and com- pound, and in fractures of the lower end of the femur. The appa- ratus is not to be applied for three or four days if there is much primary swelling. The method of application of the plaster splint in the ambu- latory treatment of fractures of the tibia and fibula alone is as follows (this is practically the method of Dollinger) : First comes the cleansing of the skin of the leg with soap and water and then the reduction of the fracture. Then, with the foot fixed at a right angle to the leg, a flannel bandage is smoothly and evenly applied THE METHOD APPIJED TO THIC TIHIA AND FIBULA 46; from the toes to just above tlie knee. This bandage is made to inehide beneath the sole of the foot a padding of ten or fifteen la\'ers of cotton wadding, making a pad about three-fourths of an inch thick, after it is compressed by the moderate pressure of the flannel bandage. Over this is now applied the plaster bandage from the base of the toes to just above the knee, especial care being IL a {r. Fig. 642. — Thomas knee splint or ambulatory treatment of leg fractures, used with a light plaster-of-Paris leg splint : a, ordinary form; b, "caliper" or convalescent splint so fitted as to keep the heel of the foot away from the boot while the toes are used ; c, rtie half-ring sometimes used at the upper end ; d, lower end of splint, as arranged for windlass traction. taken that the application is made smoothly and somewhat more firmly than is the custom in the ordinary plaster cast. The layers of the bandage should be well rubbed as they are applied, with a view' to obtaining the greatest amount of firmness with the smallest amount of material. The sole is strengthened by incorporating with the circular turns an extra thickness composed of ten or 466 THE AMBULATORY TREATiMENT OF FRACTURES twelve layers of bandage well rubbed together, and extending longitudinally along the sole. The bandage is applied especially firmly about the enlarged upper end of the tibia, and here it is made somewhat thicker. As it dries it may be pressed in so as to conform more closely to the leg just below the heads of the tibia and fibula. The assistant who stands at the foot of the table and supports the leg makes such traction or pressure as is required to keep the fragments in proper position while the plaster is being applied. The operation requires about twenty minutes, and by the time the last bandage is applied the cast should be fairly hard. It is seen that when this cast has become hardened the leg is suspended. When the patient steps upon the sole of the plaster cast, the thickness of the cotton beneath the foot separates the sole of the foot so far from the sole of the cast that the foot hangs sus- pended in its plaster shoe. Thus the weight of the body, which would come upon the foot, is borne by the diverging surface of the leg above the ankle. The chief of these is the strong head of the tibia. A lesser role is played by the head of the fibula and the tapering calf in muscular subjects. In thigh fractures the use of the long Taylor hip-splint, together with a high sole upon the well foot and crutches, is generally ac- cepted as the best method of ambulatory treatment. The advantages claimed for the ambulatory method are : Time is saved to the business man by this method — he having to give up but about seven days to a fracture of the leg. The time spent by the patient in the hospital is less than by other methods. The general health is conserved; whereas by the old method the appetite is variable, sleep is troubled, the bowels are constipated, and general discomfort prevails. There is greater general comfort by this method than by any other. In drunkards and those with a tendency to delirium tremens this liability is greatly diminished. In old people the danger of a hypostatic pneumonia is lessened. The primary swelling associated with a fracture is often avoided, and always less than by the older methods. The secondary edema and muscular weakness are less. The functional usefulness of the whole leg is greater. There is less atrophy of the muscles of the thigh and leg. The amount of the callus is diminished. There is THE ADVANTAGES CLAIMED FOR THE METHOD 467 less stiffness of neighboring joints. Union in a fracture occurs at an earlier date. Before this method can be adopted generally and in hospital treatment it must be demonstrated that it is safe, and that it offers chances of better functional results than are obtained under present methods, and that the minor advantages claimed for it by ardent German advocates are real and not iniaginar\'. The first great advantage of the method is stated to be that the stay in the hospital and the time away from one's occupation are much les- sened. Regarding this point the Massachusetts General Hospital Surgical Records were consulted for these three periods: before the use of plaster-of- Paris — that is, previous to 1S65; just at the beginning of the use of plaster-of- Paris as a splint for fracture, and in 1895, 1896, and 1S97. Thirty-five unselected cases of fracture of the tibia and fibula were tabulated from each period. The dm-ation of the average time spent in the hospital in the first period— z". e., previous to 1865— was forty-six days; in the second period— z. e., about 1866— it was forty-five days; at the present time it is sixteen days. In the second period plasters were applied to fractured legs on an average at about the twenty-eighth dav ; at the present time, on the fourteenth day. In other words, there has been since the introduction of the plaster splints a graduallv shorter detention in the hospital, as surgeons have come to recog- nize the safety of an earlier application of a fixed dressing. On an average, patients with fracture of the leg are detained in the hospi- tal to-day but sixteen days. The vers' great saving to the hospital in time by the ambulator}- treatment does not, therefore, appear. It is impossible to consider the statements made with regard to rapidity of healing, sign of callus, absence of muscular atrophy, and absence of rigidity of joints, because there are no facts availa- ble for the purpose. The advantages stated are based, most of them, upon the personal impressions of the surgeon in charge; impressions compared with scientific observations are imtrust- worthy. Krause presents a table from Paul Bruns containing the average periods of healing in a series of fractures, and compares these periods with his own fracture cases treated by the ambulators- method. This is the only attempted scientific statement of obser- 468 the; ambulatory treatment oe fractures vation on this important point. Krause concludes from a study of these tables that, "In the treatment of fractures of the middle and upper thirds of the leg, the ambulatory method shows a great advantage in the period of consolidation as well as in the time when the patient can return to work. It seems that the higher up the fracture is in the leg, the sooner a cure is effected by the ambu- latory method of treatment." Conclusions. — A review of the literature does not disclose any other advantage in the results of the ambulator}^ treatment over the present treatment of fractures of the leg than that stated by Krause. The present commonly accepted method of treating fractures of the femur by long rest in the horizontal position, with extension by weight and pulley, is not satisfactorv^ The pro- tracted stay in bed is undesirable. The use of the Taylor hip-splint in the treatment of this fracture, assisted by coaptation splints or a splint of plaster-of- Paris, is of distinct value. This, however, is a somewhat well-known method of ambulatory treatment. Theoretically and practically, the ambulator)' treatment does not perfectly immobilize; therefore, it can not preeminently suc- ceed as a means of treatment. The method in general seems to be unsurgical. Embolism, both of fat and of blood, and the likeli- hood of pressure-sores in the use of the plaster splint are dangers to be considered. It is wise to allow the injured limb to rest while the reparative process is beginning. Muscular relaxation is de- sirable in the treatment of fractures. The very admission by the advocates of the ambulatory treatment that muscular contrac- tions take place is reason enough for supposing that complete immobilization is not obtained by this method. However, in cer- tain carefully selected cases of fracture below the knee, particu- larly of the fibula, if under the care of a competent and skilful sur- geon, it is possible to conceive of the ambulatory method being used without doing harm. A consideration of the ambulatory treatment of fractures should lead to a more careful and early use of the pi aster-of- Paris splint in fractures of the leg, and to a proper application of the long hip- splint or its equivalent in fractures of the thigh, and to the early use of crutches and the high sole on the well foot in both of these lesions. the advantages claimed for the method 469 Materials for the Ordixarv Care of Closed Fractures The materials with which a physician should be provided in order to properlv care for the fractures ordinarily met with are comparatively few. There is scarcely a fracture which can not be treated satisfac- torilv bv the proper use of plaster-of- Paris. Plaster-of- Paris roller bandages. ^^'ashed crinoline or the common cheese-cloth gauze roller bandage. Plaster-of-Paris. A jack-knife for splitting plaster dressings. A pair of heavy scissors. Thin splint wood, -^ of an inch in thickness. Iron wire, j of an inch in diameter. Posterior wire splint, for adult leg. Anterior wire splint, for adult leg. Siugeon's adhesive plaster. Cotton and cheese-cloth roller bandages. Sheet wadding for padding splints. BIBLIOGRAPHY The important contributions to literature wliicli have been consulted are recorded below Dr Stimson's book upon " Fractures " will always stand as a classical work in its'especial field. Dr. Poland's work upon "The Epiphyses is also a very valuable contribution to fracture literature. The text has been kept free of all references in order that greater clearness might result. Hamilton, Fractures and Dislocations. Stimson, A Practical Treatise on Fractures and Dislocations, Lea Bros., 1899. Helferich, Atlas of Traumatic Fractures and Luxations, with a Brief Treatise, Wm. Wood & Co., 1896. Roberts, P. Blakiston, Son & Co., Philadelphia, 1897. Wharton and Curtis, The Practice of Surgery. The International Encyclopedia of Surgery ; supplementary volume vii, 1895. Dennis, F. S., System of Surgery, 1895. Cheever, Lectures on Surgery, Damrell and Upham, Boston, 1894. FRACTURE OF THE SKULL Huguenin, Cyclopaedia practische Medicin, Ziemssen, Band xii, 1897. Mills, The Nervous System and Its Diseases, 1898. Bradford and Smith, Transactions of the American Surgical Association, volume LX, page 433. _ Bullard, Medical and Surgical Reports of the Boston City Hospital, 1897. Dana, Text-book of Nervous Diseases. Courtney, Boston Medical and Surgical Journal, April 6, 1S99, page 345. Hill and Bayliss, Journal of Physiology, London, 1895, xvui, page 324. Walton, American Journal of Medical Sciences, September, 1898. Putnam, Walton, Scudder, Lund, American Journal of ^ledical Sciences, April 1S95. Phelps, Traumatic Injuries of the Brain. FRACTURE OF THE NASAL BONES Bosworth, Diseases of Nose and Throat, third edition, pages 157-161. Zuckerkandl, Anat. norm, et Patholog. des Fosses Nasales, volume I, page 429- Evans, Deflections of the Nasal Septum, Louisville Journal of Surgerv- and Medi- cine, volume V, June, 1898, pages I-4. Casselberry, Deformities of the Septum Narium, Transactions of the American Medical Association, volume XXII, No. 9, pages 469-471. Cobb, Fracture of the Nasal Bones, Journal of the American Medical Association, volume XXX, 1898, page 588. Freytag, Monatschrift fiir Ohrenheilkunde, 1896, Band xxx, Seiten 217-224. 471 472 BIBLIOGRAPHY Zuckerkandl, Anatomic der Nasenhohle, Band n. Watsin, Lancet, 1896, volume I, page 972. Roe, The American Medical Quarterly, June, 1899. FRACTURE OF THE SPINE Thorburn, A Contribution to the Surgery of the Spinal Cord. Walton, Boston Medical and Surgical Journal, December 7, 1893. The Journal of Nervous and Mental Diseases, January, 1902. Thomas, Boston Medical and Surgical Journal, September 7, 1899, page 233. Dennis, Annals of Surgery, March, 1895. Burrell, Transactions of the Massachusetts Medical Society, 1887. Taylor, Journal of the Boston Society of the Medical Sciences, December, 1898. Wagner and Stolper, Die Verletzungen des Wirbelsaule und des Riickenmarks, 1898, Seite 415. Kocher, Mittheilungen Grenzgebieten der Medicin und Chirurgie, 1896. White, Transactions American Surgical Association, vol. IX. Cheever, Boston Medical and Surgical Journal, September 28, 1893. Pilcher, Annals of Surgery, volume XI, pages 187-200. Prewitt, Transactions American Surgical Association, volume XVI, page 255. FRACTURE OF THE SCAPULA Blake, Boston City Hospital Reports, 1899, page 368. FRACTURE OF THE HUMERUS Bruns, Deutsche Chirurgie, Theil 28, 2. Halfte. Murray, New York Medical Journal, June 25, 1892. Monks, Boston City Hospital Medical and Surgical Reports, 1895; also Boston Medical and Surgical Journal, March 21, 1895, January 9, 1896, and December 4, 1895- Lund, Boston City Hospital Reports for 1897, page 389. AUis, Annals of the Anatomical and Surgical Society, Brooklyn, 1880, II, 289. Smith, Boston Medical and Surgical Journal, July, 1895. Stimson, Roberts, Allis, Transactions of the American Surgical Association, 1881 to 1898. FRACTURE OF THE FOREARM Pilcher, Paper read to Association of Military Surgeons of the United States, Berlin Printing Co., Columbus, Ohio. Medical Record, 1878, II, 74. Annals of An- atomical and Surgical Association, Brooklyn, 1887, ill, page 33. Moore, Transactions of the Medical Society, State of New York, 1880. Bolles, Boston City Hospital Reports, third series, 1882, page 340. Conner, Journal of the American Medical Association, 1894, page 54- Roberts, Medical News, 1890, LVii, 615. Annals of Surgery, 1892, xvi. Mouchet, A., Revue de Chirurgie, May, 1900. FRACTURE OF THE THIGH Cabot, Boston Medical and Surgical Journal, January 3, 1S84, page 6. Allis, Transactions of the American Surgical Association, volume ix, 1891, page 329. Medical News, November 21, 1891. BIBLIOGRAPHY 473 Hutchinson, Lancet, 1S98, 11, 1630. Packard, International Encyclopaedia of Surgery. Whitman, Annals of Surgery, June, 1897, page I. Senn, Journal of the American Medical Association, August 3, 1889. Ridlon, Transactions of the American Orthopedic Association, 1887, page 186. Lane, Medicochirurgical Transactions, London, 1888. Scudder, Boston Medical and Surgical Journal, March 22, 29, 1900. SEPARATION OF THE LOWER EPIPHYSIS OF THE FEMUR Annals of Surgery, Philadelphia, 1898, XXVIII, 664. Annals of f lynecolog}', November, 1S90. • British Medical Journal, December, 1894, page 671. New York Medical Record, October 5, 1895. Annals of Surgery, March, 1896. Archives Generales, March and April, 1884, volume xiii, page 272. Transactions of the American Surgical Association, 1895. Liverpool Medicochirurgical Journal, January, 1885, page 41. Liverpool Medicochirurgical Journal, July, 1883. Stimson, Fractures and Dislocations, 1899. Hutchinson, Lancet, May 13, 1899. McBurney, Annals of Surgery, March, 1896, XXII, 506. Harte, Transactions of the American Surgical Association, 1895. Deleus, Archives Generale de Medicine, 1884, volume xiii, page 272. Poland, Traumatic Separation of the Epiphyses, 1898. Smith, Transactions of the American Surgical Association, volume VIII. FRACTURE OF THE PATELLA Powers, Annals of Surgery, July, 189S. Bull, New York Medical Record, xxxvii, 1890. McBurney, Annals of Surgery, 1895, xxi, 312. Pilcher, Annals of Surgery, 1890, xii. Stimson, Annals of Surgery, 1895, xxi, 603 ; 1896, XXiv, 45. Cabot, Boston Medical and Surgical Journal, CXXV. Dennis, System of Surgery. Lund, Boston Medical and Surgical Journal, 1896, CXXXV, ;^;^S. Fowler, Annals of Surgery, January, 1891. Macewen, Annals of Surgerj', 1887, volume v, page 177. Phelps, New York Medical Journal, June, 1890. White, New York Medical Record, October 27, 1888. Beach, New York Medical Record, March 15, 1890. FRACTURE OF THE LEG Cabot, The Boston Medical and Surgical Journal, January' 3, 1894, page 6. Lovett, Boston City Hospital Medical Reports, 1899, page 222. AUis, Annals of Surgery, 1897. Tiffany, Annals of Surgery, 1896, xxiii, 449. Lane, Transactions of the Clinical Society, London, xxvii, 167. Osgood, Robert, Transactions of the American Orthopedic Association, 1902. Stimson, New York Medical Journal, June 25, 1892. 474 BIBLIOGRAPHY Smith, N. R., Treatment of Fractures of the Lower Extremity, Baltimore, Kelly and Piet, 1867. GUNSHOT WOUNDS OF BONE Makins, Geo. Henry, Surgical Experiences in South Africa, 1899-1900 (volume of 486 pages, published by Smith, Elder & Co., 1901). Borden, W. C, The Use of the Rontgen Ray by the Medical Department of the United States Army in the War with Spain, 1898, Government Printing Office, 1900. Kocher, T., Zur Lehre von den Schusswunden durch kleinkaliber Geschosse, Cassel, 1895, Th. Q. Fisher & Co. La Garde, Boston Medical and Surgical Journal, January 18, 1900, p. 57 ; October 25, 1900. Report of the Surgeon-General of United States Army, 1893. Dennis, System of Surgery, volume I, p. 460. Treves, F., London Lancet, 1900, i, 1359. Dent, C, British Medical Journal, 1900, il, 632 and 634. MacCormac, Sir Wm., London Lancet, 1900, i, 1485. Thomson, Sir Wm., British Medical Journal, 1901, 11, 265. London Lancet, II, 1901, 264. Nancrede, Transactions of the American Surgical Association, 1899, 1900. Hall, Edward J., London Lancet, 1901, i, 130, 1755. THE AMBULATORY TREATMENT OF FRACTURES Krause, Deutsche medicinische Wochenschrift, 1891, No. 13. Korsch, Berliner klinische Wochenschrift, No. 2. Bruns, Beitrage zur klinische Chirurgie, Band X, Heft il, 18. DoUinger, Centralblatt fiir Chirurgie, 1893, No. 46. Warbasse, Transactions of the Brooklyn Surgical Society, October, 1894. Bardeleben, Verhandlungen der deutsche Gesellschaft fiir Chirurgie, XXIIL Kon- gress, 1894. Albers, Verhandlungen der deutsche Gesellschaft fiir Chirurgie, XXIIL Kongress, 1894. Krause, Verhandlungen der deutsche Gesellschaft fiir Chirurgie, XXIIL Kongress, 1894. Pilcher, Transactions of the American Surgical Association, volume Xiv, 1896. Woodbury, New York Medical Record, 1897. Roberts, Transactions of the American Surgical Association, volume xiv, 1896. Woolsey, New York Medical Record, 1897. Cabot, New York Medical Record, 1897. Bradford, New York Medical Record, 1897. , THE EPIPHYSES Quain, Dwight, Gray, Morris. Poland,- John, f.R.C.S., Traumatic Separation of the Epiphyses, 1898. Briinne, Das Verhaltniss die Gelenkkapselen zu die Epiphyse die Extremitaten- Knochen. MASSAGE Bennett, W. H., London Lancet, June 2, 1900; London Lancet, Feb. 5, 1898. INDEX Abscess of jaw, 61, 71 Acromial process of scapula, 121 treatment, 123 Active motion after Colles' fracture, 242 after fracture of femur, 302 of leg, 378 after separation of lower epiph- ysis of femur, 321 in fracture of patella, 337 Ambulatory treatment : of fracture of shoulder, 143 of thigh, 303 of fractures, 462 advantages claimed, 466 conclusions, 468 early advocates, 462 materials for ordinary care of closed fractures, 469 method of application of plas- ter splint, 464 reports of cases, 463 American Surgical Association, con- clusions expressing views of, upon medicolegal relations of X-rays; adopted in May, 1900, 438 Anesthetics, use of, in examination: of anatomical neck of hu- merus, 132 of Colles' fracture, 226, 228 of elbow, 162, 180, 191 of hip, 263 of leg, 353, 375 of shoulder, 126, 130 Anesthetics, use of, in treatment : of Colles' fracture, 236 of fracture of carpus, 247 of forearm, 201 of shaft of femur, 286 of shaft of humerus, 154 of surgical neck of humerus, 141 of greenstick fracture of fore- arm, 214 of open fracture of leg, 375 of Pott's fracture, 387 Ankylosis of ankle-joint, 405 Arthritis after fracture of leg, 380 Asch tube, 49 Astragalus, 400 open fracture, 404 treatment, operative, 405 treatment, 400 Atrophy, muscular, after fracture of humerus, 158 Bandage, dextrin, 460 application, 460 formula, 460 elastic rubber, in fracture of patella, 330 flannel, substituted for plaster sphnt, 379, 404 plaster-of-Paris, 441 Bardeleben, quoted: law concerning ambulatory treatment of fractures, 463 Base-ball finger, 257 Base of skull, 26 hemorrhage, 26 symptoms, 26 Bed-sores, 270, 276, 366 treatment, 270, 276 Bennett's fracture, 252 Bibliography, 471 Bladder (urinary), rupture of, 108 symptoms, 108 treatment, operative, 109 Blebs, treatment of, 359 Borden (W. C), quoted: infection in gunshot wounds, 419 treatment, 421 Bradford frame, 105, 312 making of, 313 Brain in fractured skull, 17 compression of, 18 concussion and contusion of, 17 laceration of, 18 symptoms, 18 Bryant's method of measurement after fracture of neck of femur, 265 Buck's extension apparatus (modi- fied), 288 application of, 291 materials required for, 288 475 476 INDKX Bullard, Dr. (Boston City Hospital), quoted: results of fracture of skull, 38 Cabot's posterior wire splint, 310, 332, 364 application, 310, 367 covering, 365 making, 365 padding of, for reception of lower extremity, 366 Carpus, 246 symptoms, 246 treatment, 246 metacarpus, and phalanges, 246 Cauda equina, compression of, in fracture of spine, 77, 90 lesion of, 87 treatment, 87, 93 Clavicle, 110 anatomy, 110 operative treatment, 120 in ununited fractures, 120 prognosis, 119 symptoms, 111 in childhood, 112 treatment in adults, 113 modified Sayre dressing, 116 recumbent, 113 treatment in children, 117 Codman, Ernest Amory: Rontgen ray and its relation to fractures, 424 CoUes' fracture, 223 anatomy, 223 differential diagnosis, 231 contusion of bones near wrist, 232 dislocation of wrist back- ward, 232 fracture of shaft of one or both bones low down, 233 separation of lower epiphy- sis of radius, 235 sprain of wrist, 231 lesions associated with, 236 operative treatment for result- ing deformity, 245 prognosis and result, 244 "reversed," 244 symptoms, 226 treatment, 236 a method of reduction, 236 retentive apparatus, 239 application of, 240, 241 Coma, 30, 33 alcoholic, 30 from apoplexy, 30 from hemorrhagic internal pachy- meningitis, 31 Coma from opium-poisoning, 30 in uremia, 30 Compression of brain, 18 symptoms, 18 Concussion and contusion of brain, 17 symptoms, 17 Condyle of humerus: external, 173, 194 treatment, 182 internal, 172 treatment, 182 Contusion of bones near wrist, 232 Coracoid process of scapula, 129 Coronoid process of ulna, 198 symptoms, 201 Cystitis after fracture of spine, 81 92 Deformity after CoUes' fracture, 245 after fracture of clavicle, 119 of leg, 354 of metacarpal bones, 253, 257 of shaft of femur, 297 backward sagging of thigh, 298 eversion of foot, 297 outward bowing, 297 from separation of epiphysis of humerus, upper, 145 in CoUes' fracture, 226 anteroposterior, 226 silver-fork deformity, 227 lateral, 227 slight deformity only, 228, 230 in fracture of both radius and ulna, 192, 210 of shaft of radius, 195 in fractures of vertebrae, 76 in greenstick fracture of bones of forearm, 192 in Pott's fracture, 385, 398 reversed Pott's deformity, 386 in separation of lower epiphysis of radius, 197 of nose from fracture, 44, 47, 51 from syphilis, 46 Dislocation of hip, 266 of humeral head, 131, 146 treatment, 146 operative, 147 of radius and ulna backward, with or without fracture of coro- noid process of ulna, 169 treatment, 187 of wrist, backward, 232 DoUinger's method of application of plaster splint in ambulatory treat- ment of fracture's, 464 Drainage in open fracture of leg, 377 IxNDEX 47 EccHYMOSis in fracture of leg, 355 Edema, causes of, after fracture of leK or tliigh, 384 cere lira 1, 21 malignant, 321 Elbow, after-care of injuries, 188 omission of splint, or reten- tive apparatus, 189 method of examination, 162 carrying angle, 165 head of radius, 163 measurements, 1 65 movements at elbow-joint, 165 palpation of the three bony points, 163 summary of order of examina- tion, 166 the three bony points of the elbow region, 163 prognosis, 189 traumatic lesions of, 168 of lower end of humerus, 168 of radius and ulna, 168 symptoms, 169 treatment, 181 acutely flexed position, 182, 187 method of using, 182 precautions in using, 184 Elbow-joint, treatment of, with frac- ture of shaft of humerus, 155 EmboUsm, 383 fat, 322 symptoms, 323 treatment, 323 Emergency method of putting up a fracture of the thigh or hip, 283 Emphysema in fracture of nasal bones, 46 of ribs, 95, 99 of superior maxilla, 56 Epicondyle, internal, 172 treatment, 182 Epiphyses, anatomical facts regard- ing the, 407 acromion process of scapula, 412 date of appearance of ossification in chief epiphyses of long bones (after Poland), 408 femur, lower epiphysis of, 409 humerus, lower epiphysis of, 411 upper epiphysis of, 409 importance of exact knowledge, 408 order of frequency of separation of epiphyses (after Poland), 408 radius, lower epiphysis of, 410 tubia, lower epiphysis of, 412 upper epiphysis of, 412 Epiphvsis, fracture of, radial, lower, 235 separation of acromion, 121 Epiphysis, separation of femur, lower epiphysis, 314, 410 anatomy, 315, 410 complications, 316 diagnosis, 316 prognosis, 318 treatment, 318 fat embolism, 322 operative method of reduction, 320 reduction by manipula- tion when the frag- ment is displaced for- ward, 319 traumatic gangrene, septicemia, malig- nant edema, 321 humerus, 132 lower epiphysis, 175 diagnosis, 178 treatment, 188 upper epiphysis, 132, 140, 146, 409 prognosis, 144 treatment, 140 radius, 195 lower epiphysis, 197, 235, 411 treatment, 197, 209, 235 tibia, 351 lower epiphysis, 356, 412 upper epiphysis, 351 Ethmoid, cribriform plate of, 28 Extension weights after fracture of neck of fenmr, 271 of shaft of femur, 295 Extravasation of urine, 108, 109 Face, bones of, 44 malar bone, 52 maxilla, inferior, 59 superior, 56 nasal bones, 44 Feeding, after fracture of jaw, by mouth, 70 nasal, 58 Femur, 260 gunshot fracture, 422 mortality, 422 comparative, in different wars, 423 in South African war, 424 prognosis, 424 symptoms, 422 treatment, 423 neck of. See Hip. shaft of, 280 after-treatment and progress, 301 measurement, 282 Dr. Keen's method, 283 478 INDEX Femur, shaft of, symptoms, 282 treatment, 283 Buck's extension apparatus, 288 emergency treatment, 283 method of examination, 287 transportation of a patient, 283 in childhood, 309 symptoms, 309 treatment, 309 Bradford frame, 312 Cabot's posterior wire splint, 310 prognosis, 304 results, 305 fractures of adult life, 307 of childhood, 306 of old age, 307 subtrochanteric fracture, 299 symptoms, 299 treatment, 299 operative, 300 supracondyloid fracture, 300 symptoms, 300 treatment, 300 Flat-foot, traumatic, 404 treatment, 404 Foot, bones of, 400 astragalus, 400 and OS calcis, open fracture of, 404 metatarsal bones, 405 OS calcis, 401 phalanges, 406 Forearm, bones of: CoUes' fracture, 223 olecranon, 214 radius and ulna, 192 Fragments of bone in open fractures, 376 slightly fixed, 376 Gangrene of leg, after fracture of femur, 308 of lower leg, 361 treatment, 361 from separation of lower epiph- ysis of femur, 316, 321 traumatic, 321, 361 Greenstick fracture of bones of fore- arm, 192 treatment, 213 of clavicle, 112 Gunshot fractures of bone, 413 comparison of old and modern bullet, 418 explosive effect of bullet, 415 factors upon which amount of damage to bone is de- pendent, 413 Gunshot fractures of bone, factors upon which amount of damage to bone is dependent, resist- ance, 415 revolution of bullet, 414 shape of bullet, 413 velocity of bullet, 413 prognosis in 'fractures of femur 424 ricochet bullet, 417 the modern rifle, 413 treatment, 419 first field dressing, 419 fracture of femur, 423 infected wounds, 421 noninfected wounds, 420 operative, 421 wounds of entrance and exit, 417 of modern projectiles less grave, 419 Head injury, cases of, 39 I. Middle meningeal hemor- rhage with fracture of skull, 39 II. Open depressed fracture of skull; paralysis of one- half of body, 41 III. Middle meningeal hemor- rhage; fracture of skull, 43 Heel, care of, in treatment of frac- ture of leg, 366 of Pott's fracture, 394 Hematoma of cartilaginous septum of nose, 51 of scalp, 24 I HematomyeUa, 87 Hemorrhage, extradural, 19, 88 sources of, 20 symptoms of, 19 in fracture of base of skull, 26, 28 of humerus, 150 of leg, 360 into pharynx, 29 into spinal cord, 86 hematomyelia, 87 middle meningeal, cases of, with fracture of skull, 39,, 43 subconjunctival, 28, 29, 55 Hip, or neck of femur, 260 anatomy, 260 fracture in adults, 260 examination, 263 impacted and unimpacted , 261 measurement, 264 Bryant's method, 265 prognosis and result, 268 IXDUX 479 liip, fracture in adulls, results allir, 268 syin])toms, 261 Ireatinent, 269 after-care of the simple traction method, 271 fixation method, 272 Thomas hip-splint, 273 general considerations, 269 operative treatment, 277 treatment of the frac- tured hip, 271 fracture in childhood, 277 immediate result, 280 late restilt, 280 symptoms, 280 treatment, 280 Hot-air treatment, 245, 404 Humerus, 125 after-care, 143, 147 anatomical neck of, 132, 146 treatment, 140 with dislocation of upper frag- ment, 146 after-treatment of oper- ated cases, 147 treatment, 146 anatomy, 125 diagnosis, 129 examination of shoulder, 126 prognosis and result, 144 shaft of, 147 fracture in the newborn, 158 treatment, 158 (transverse) above the con- dyles, 173, 186 treatment, 186 malignant disease, 162 musculospiral nerve in fracture of the humerus, 159 prognosis, 157 symptoms, 148 treatment of fractures with con- siderable displace- ment, 156 after-care, 157 operative, 156 with little or no displace- ment, 151 after-treatment, 156 simple dislocation of humeral head, subcoracoid, 131 surgical neck of, fracture of, 140, 1 46 treatment, 140 with dislocation of upper fragment, 146 after-treatment of operated cases, 147 treatment, 146 Humerus, surgical neck of, oblique fracture, witii great disj)laeement, 146 treatment, 146 operative, 146 Ice-bags, 362 Hium, 103 Infection in fracture of metatarsal bones, 406 of nasal bones, 46, 50, 51 of superior maxilla, 57 in gunshot fractures, 419, 420 of femur, 424 in open fracture of leg, 375 Keen's method of measuring lengths of lower extremities, 283 Kocher's classification of parts of long bones injured in gunshot wounds, 415 Krause, quoted : advantages of ambu- latory treatment, 468 table containing average periods of heaHng, 467 La Garde, quoted : wounds of modern projectiles, 418 Lee-Metford (EngUsh) bullet, size, 418 velocity, 418 weight, 418 Leg, 346 anatomy, 346 examination of fractured leg, 351 general observations, 350 Pott's fracture, 384 prognosis, 380 results, 381 refracture, 384 thrombosis and embolism, 383 symptoms, 353 treatment, 356 after-care, 379 care of fracture of the leg after the permanent dressing has been applied, 377 fractures difficult to hold re- duced, 370 fractures with considerable im- mediate swelling, 359 permanent dressing, 364 care of heel, 366 temporarv dressing, 362 in fractures with little or no displacement or swelling, 357 48o INDEX Leg, treatment, open fractures, 374 permanent dressing, 374 temporary dressing, 374 wound of soft parts, 375 Limitation of motion after CoUes' fracture, 244, 245 after fracture of bones of fore- arm, 212 of elbow, 190 of olecranon, 222 of patella, 340, 344 of scaphoid bone of wrist, 247, 249 after open fracture of astragalus and OS calcis, 405 after separation of lower epiph- ysis of femur, 321 MacCormac (Sir William), quoted: treatment of gunshot fracture of femur, 422 Makins (George Henry), quoted : gun- shot wounds in South African war, 416 gunshot fracture of femur, 422 prognosis, 424 treatment by amputation, 422 Malar bone, 52 complications, 55 examination, 52 symptoms, 53 treatment, 55 Malignant disease, 162 Massachusetts General Hospital, cases treated at : results after fracture of femur, 305 of hip, 268 of leg, 381 of patella, 341 statistics concerning ambulatory treatment, 467 Massage after fracture of astragalus, 400 of bones of forearm, 210 of clavicle, 119 of elbow, 189 of humerus, 144, 147, 157 of leg, 378 of metacarpal bones, 257 of patella, 331, 336 with operative treatment, 345 of ribs, 99 of scapula, 124 of shaft of femur, 302 after Pott's fracture, 397 after separation of lower epiphyses of femur, 321 in CoUes' fracture, 242, 245 in fracture of carpus, 248 of olecranon, 220 Massage in fracture of os calcis, 404 Materials for ordinary care of closed fractures, 469 Mauser bullet, revolution of, 415 size, 418 velocity, 418 weight, 418 Maxilla, inferior, 59 examination, 60 fracture of body of jaw, 62 of ramus upon same or opposite sides of inferior maxilla, 70 of coronoid and articular pro- cesses, 71 of ramus, just behind molar teeth, 69 symptoms, 60 treatment, 61, 62, 69, 70, 71 superior, 56 after-care, 58 diagnosis, 56 treatment, 57 Measurement in CoUes' fracture, 225 in dislocation of humeral head, 131 in fracture of elbow, 165 of external condyle, 173 of humerus, 129, 150 of leg, 353 of neck of femur, 264 of shaft of femur, 282, 295, 301 in Pott's fracture, 386 in T-fracture into elbow- joint, 180 Metacarpal bones, 249 differential diagnosis, 253 symptoms, 249 treatment, 253 Metatarsal bones, 405 complications, 406 symptoms, 405 treatment, 406 Morphin, use of, 369 Musculospiral nerve in fracture of humerus, 159 prognosis, 160 symptoms of injury, 159 compression, 160 contusion, 159 treatment, 1 60 operative, 160 NancrEde, quoted : gunshot wounds of bones, 417, 421 Nasal bones, 44 anatomy, 44 complications, 46 prognosis, 51 symptoms, 46 treatment, 49 septum in fracture of nose, 47 dislocation, 47 INDHX 481 Nasal septum, lesions, 48 hori/.oiual fractures, 48 sigmoid deviations, 48 treatment, 49 vertical fractures, 48 Necrosis after fracture of humerus, with dislocation of upjjer frag- ment, 147 of leg, 38 1 of lower jaw , dl of metatarsal bones, 406 of upi)er jaw, 57 after separation of lower epiphysis of femur, 316, 318 in open fractures of the phalanges, 259 Nerves, lesions of, 28, 29 after separation of lower epiph- ysis of femur, 316 in fracture of base of skull, 28 29 of humerus, 159 of the vertebrae, 74 spinal, anatomy, 74 Nonunion of fracture of clavicle, 120 operative treatment, 120 of hip, 268 of leg, 380 of fractures, 212 causes, 213 treatment, 213 operative, 213, 222 Nose, deformity of, from fracture 44 47, 51 from syphilis, 46 Nussbaum, von, quoted: first dress- ing of gunshot wounds, 419 Olecranon, 214 after-care, 220 anatomy, 214 process, 171 summary of treatment, 222 symptoms, 214 treatment, 217 if fracture is open, 220 operative, 219 Orbital plate, 27 Os calcis, 401 open fracture, 404 treatment, operative, 405 results, 404 flat-foot, 404 symptoms, 402 treatment, 403 Paralysis in fracture of skull, 18, 34 in fractures of vertebrae, 76 cervicodorsal region, 80 dorsal, 79 Paralysis in fractures of vertebrae, last dorsal and lumbar, 77 midccrvical region, 81 in lesions of sjjinal cord, 82 ol)stelrical, 159 of muscidospiral nerve, in frac- ture of humerus, 148, 159 Passive motion after Colics' fracture 242, 245 after fracture of astragalus, 400 of bones of the forearm, 210 of carpus, 248 of clavicle, 1 19 of ell)ovv, 189 of femur (shaft), 302, 303 of humerus, 147, 157 of leg, 378 of olecranon, 221 after Pott's fracture, 397 after separation of lower epij)h- ysis of femur, 321 in fracture of patella, with operative treatment, 345 Patella, 324 anatomy, 324 open fracture, 338 treatment, 338 operative interference in recent closed fractures, 342 conditions suitable, 344 danger of sepsis, 343 indications, 345 method of operation, 345 proper time to operate 344 restoration of function of joint following operative treatment, 345 prognosis, 339 results, 341 symptoms, 328 treatment, 329 limitation and removal of effu- sion, 329 maintenance of reduction until union is satisfactory, 334 reduction of fragments, 332 restoration of function of joint 336 summary of treatment by ex- pectant or nonoperative meth- od, 337 Pelvis, 103 complications, 106 rupture of urethra, 107 of urinary bladder, 108 visceral lesions, 106 examination, 103 prognosis, 109 treatment, 105 482 IND^X Phalanges, 257, 406 of the foot, 406 treatment, 406 of the hand, 257 open fracture, 259 operative treatment, 259 symptoms, 257 treatment, 257 Plaster-of -Paris bandage after separa- tion of lower epiphysis of femur, 321 in fracture of leg, 357, 359 employment of, 441 application to patient, 458 dextrin bandage, 460 making of bandages, 441 removal of the plaster splint, 460 rolling the plaster, 441 shoulder cap, 141 splint, traction, early use, 462 method of application, 372 Pleurisy in fracture of ribs, 95 Pneumonia, asthenic hypostatic, 271 Poland, John (his "Traumatic Sepa- ration of the Epiphyses" quoted), 408 Pott's fracture, 384 anatomy, 384 lesions which may be present, 384 open fracture, 398 indications for amputation, 398 operative treatment of old frac- tures, 398 prognosis and results, 398 symptoms, 385 treatment, 386 care, after permanent dressing is apphed, 396 Dupuytren splint, 387 lateral and posterior plaster- of-Paris splints (Stimson's splint), 394 posterior wire splint with curved foot-piece, 393 temporary dressing, 387 Pubic portion of ring of pelvis, 105 Radio-ulnar joint, inferior, in- volvement of, in CoUes' fracture, 244 Radius and ulna, dislocation of, 169, 194 fracture of, 192 of coronoid process of ulna, 198 of neck and head of radius, 194 symptoms, 194 treatment, 188, 208 of neck or head of, 172, 194 Radius and ulna, fracture of shaft of radius, 195' symptoms, 195 treatment, 208 operative, 209 of shaft of ulna, 197 incomplete or greenstick frac- ture, 192 prognosis and result of treat- ment, 211 separation of lower epiphysis of radius, 195 symptoms, 192 treatment, 201 of open fractures, 211 subluxation of head of radius, 169, 194 Reflexes in fractures of the vertebrae, 76 dorsal, 80 Refracture of bones of the lower extremity, 384 Retention and incontinence, in frac- tures of the vertebrae, 77 Ribs, 94 anatomy, 94 complications, 95, 99 symptoms, 94 treatment, 95 after-treatment, 99 operative, 99 Roe's elevator, 49 Rontgen ray and its relation to frac- tures, 425 assistance of, in diagnosis, 432 in examination, 432 in knowledge of pathology and treatment of fractures, 431 Crooke's tube, 426 effects of X-rays, extent of, 427 accuracy and inaccuracy of pictures, 431 distortion of shadows, 427, 434 fluoroscope, 426, 434 forms of fracture in which X- ray gives great assistance, 433 elbow, 434 femur, upper extremity of, 435 foot, bones of, 436 patella, 435 shoulder-joint, 433 wrist, 435 medicolegal relations of X-rays; conclusions expressing views of American Surgical Associa- tion adopted in May, 1900, 438 use of, as a method of record in rare fractures, 433 INDEX 483 Rontgen ray, use of, in demonstrat- ing to students, 432 X-ray burns and dermatitis, 436 X-ra)^ picture and photograph, comi)arison of, 426 Rontgen raj-s in Colles' fracture, 231, 232, 233, 238, 435 in fracture of astragahis, 400 of carpus, 246, 435 of coronoid process of idna, 201 of elbow, 181, 434 of humerus, 130, 434 of neck and head of radius, 194 of neck of femur, 267 in gunshot fractures, 420 in knowledge of epiphyses, 407, 435 Sand-bags, 271, 293 Sayre dressing (modified) in frac- ture of clavicle, 116, 118 Scaphoid bone of wrist, 246 diagnosis, 246 Scapula, 121 acromial process, 121 body of scapula, 121 neck of scapula, 121 treatment in general, 123 Sepsis. See Injection. Septicemia, 321 Shock after fracture of jaw, 58 of neck of femur in the aged, 268 of pelvis, 107 of shaft of femur, 308 of the vertebrjE, 76, 93 after gunshot fracture of femur, 422 after rupture of urinary bladder, 108 after separation of lower epiphysis of femur, 316 Shortening of the leg after separation of lower epiphysis of femur, 318 in fracture of leg, 353, 380 of neck of femur, 262, 265, 268, 277, 278 correction, 275 of shaft of femur, 282, 305 prevention, 295 Skull, 17, 22 compression of brain, 18 concussion and contusion of brain, 17 diagnosis, 33 examination of patient, 31 general condition, 32 local condition, 32 fracture of base, 26, 59 of vault, 24 Skull, general observations, 33 hemorrhage, extradural, 19 laceration of brain, 18 later results of fracture, 38 operative interference, 36 prognosis, 38 subarachnoid serous exudation (cerebral edema), 21 treatment, 34 ear, 35 mouth, 36 nose, 35 scalp, 35 unconscicnisness resulting from other than surgical causes, 30 Slings for Colles' fracture, 240 for fractured humerus, 155 Smith anterior wire splint, 369 Spinal cord, anatomy, 72 lesions of, 73, 82, 93 how to localize, 73 transverse and partial, 82 symptoms, 82 treatment, 85, 93 operative, 85, 87, 93 Spine, injury to, examination, 76 Sphnts for Colles' fracture, 239, 244 for fracture of astragalus, 400 of bones of forearm, after-care of wooden and tin splints, 207 in greenstick fractures, 214 internal right angle (of tin) , 206, 209 palmar and dorsal (of wood) , 205, 208 method of application, 206 plaster-of-Paris, 202, 208 after-care, 203 precautions in using, 202 of carpus, 248 of elbow, internal right angle, 186, 187 appHcation of, 187 right-angle internal angular, 181 of humerus, coaptation, 156 internal angular, 156 plaster-of-Paris, 157 application of, 157 of jaw, buckle and strap, 69 chin-piece, 64 dental, 57, 62 making of, 67 temporary, 58 of leg, pillow and side, 362 plaster-of-Paris, 357, 363, 368, 372, 377 posterior wire and side, 364, 377 of metacarpal bones, 255 484 INDEX Splints for fracture of metatarsal bones, 406 of olecranon, internal right- angle, 218 long internal, 218 of OS calcis, 404 of patella, 332 in open fracture, 336 plaster-of-Paris, 335 method of making, 335 of phalanges of foot, 406 of hand, 258 of shaft of femur, Buck's ex- tension apparatus, 289 emergency, 283 application, 283 permanent dressing, 286 for Pott's fracture, Dupuytren, 387 application of, 391 defect of, 393 lateral and posterior plaster- of-Paris (Stimson's splint), 394 posterior wire, with curved foot-piece, 393 application of, 393 nasal, 50 Cobb's, 50 Coolidge's, 50 tin, 50 Sponge compresses in fracture of patella, 330 Sprain of wrist, 231 Sternum, 100 complications, 101 diagnosis, 101 treatment, 101 operative, 102 Stimson's splint, 394 Subarachnoid serous exudation, 21 Subluxation of head of radius, 169, 194 Suturing fractured bone, humerus, 156 jaw, 59 leg, 373, 376 radius and ulna, 209, 211 Synovitis in fracture of patella, 329 treatment by aspiration, 334 by massage, 331 Taylor hip traction splint, 303 application of, 303 use of, in ambulatory treat- ment of fracture of thigh, 303, 466, 468 steel back-brace, 102 Teeth, after fracture of jaw, 57, 60, 61 Temperature, pulse, and respiration in fracture of skull, 18, 34, 38 Temporal bone, fracture of petrous portion of, 28 Tenotomy of tendo Achillis, 372 Tetanus after a fracture, 223 treatment, 223 T-fracture into elbow-joint, 180 treatment, 182 Thomas hip-splint, 273 application, 275 description, 273 knee-splint, 462 Thomson (Prof. Elihu), quoted: effects of X-rays on the tissues; a personal experiment, 437 Three bony points of elbow region, 163 Thrombosis, 383 Tibia, oblique fracture of, 370 Trephining in fracture of vertebrae, 89 T-splint, 106, 271, 289 Ulna, shaft of, symptoms, 197 treatment, 209 Union of bones, time necessary for, after separation of lower epiphysis of femur, 321 in Colles' fracture, 243, 244 in fracture of astragalus, 401 of bones of forearm, 209 of elbow, 189 of humerus, 144 in the new-born, 159 shaft, with considerable displacement, 157 with little or no dis- placement, 156 of leg, 378 of metatarsals, 405 of olecranon, 222 of OS calcis, 404 of patella, 334 with operative treat- ment, 345 of phalanges, 259 of shaft of femur, 301 in greenstick fracture of forearm, 214 in refractures, 384 Ununited fractures. See N onuniofi. Urethra, injury to, in fracture of pubic bone, 105 rupture of, in fracture of pelvis, 107 extravasation, 108 symptoms, 107 treatment, 107 Vault of skull, 24 Vertebrae, fractures of, 72 anatomy, 72 dislocations of, 73 examination of an injury to the spine, 76 INDEX 485 Vertebra2, general syiii])l(inisc(inHn(m to fractures of tlie, 76 gunshot fractures, 9^ treatment, 9^ lesions following injury to definite vertebrae; with table, 75 ])rognosis, 81 symptoms of fracture of different regions of the spine, tlie cord being involved, 77 injuries to cer\'icodorsal region, opposite cervical enlarge- ment of spinal cord, 80 to the dorsal vertebrae, 79 to the first two cervical vertebrae, 81 to last dorsal and lumbar vertebrae, 77 operation, time for, 79 prognosis, 77 \'ertebrae, symptoms of fracture, injuries to midcervical region, 80 treatment, 81 plaster-of-Paris jacket, 90 method of applying, 91 summary, 93 Vertical susj^ension in fracture of thigh in childhood, 312 Visceral lesions in fractures of ])elvis, 106 V-shaped pad, in fracture of Inimerus, 141, 153 Wiring fractured bones of the jaw, 59, 62, 71 of the pelvis, 106 Wounds of open fractures, cleansing, 375, 399 COLUMBIA UNIVERSITY This book is du© on the date indicated below, or at the expiration of a definite period after the date of borrowing, i as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(638)M50 ^^r^ vjLj- RDlOl Scudder Scu2 1902 COLUMBIA UNIVERSITY LIBRARIES (hsI.sU) RD 101 Scu2 1902 C.Z Thelreat!!; 2002141086