Manual of Surgery Volume II Part 2

_Injuries to nerve-trunks_ are comparatively common, especially in fractures of the arm, where the radial (musculo-spiral) nerve is liable to suffer.

The nerve may be implicated at the time of the injury, being compressed, bruised, lacerated, or completely torn across by broken fragments, or it may be involved later by the pressure of callus. The symptoms depend upon the degree of damage sustained by the nerve, and vary from partial and temporary interference with sensation and motion to complete and permanent abrogation of function.

In rare instances _fat embolism_ is said to occur, and fat globules are alleged to have been found in the urine. In persons addicted to excess of alcohol, _delirium tremens_ is a not infrequent accompaniment of a fracture which confines the patient to bed.

#Prognosis in Simple Fractures.#--_Danger to life_ in simple fractures depends chiefly on the occurrence of complications. In old people, a fracture of the neck of the femur usually necessitates long and continuous lying on the back, and bronchitis, hypostatic pneumonia, and bed-sores are p.r.o.ne to occur and endanger life. Fractures complicated with injury to internal organs, and fractures in which gangrene of the limb threatens, are, of course, of grave import.

The prognosis as regards the _function of the limb_ should always be guarded, even in simple fractures. Incidental complications are liable to arise, delaying recovery and preventing a satisfactory result, and these not only lead to disappointment, but may even form a ground for actions for malpraxis.

The chief and most frequent cause of permanent disability after fracture is angular displacement. A comparatively small degree of angularity may lead to serious loss of function, especially in the lower limb; the joints above and below the fracture are placed at a disadvantage, arthritic changes result from the abnormal strain to which they are subjected, and rarefaction of the bone may also ensue.

Fibrous union is a common result in fractures of the neck of the femur in old people and in certain other fractures, such as fracture of the patella, of the olecranon, coronoid and coracoid processes, and although this does not necessarily involve interference with function, the patient should always be warned of the possibility.

Impairment of growth and eventual shortening of the limb may result from involvement of an epiphysial junction.

Stiffness of joints is liable to follow fractures implicating articular surfaces, or it may result from arthritic changes following upon the injury.

Osseous ankylosis is not a common sequel of simple fractures, but locking of joints from the mechanical impediment produced by the union of imperfectly reduced fragments, or from ma.s.ses of callus, is not uncommon, especially in the region of the elbow.

Wasting of the muscles and dema of the limb often delay the complete restoration of function. Delayed union, want of union, and the formation of a false joint have already been referred to.

#Treatment.#--The treatment of a fracture should be commenced as soon after the accident as possible, before the muscles become contracted and hold the fragments in abnormal positions, and before the blood and serum effused into the tissues undergo organisation.

Care must be taken during the transport of the patient that no further damage is done to the injured limb. To this end the part must be secured in some form of extemporised splint, the apparatus being so designed as to control not only the broken fragments, but also the joints above and below the fracture.

When the ordinary method of removing the clothes involves any risk of unduly moving the injured part, they should be slit open along the seams.

The patient should be placed on a firm straw, horse-hair, or spring mattress, stiffened in the case of fractures of the pelvis or lower limbs by fracture-boards inserted beneath the mattress. Special mattresses constructed in four pieces, to facilitate the nursing of the patient, are sometimes used.

In many cases, particularly in muscular subjects, in restless alcoholic patients, and in those who do not bear pain well, a general anaesthetic is a valuable aid to the accurate setting of a fracture, as well as a means of rendering the diagnosis more certain.

The procedure popularly known as "setting a fracture" consists in restoring the displaced parts to their normal position as nearly as possible, and is spoken of technically as the _reduction_ of the fracture.

_The Reduction of Fractures._--In some cases the displacement may be overcome by relaxing the muscles acting upon the fragments, and this may be accomplished by the stroking movements of ma.s.sage. In most cases, however, it is necessary, after relaxing the muscles, to employ _extension_, by making forcible but steady traction on the distal fragment, while _counter-extension_ is exerted on the proximal one, either by an a.s.sistant pulling upon that portion of the limb, or by the weight of the patient's body. The fragments having been freed, and any shortening of the limb corrected in this way, the broken ends are moulded into position--a process termed _coaptation_.

The reduction of a recent greenstick fracture consists in forcibly straightening the bend in the bone, and in some cases it is necessary to render the fracture complete before this can be accomplished.

In selecting a means of retaining the fragments in position after reduction, the various factors which tend to bring about re-displacement must be taken into consideration, and appropriate measures adopted to counteract each of these.

In addition to retaining the broken ends of the bone in apposition, the after-treatment of a fracture involves the taking of steps to promote the absorption of effused blood and serum, to maintain the circulation through the injured parts, and to favour the repair of damaged muscles and other soft tissues. Means must also be taken to maintain the functional activity of the muscles of the damaged area, to prevent the formation of adhesions in joints and tendon sheaths, and generally to restore the function of the injured part.

_Practical Means of Effecting Retention--By Position._--It is often found that only in one particular position can the fragments be made to meet and remain in apposition--for example, the completely supine position of the forearm in fracture of the radius just above the insertion of the p.r.o.nator teres. Again, in certain cases it is only by relaxing particular groups of muscles that the displacement can be undone--as, for instance, in fracture of the bones of the leg, or of the femur immediately above the condyles, where flexion of the knee, by relaxing the calf muscles, permits of reduction.

_Ma.s.sage and Movement in the Treatment of Fractures._--Lucas-Championniere, in 1886, first pointed out that a certain amount of movement between the ends of a fractured bone favours their union by promoting the formation of callus, and advocated the treatment of fractures by ma.s.sage and movement, discarding almost entirely the use of splints and other retentive appliances. We were early convinced by the teaching of Lucas-Championniere, and have adopted his principles in fractures.

In the majority of cases the ma.s.sage and movement are commenced at once, but circ.u.mstances may necessitate their being deferred for a few days. The measures adopted vary according to the seat and nature of the fracture, but in general terms it may be stated that after the fracture has been reduced, the ends of the broken bone are retained in position, and gentle ma.s.sage is applied by the surgeon or by a trained ma.s.seur. The lubricant may either be a powder composed of equal parts of talc and boracic acid, or an oily substance such as olive oil or lanolin. The rubbing should never cause pain, but, on the contrary, should relieve any pain that exists, as well as the muscular spasm which is one of the most important causes of pain and of displacement in recent fractures. The parts on the proximal side of the injured area are first gently stroked upwards to empty the veins and lymphatics, and to disperse the effused blood and serum. The process is then applied to the swollen area, and gradually extended down over the seat of the fracture and into the parts beyond. In this way the circulation through the damaged segment of the limb is improved, the veins are emptied of blood, the removal of effused fluid is stimulated, and the muscular irritability allayed. The joints of the limb are gently moved, care being taken that the broken ends of the bone are not displaced. After the rubbing has been continued for from fifteen to twenty minutes, the limb is placed in a comfortable position, and retained there by pillows, sand-bags, or, if found more convenient, by a light form of splint.

The ma.s.sage is repeated once each day; the sittings last from ten to fifteen minutes. The sequence should be, first, ma.s.sage; second, pa.s.sive movement; and third, active movement. At first ma.s.sage predominates, and more pa.s.sive than active movement; gradually ma.s.sage is lessened and movements are increased, active movements ultimately preponderating.

_Splints and other Appliances._--The appropriate splints for individual fractures and the method of applying them will be described later; but it may here be said that the general principle is that when dealing with a part where there is a single bone, as the thigh or upper arm, the splint should be applied in the form of a _ferrule_ to surround the break; while in situations where there are two parallel bones, as in the forearm and leg, the splint should take the form of a _box_.

_Simple wooden splints_ of plain deal board or yellow pine, sawn to the appropriate length and width; or _Gooch's splinting_, which consists of long strips of soft wood, glued to a backing of wash-leather, are the most useful materials. Gooch's splinting has the advantage that when applied with the leather side next the limb it encircles the part as a ferrule; while it remains rigid when the wooden side is turned towards the skin. Perforated sheet lead or tin, stiff wire netting, and hoop iron also form useful splints.

When it is desirable that the splint should take the shape of the part accurately, a plastic material may be employed. Perhaps the most convenient is _poroplastic felt_, which consists of strong felt saturated with resin. When heated before a fire or placed in boiling water, it becomes quite plastic and may be accurately moulded to any part, and on cooling it again becomes rigid. The splint should be cut from a carefully fitted paper pattern. Millboard, leather, or gutta-percha softened in hot water, and moulded to the part, may also be employed.

In conditions where treatment by ma.s.sage and movement is impracticable, and where movable splints are inconvenient, splints of _plaster of Paris_, _starch_, or _water-gla.s.s_ are sometimes used, especially in the treatment of fractures of the leg. When employed in the form of an immovable case, they are open to certain objections--for example, if applied immediately after the accident they are apt to become too tight if swelling occurs; and if applied while swelling is still present, they become slack when this subsides, so that displacement is liable to occur.

When it is desired to enclose the limb in a plaster case, coa.r.s.e muslin bandages, 3 yards long, and charged with the finest quality of thoroughly dried plaster of Paris, are employed. The "acetic plaster bandages" sold in the shops set most quickly and firmly. Boracic lint or a loose stocking is applied next the skin, and the bony prominences are specially padded. The plaster bandage is then placed in cold water till air-bubbles cease to escape, by which time it is thoroughly saturated, and, after the excess of water is squeezed out, is applied in the usual way from below upward. From two to four plies of the bandage are required. In the course of half an hour the plaster should be thoroughly set. To facilitate the removal of a plaster case the limb should be immersed for a short time in tepid water.

A convenient and efficient splint is made by moulding two pieces of poroplastic felt to the sides of the limb, and fixing them in position with an elastic webbing bandage; this apparatus can be easily removed for the daily ma.s.sage.

_Padding_ is an essential adjunct to all forms of splints. The whole part enclosed in the splint must be covered with a thick layer of soft and elastic material, such as wool from which the fat has not been removed. All hollows should be filled up, and all bony projections specially protected by rings of wadding so arranged as to take the pressure off the prominent point and distribute it on the surrounding parts. Opposing skin surfaces must always be separated by a layer of wool or boracic lint. A bandage should never be applied to the limb underneath the splints and pads, as congestion or even gangrene may be induced thereby.

#Operative Treatment of Simple Fractures.#--Operation in simple fracture is specially called for (1) in fracture into or near a joint where a permanently displaced fragment will cause locking of the joint; (2) when fragments are drawn apart, as in fractures of the patella or olecranon; (3) when displacement, especially shortening, cannot be remedied by other means; (4) when complications are present, such as a torn nerve-trunk or a main artery; (5) when non-union is to be feared, as in certain cases of fracture of the neck of the femur in old people. Under such circ.u.mstances it is necessary to expose the fracture by operation, and to place the fragments in accurate apposition, if necessary, fixing them in position by wires, pegs, plates, or screws (_Op. Surg._, p. 52). Operative interference is usually delayed till about five to seven days after the injury, by which time the effect of other measures will have been estimated, accurate information obtained by means of the X-rays regarding the nature of the lesion and the position of the fragments, and the tissues recovered their normal powers of resistance. Such operations, however, are not to be undertaken lightly, as they are often difficult, and if infection takes place the results may be disastrous.

Arbuthnot Lane and Lambotte advocate a more general resort to operative measures, even in simple and uncomplicated fractures, and it must be conceded that in many fractures an open operation affords the only means of securing accurate apposition and alignment of the fragments.

Both before and after operation, ma.s.sage and movement are to be carried out, as in fractures treated by other methods.

COMPOUND FRACTURES

The essential feature of a compound fracture is the existence of an open wound leading down to the break in the bone. The wound may vary in size from a mere puncture to an extensive tearing and bruising of all the soft parts.

A fracture may be rendered compound _from without_, the soft parts being damaged by the object which breaks the bone--as, for example, a cart wheel, a piece of machinery, or a bullet. Sloughing of soft parts resulting from the pressure of improperly applied splints, also, may convert a simple into a compound fracture. On the other hand, a simple fracture may be rendered compound _from within_--for example, a sharp fragment of bone may penetrate the skin; this is the least serious variety of compound fracture.

As a rule, it is easy to recognise that the fracture is compound, as the bone can either be seen or felt.

The _prognosis_ depends on the success which attends the efforts to make and to keep the wound aseptic, as well as on the extent of damage to the tissues. When asepsis is secured, repair takes place as in simple fracture, only it usually takes a little longer; sometimes the reason for the delay is obvious, as when the compound fracture is the result of a more severe form of violence and where there is comminution and loss of one or more portions of bone that would have contributed to the repair. Sometimes the delay cannot be so explained; Bier suggested that it is due to the escape of blood at the wound, whereas in simple fractures the blood is retained and a.s.sists in repair.

If sepsis gains the upper hand in a compound fracture there is, firstly, the risk of infection of the marrow--osteomyelitis--which in former times was liable to result in pyaemia; in the second place, not only do loose fragments tend to die and be thrown off as sequestra, but the ends of the fragments themselves may undergo necrosis; involving as this does the dense cortical bone of the shaft, the dead bone is slow in being separated, and until it is separated and thrown off, no actual repair can take place. The sepsis stimulates the bone-forming tissues and new bone is formed in considerable amount, especially on the surface of the shaft in the vicinity of the fracture; in macerated specimens it presents a porous, crumbling texture. Sometimes the new bone--which corresponds to the involucrum of an osteomyelitis--imprisons a sequestrum and prevents its extrusion, in which case one or more sinuses may persist indefinitely.

Cases are met with where such sinuses have existed for the best part of a long life and have ultimately become the seat of epithelioma.

It should be noted that all the above changes can be followed in skiagrams.

_Treatment._--The leading indication is to ensure asepsis. Even in the case of a small punctured wound caused by a pointed fragment coming through the skin it is never wise to a.s.sume that the wound is not infected. It is much safer to enlarge such a wound, pare away the bruised edges, and disinfect the raw surfaces.

In cases of extensive laceration of the soft parts, all soiled, bruised, or torn portions of tissue should be clipped away with scissors, blood-clots removed, and the bleeding arrested by forci-pressure or ligature. If there is any reason to believe that the wound is infected, any fragments of bone completely separated from the periosteum should be removed. In comminuted fractures, extension applied by strips of plaster or by means of ice-tong callipers or Steinmann's apparatus (p. 150) often facilitates replacement of the fragments and their retention in position. Plates and screws are not recommended for comminuted fractures, owing to the mechanical difficulty of fixing a number of small fragments and the risks of infection. The wound should be purified with eusol, and the surrounding parts painted with iodine. On the whole, it is safer not to attempt to obtain primary union by completely closing such wounds, but rather to drain or pack them. To increase the local leucocytosis and so check the spread of infection, a Bier's constricting bandage may be applied.

In other respects the treatment is carried out on the same lines as in simple fractures, provision being made for dressing the wound without disturbance of the fracture. Ma.s.sage and movement should be commenced after the wound is healed and the condition has become a.n.a.logous to a simple fracture.

#Question of Amputation in Compound Fractures.#--Before deciding to perform primary amputation of a limb for compound fracture, the surgeon must satisfy himself (1) that the attainment of asepsis is impossible; (2) that the soft parts are so widely and so grossly damaged that their recovery is improbable; (3) that the vascular and nervous supply of the parts beyond has been rendered insufficient by destruction of the main blood vessels and nerve-trunks; (4) that the bones have been so shattered as to be beyond repair; and (5) that the limb, even if healing takes place, will be less useful than an artificial one.

In attempting to save the limb of a young subject, it is justifiable to run risks which would not be permissible in the case of an older person. To save an upper limb, also, risks may be run which would not be justifiable in the case of a lower limb, because, while a serviceable artificial leg can readily be procured, any portion of the natural hand or arm is infinitely more useful than the best subst.i.tute which the instrument-maker can contrive. The risk involved in attempting to save a limb should always be explained to the patient or his guardian, in order that he may share the responsibility in case of failure.

Whether or not the amputation should be performed at once, depends upon the general condition of the patient. If the injury is a severe one, and attended with a profound degree of shock, it is better to wait for twenty-four or forty-eight hours. Meanwhile the wound is purified, and the limb wrapped in a sterile dressing. Means are taken to counteract shock and to maintain the patient's strength, and evidence of infection or of haemorrhage is carefully watched for. When the shock has pa.s.sed off, the operation is then performed under more favourable auspices. Clinical experience has proved that by this means the mortality of primary amputations may be materially diminished, especially in injuries necessitating removal of an entire limb.

Having decided to amputate, it is important to avoid having bruised, torn, or separated tissues in the flaps, as these are liable to slough or to become the seat of infection. In this connection it should be borne in mind that the damage to soft tissues is always wider in extent than appears from external examination.

The attempt to save a limb may fail and amputation may be called for later because of spreading infective processes, osteomyelitis, or gangrene; to prevent exhaustion from prolonged suppuration and toxin absorption; or on account of secondary haemorrhage.