in estimating the gravity of the case in a fracture accident is the
certainty of the total loss of the services of the patient during
treatment--certainly for a considerable period of time; perhaps
permanently. For example, the fracture of the jaw of a steer just
fattening for the shambles will involve a heavier loss than a similar
accident to a horse. Usually the fracture of the bones of the
extremities in a horse is a very serious casualty, the more so
proportionately as the higher region of the limb is affected. In working
animals it is exceedingly difficult to treat a fracture in such manner
as to restore a limb to its original perfection of movement. A fracture
of a single bone of an extremity in a breeding stallion or mare will not
necessarily impair the value of the animal as a breeder. Other
specifications under this head, though pertinent and more or less
interesting, may be omitted.
(4) Age and temper are important factors of cure. A young, growing,
robust patient whose vis vitae is active is amenable to treatment which
one with a waning constitution and past mature energies would be unable
to endure, and a docile, quiet disposition will act cooperatively with
remedial measures which would be neutralized by the fractious opposition
of a peevish and intractable sufferer.
The fulfillment of three indications is indispensable in all fractures.
The first is the reduction, or the replacement, of the parts as nearly
as possible in their normal position. The second is their retention in
that position for a period sufficient for the formation of the
provisional callus, and the third, which, in fact, is but an incident of
the second, the careful avoidance of any accidents or causes of
miscarriage which might disturb the curative process.
In reference to the first consideration, it must be remembered that the
accident may befall the patient at a distance from his home, and his
removal becomes the first duty to be attended to. Of course, this must
be done as carefully as possible. If he can be treated on the spot, so
much the better, though this is seldom practicable, and the method of
removal becomes the question calling for settlement. But two ways
present themselves--he must either walk or be carried. If the first, it
is needless to say that every caution must be observed in order to
obviate additional pain and to avoid any aggravation of the injury. Led
slowly, and with partial support, if practicable, the journey will not
always involve untoward results. If he is carried, it must be by means
of a wagon, a truck, or an ambulance; the last being designed and
adapted to the purpose, would, of course, be the most suitable vehicle.
As a precaution which should never be overlooked, a temporary dressing
should first be applied. This may be so done as for the time to answer
all the purposes of the permanent adjustment and bandaging. Without thus
securing the patient, a fracture of an inferior degree may be
transformed to one of the severest kind, and, indeed, a curable changed
to an incurable injury. We recall a case in which a fast-trotting horse,
after running away in a fright caused by the whistle of a locomotive,
was found on the road limping with excessive lameness in the off fore
leg, and walked with comparative ease some 2 miles to a stable before
being seen by a surgeon. His immediate removal in an ambulance was
advised, but before that vehicle could be procured the horse lay down,
and upon being made to get upon his feet was found with a well-marked
comminuted fracture of the os suffraginis, with considerable
displacement. The patient, however, after long treatment, made a
comparatively good recovery and though with a large, bony deposit, a
ringbone, was able to trot in the forties.
The two obvious indications in cases of fracture are reduction, or
replacement, and retention.
In an incomplete fracture, where there is no displacement, the necessity
of reduction does not exist. With the bone kept in place by an intact
periosteum, and the fragments secured by the uninjured fibrous and
ligamentous structure which surrounds them, there is no dislocation to
correct. Reduction is also at times rendered impossible by the seat of
the fracture itself, by its dimensions, alone, or by the resistance
arising from muscular contraction. That is illustrated even in small
animals, as in dogs, by the exceeding difficulty encountered in
bringing together the ends of a broken femur or humerus, the muscular
contractions being even in these animals sufficiently forcible to renew
the displacement.
It is generally, therefore, only fractures of the long bones, and then
at points not in close proximity to the trunk, that may be considered to
be amenable to reduction. It is true that some of the more superficial
bones, as those of the head, of the pelvis, and of the thoracic walls,
may in some cases require special manipulations and appliances for their
retention in their normal positions; hence the treatment of these and of
a fractured leg can not be the same.
The methods of accomplishing reduction vary with the features of each
case, the manipulations being necessarily modified to meet different
circumstances. If the displacement is in the thickness of the bone, as
in transverse fracture, the manipulation of reduction consists in
applying constant pressure upon one of the fragments, while the other is
kept steady in its place, the object of the pressure being the
reestablishment of the exact coincidence of the two bony surfaces. If
the displacement has taken place at an angle it will be sufficient in
order to effect the reduction to press upon the summit, or apex, of the
angle until its disappearance indicates that the parts have been brought
into coaptation. This method is often practiced in the treatment of a
fractured rib. In a longitudinal fracture, or when the fragments are
pressed together by the contraction of the muscles to which they give
insertion until they so overlap as to correspond by certain points of
their circumference, the reduction is to be accomplished by effecting
the movements of extension, counter extension, and coaptation. Extension
is accomplished by making traction upon the lower portion of the limb.
Counter extension consists in firmly holding or confining the upper or
body portion in such manner, that it shall not be affected by the
traction applied to the lower part. In other words, the operator,
grasping the limb below the fracture, draws it down or away from the
trunk, while he seeks not to draw away, but simply to hold the upper
portion still until the broken ends of bone are brought to their natural
relative positions, when the coaptation, which is thus effected, has
only to be made permanent by the proper dressings to perfect the
reduction.
In treating fractures in small animals the strength of the hand is
usually sufficient for the required manipulations. In the fracture of
the forearm of a dog, for example, while the upper segment is firmly
held by one hand the lower may be grasped by the other and the bone
itself made to serve the purpose of a lever to bring about the desired
coaptation. In such case that is sufficient to overcome the muscular
contraction and correct the overlapping or other malposition of the
bones. If, however, the resistance can not be overcome in this way, the
upper segment may be committed to an assistant for the management of
the counter extension, leaving to the operator the free use of both
hands for the further manipulation of the case.
If the reduction of fractures in small animals is an easy task, however,
it is far from being so when the patient is a large animal whose
muscular force is largely greater than that of several men combined. In
such case resort must be had not only to superior numbers for the
necessary force, but in many cases to mechanical aids. A reference to
the manner of proceeding in a case of fracture with displacement of the
forearm of a horse will illustrate the matter. The patient is first to
be carefully cast, on the uninjured side, with ropes or a broad, leather
strap about 18 feet long passed under and around his body and under the
axilla of the fractured limb and secured at a point opposite to the
animal and toward his back. This will form the mechanical means of
counter extension. Another rope will then be placed around the inferior
part of the leg below the point of fracture, with which to produce
extension, and this will sometimes be furnished with a block and
pulleys, in order to augment the power when necessary; there is, in
fact, always an advantage in their use, on the side of steadiness and
uniformity, as well as of increased power. It is secured around the
fetlock or the coronet or, what is better, above the knee and nearer the
point of fracture, and is committed to assistants. The traction on this
should be firm, uniform, and slow, without relaxing or jerking, while
the operator carefully watches the process. If the bone is superficially
situated he is able, by the eye, to judge of any changes that may occur
in the form or length of the parts under traction, and discovering, at
the moment of its happening, the restoration of symmetry in the
disturbed region he gently but firmly manipulates the place until all
appearance of severed continuity has vanished. Sometimes the fact and
the instant of restoration are indicated by a peculiar sound or "click"
as the ends of the bones slip into contact, to await the next step of
the restorative procedure.
The process is the same when the bones are covered with thick muscular
masses except that it is attended with greater difficulties from the
fact that the finger must be substituted for the eye and taxis must take
the place of sight.
It frequently happens that perfect coaptation is prevented by the
interposition, between the bony surfaces, of such substances as a small
fragment of detached bone or a clot of blood; sometimes the extreme
obliquity of the fracture, by permitting the bones to slip out of place,
is the opposing cause. These are difficulties which can not always be
overcome, even in small-sized animals, and still it is only when they
are mastered that a correct consolidation can be looked for. Without it
the continuity between the fragments will be by a deformed callus, the
union will leave a shortened, crooked, or angular limb, and the animal
will be disabled.
If timely assistance can be obtained, and the reduction accomplished
immediately after the occurrence of the accident, that is the best time
for it, but if it can not be attended to until inflammation has become
established and the parts have become swollen and painful, time must be
allowed for the subsidence of these symptoms before attempting the
operation. A spasmodic, muscular contraction which sometimes interposes
a difficulty may be easily overcome by subjecting the patient to general
anesthesia, and need not, therefore, cause any loss of time. A tendency
to this may also be overcome by the use of sedatives and antiphlogistic
remedies.
The reduction of the fracture having been accomplished, the problem
which follows is that of retention. The parts which have been restored
to their natural position must be kept there, without disturbance or
agitation, until the perfect formation of a callus, and it is here that
ample latitude exists for the exercise of ingenuity and skill by the
surgeon in the contrivance of the necessary apparatus. One of the most
important of the conditions which are available by the surgeon in
treating human patients is denied to the veterinarian in the management
of those which belong to the animal tribes. This is position. The
intelligence of the human patient cooperates with the instructions of
the surgeon, in the case of the animal sufferer there is a continual
antagonism between the parties, and the forced extension and fatiguing
position which must for a considerable period be maintained as a
condition of restoration require special and effective appliances to
insure successful results. To obtain complete immobility is scarcely
possible, and the surgeon must be content to reach a point as near as
possible to that which is unattainable. For this reason, as will
subsequently be seen, the use of slings and the restraint of patients in
very narrow stalls is much to be preferred to the practice sometimes
recommended of allowing entire freedom of motion by turning them loose
in box stalls. Temporary and movable apparatus are not usually of
difficult use in veterinary practice, but the restlessness of the
patients and their unwillingness to submit quietly to the changing of
the dressings render it obligatory to have recourse to permanent and
immovable bandages, which should be retained without disturbance until
the process of consolidation is complete.
The materials composing the retaining apparatus consist of oakum,
bandages, and splints, with an agglutinating compound which forms a
species of cement by which the different constituents are blended into a
consistent mass to be spread upon the surface covering the locality of
the fracture. Its components are black pitch, rosin, and Venice
turpentine, blended by heat. The dressing may be applied directly to
the skin, or a covering of thin linen may be interposed. A putty made
with powdered chalk and the white of egg is recommended for small
animals, though a mixture of sugar of lead and burnt alum with the
albumen is preferred by others. Another formula is spirits of camphor,
Goulard's extract, and albumen. Another recommendation is to saturate
the oakum and bandages with an adhesive solution formed with gum arabic,
dextrin, flour paste, or starch. This is advised particularly for small
animals, as is also the silicate of soda. Dextrin mixed while warm with
burnt alum and alcohol cools and solidifies into a stony consistency,
and is preferable to plaster of Paris, which is less friable and has
less solidity, besides being heavier and requiring constant additions as
it becomes older. Starch and plaster of Paris form another good
compound.
In applying the dressing the leg is usually padded with a cushion of
oakum thick and soft enough to equalize the irregularities of the
surface and to form a bedding for the protection of the skin from
chafing. Over this the splints are placed. The material for these is,
variously, pasteboard, thin wood, bark, laths, gutta-percha, strips of
thin metal, as tin or perhaps sheet iron. They should be of sufficient
length not only to cover the region of the fracture but to extend
sufficiently above and below to render the immobility more nearly
complete than in the surrounding joints. The splints, again, are covered
with cloth bandages--linen preferably--soaked in a glutinous mixture.
These bandages are to be carefully applied, with a perfect condition of
lightness. They are usually made to embrace the entire length of the leg
in order to avoid the possibility of interference with the circulation
of the extremity as well as for the prevention of chafing. They should
be rolled from the lower part of the leg upward and carefully secured
against loosening. In some instances suspensory bandages are
recommended, but except for small animals our experience does not
justify a concurrence in the recommendation.
These permanent dressings always need careful watching with reference to
their immediate effect upon the region they cover, especially during the
first days succeeding that of their application. Any manifestation of
pain, or any appearance of swelling above or below, or any odor
suggestive of suppuration should excite suspicion, and a thorough
investigation should follow without delay. The removal of the dressing
should be performed with great care, and especially so if time enough
has elapsed since its application to allow of a probability of a
commencement of the healing process or the existence of any points of
consolidation. With the original dressing properly applied in its
entirety in the first instance, the entire extremity will have lost all
chance of mobility, and the repairing process may be permitted to
proceed without interference. There will be no necessity and there need
be no haste for removal or change except under such special conditions
as have just been mentioned, or when there is reason to judge that
solidification has become perfect, or for the comfort of the animal, or
for its readaptation in consequence of the atrophy of the limb from want
of use. Owners of animals are often tempted to remove a splint or
bandage prematurely at the risk of producing a second fracture in
consequence of the failure of the callus properly to consolidate.
The method of applying the splints which we have described refers to the
simple variety only. In a compound case the same rules must be observed,
with the modification of leaving openings through the thickness of the
dressing, opposite the wound, in order to permit the escape of pus and
to secure access to the points requiring the application of treatment.
FRACTURE OF CRANIAL BONES.
Fractures of the cranial bones in large animals are comparatively rare,
though the records are not destitute of cases. When they occur, it is as
the result of external violence, the sufferers being usually run-aways
which have come in collision with a wall or a tree or other obstruction,
or it may occur in those which in pulling upon the halter have broken it
with a jerk and been thrown backward, as may occur in rearing too
violently. Under these conditions we have witnessed fractures of the
parietal, of the frontal, and of the sphenoid bones. These fractures may
be of both the complete and the incomplete kinds, which indeed is
usually the case with those of the flat bones, and they are liable to be
complicated with lacerations of the skin, in consequence of which they
are easily brought under observation. When the fact is otherwise and the
skin is intact, however, the diagnosis becomes difficult.
_Symptoms._--The incomplete variety may be unaccompanied with any
special symptoms, but in the complete kind one of the bony plates may be
so far detached as to press upon the cerebral substance with sufficient
force to produce serious nervous complications. When the injury occurs
at the base of the cranium hemorrhage may be looked for, with paralytic
symptoms, and when these are present the usual termination is death. It
may happen, however, that the symptoms of an apparently very severe
concussion may disappear, resulting in an early and complete recovery,
and the surgeon will therefore do well to avoid undue haste in venturing
upon a prognosis. In fractures of the orbital or the zygomatic bones the
danger is less pressing than with injuries otherwise located about the
head.
_Treatment._--The treatment of cranial fractures is simple, though
involving the best skill of an experienced surgeon. When incomplete
hardly any interference is needed; even plain bandaging may usually be
dispensed with. In the complete variety the danger to be combated is
compression of the brain, and attention to this indication must not be
delayed. The means to be employed are the trephining of the skull over
the seat of the fracture and the elevation of the depressed bone or the
removal of the portion which is causing the trouble. Fragments of bone
in comminuted cases, bony exfoliations, collections of fluid, or even
protruding portions of the brain substance must be carefully cleansed
away and a simple bandage so applied as to facilitate the application of
subsequent dressings.
FRACTURES OF THE BONES OF THE FACE.
In respect to their origin--usually traumatic--these injuries rank with
the preceding, and are commonly of the incomplete variety. They may
easily be overlooked, and may even sometimes escape recognition until
the reparative process has been well established and the wound is
discovered owing to the prominence caused by the presence of the
provisional callus which marks its cure. When the fracture is complete
it will be marked by local deformity, mobility of the fragments, and
crepitation. Nasal hemorrhage, roaring, frequent sneezing, loosening or
loss of teeth, difficulty of mastication, and inflammation of the
cavities of the sinuses are varying complications of these accidents.
The object of the treatment should be the restoration of the depressed
bones as nearly as possible to their normal position and their retention
in place by protecting splints, which should cover the entire facial
region. Special precautions should be observed to prevent the patient
from disturbing the dressing by rubbing his head against surrounding
objects, such as the stall, manger, rack, etc. Clots of blood in the
nasal passages must be washed out, collections of pus removed from the
sinuses, and, if the teeth are loosened and liable to fall out, they
should be removed. If roaring is threatened, tracheotomy is indicated.
FRACTURES OF THE PREMAXILLARY BONE.
These are mentioned by continental authors and are usually encountered
in connection with fractures of the nasal bone, and may take place
either in the width or the length of the bone.
The deformity of the upper lip, which is drawn sidewise in this lesion,
renders it easy of diagnosis. The abnormal mobility and the crepitation,
with the pain manifested by the patient when undergoing examination, are
concurrent symptoms. Looseness of the teeth, abundant salivation, and
entire inability to grasp the feed complete the symptomatology of these
accidents. In the treatment splints of gutta-percha or leather are
sometimes used, but they are of difficult application. Our own judgment
and practice are in favor of the union of the bones by means of metallic
sutures.
FRACTURES OF THE LOWER JAW.
A fracture here is not an injury of infrequent occurrence. It involves
the body of the bone, at its symphysis, or back of it, and includes one
or both of its branches, either more or less forward, or at the
posterior part near the temporomaxillary articulation, at the coronoid
process.
Falls, blows, or other external violence, or powerful muscular
contractions during the use of the speculum, may be mentioned among the
causes of this lesion. The fracture of the neck, or that portion formed
by the juncture of the two opposite sides, and of the branches in front
of the cheeks, causes the lower jaw, the true dental arch, to drop,
without the ability to raise it again to the upper, and the result is a
peculiar and characteristic physiognomy. The prehension and mastication
of feed become impossible; there is an abundant escape of fetid and
sometimes bloody saliva, especially if the gums have been wounded; there
is excessive mobility of the lower end of the jawbone; and there is
crepitation, and frequently paralysis of the under lip. Although an
animal suffering with a complete and often compound and comminuted
fracture of the submaxilla presents at times a serious aspect, the
prognosis of the case is comparatively favorable, and recovery is
usually only a question of time. The severity of the lesion corresponds
in degree to that of the violence to which it is due, also to the
resulting complications and the situation of the wound. It is simple
when at the symphysis, but becomes more serious when it affects one of
the branches, and most aggravated when both are involved. Fracture of
the coronoid process becomes important principally as an evidence of the
existence of a morbid diathesis, such as osteoporosis, or the like.