course, determine the treatment. For a simple fracture, without
displacement, provided there is no laceration of the periosteum, an
ordinary supporting bandage will usually be sufficient, but when there
is displacement the reduction of the fracture must first be
accomplished, and for this special splints are necessary. In a fracture
of the symphysis or of the branches the adjustment of the fragments by
securing them with metallic sutures is the first step necessary, to be
followed by the application of supports, consisting of splints of
leather or sheets of metal, the entire front of the head being then
covered with bandages prepared with adhesive mixtures. During the entire
course of treatment a special method of feeding becomes necessary. The
inability of the patient to appreciate the situation, of course,
necessitates a resort to an artificial mode of introducing the necessary
feed into his stomach; this is accomplished by forcing between the
commissures of the lips, in a liquid form, by means of a syringe, the
milk or nutritive gruels selected for his sustenance until the
consolidation is sufficiently advanced to permit the ingestion of feed
of a more solid consistency. The callus will usually be sufficiently
hardened in two or three weeks to allow of a change of diet to mashes of
cut hay and scalded grain, until the removal of the dressing restores
the animal to its old habit of mastication.
FRACTURES OF VERTEBRAE.
These are not very common, but when they do occur the bones most
frequently injured are those of the back and loins.
_Causes._--The ordinary causes of fracture are responsible here as
elsewhere, such as heavy blows on the spinal column, severe falls while
conveying heavy loads, and especially violent efforts in resisting the
process of casting. Although occurring more or less frequently under the
latter circumstances, the accident is not always attributable to
carelessness or error in the management. It may, of course, sometimes
result from such a cause as a badly prepared bed, or the accidental
presence of a hard body concealed in the straw, or to a heavy fall when
the movements of the patient have not been sufficiently controlled by an
effective apparatus and its skillful adaptation, but it is quite as
liable to be caused by the violent resistance and the consequent
powerful muscular contraction by the frightened patient. The simple fact
of the overarching of the vertebral column, with excessive pressure
against it from the intestinal mass, owing to the spasmodic action of
the abdominal muscles, may account for it, and so also may the struggles
of the animal to escape from the restraint of the hobbles while frantic
under the pain of an operation without anesthesia. In these cases the
fracture usually occurs in the body or the annular part, or both, of the
posterior dorsal or the anterior lumbar vertebra. When the transverse
processes of the last-named bones are injured, it is probably in
consequence of the heavy concussion incident to striking the ground when
cast. The diagnosis of a fracture of the body of a vertebra is not
always easy, especially when quite recent, and more especially when
there is no accompanying displacement.
_Symptoms._--There are certain peculiar signs accompanying the
occurrence of the accident while an operation is in progress which
should at once excite the suspicion of the surgeon. In the midst of a
violent struggle the patient becomes suddenly quiet; the movement of a
sharp instrument, which at first excited his resistance, fails to give
rise to any further evidence of sensation; perhaps a general trembling,
lasting for a few minutes, will follow, succeeded by a cold, profuse
perspiration, particularly between the hind legs, and frequently there
will be micturition and defecation. Careful examination of the vertebral
column may then detect a slight depression or irregularity in the
direction of the spine, and there may be a diminution or loss of
sensation in the posterior part of the trunk, while the anterior portion
continues to be as sensitive as before. In making an attempt to get upon
his feet, however, upon the removal of the hobbles, only the fore part
of the body will respond to the effort, a degree of paraplegia being
present, and while the head, neck, and fore part of the body will be
raised, the hind quarters and hind legs will remain inert. The animal
may perhaps succeed in rising and probably may be removed to his stall,
but the displacement of the bone will follow, converting the fracture
into one of the complete kind, either through the exertion of walking or
by a renewed attempt to rise after another fall before reaching his
stall. By this time the paralysis is complete, and the extension of the
meningitis, which has become established, is a consummation soon
reached.
To say that the prognosis of fracture of the body of the vertebra is
always serious is to speak very mildly. It would be better, perhaps, to
say that _occasionally_ a case _may_ recover. Fractures of the
transverse processes are less serious.
_Treatment._--Instead of stating the indication in this class of cases
as if assuming them to be amenable to treatment, the question naturally
would be: Can any treatment be recommended in a fracture of the body of
a vertebra? The only indication in such a case, in our opinion, is to
reach the true diagnosis in the shortest possible time and to act
accordingly. If there is displacement, and the existence of serious
lesions may be inferred from the nervous symptoms, the destruction of
the suffering animal appears to suggest itself as the one conclusion in
which considerations of policy, humanity, and science at once unite.
If, however, it is fairly evident that no displacement exists; that
pressure upon the spinal cord is not yet present; that the animal with a
little assistance is able to rise upon his feet and to walk a short
distance--it may be well to experiment upon the case to the extent of
placing the patient in the most favorable circumstances for recovery and
allow nature to operate without further interference. This may be
accomplished by obtaining immobility of the whole body as much as
possible, and especially of the suspected region, by placing the patient
in slings, in a stall sufficiently narrow to preclude lateral motion,
and covering the loins with a thick coat of agglutinative mixture.
Developments should be watched and awaited.
FRACTURE OF THE RIBS.
The different regions of the chest are not equally exposed to the
violence that causes fractures of the ribs, and they are therefore
either more common or more easily discovered during life at some points
than at others. The more exposed regions are the middle and the
posterior, while the front is largely covered and defended by the
shoulder. A single rib may be the seat of fracture, or a number may be
involved, and there may be injuries on both sides of the chest at the
same time. It may take place lengthwise, in any part of the bone, though
the middle, being the most exposed, is the most frequently hurt.
Incomplete fractures are usually lengthwise, involving a portion only of
the thickness of one or other of the surfaces. The complete kind may be
either transverse or oblique, and are most commonly denticulated. The
fracture may be comminuted, and a single bone may show one of the
complete and one of the incomplete kind at different points. The extent
of surface presented by the thoracic region, with its complete exposure
at all points, explains the liability of the ribs to suffer from all the
forms of external violence.
_Symptoms._--In many instances fractures, especially the incomplete
variety, of these bones continue undiscovered, without displacement,
though the evidences of local pain, a certain amount of swelling, and a
degree of disturbance of the respiration, if noticed during the
examination of a patient, may suggest a suspicion of their existence.
Abnormal mobility and crepitation are difficult of detection, even when
present, and they are not always present. When there is displacement the
deformity which it occasions will betray the fact, and when such an
injury exists the surgeon, in view of possible and probable
complications of thoracic trouble, of course will become vigilant and
prepare himself for an encounter with a case of traumatic pleuritis or
pneumonia. Fatal injuries of the heart are recorded. Subcutaneous
emphysema is a common accompaniment of broken ribs, and I recall the
death, from this cause, of a patient of my own which had suffered a
fracture of two ribs in the region of the withers, under the cartilages
of the shoulder, and of which the diagnosis was made only after the
fatal ending of the case.
These hurts are not often of a very serious character, though the union
is never so solid and complete as in other fractures, the callus being
usually imperfect and of a fibrous character, with an amphiarthrosis
formation. Still, complications occur which may impart gravity to the
prognosis.
_Treatment._--Fractures with but a slight or no displacement need no
reduction. All that is necessary is a simple application of a blistering
nature as a preventive of inflammation or for its subjugation when
present, and in order to excite an exudation which will tend to aid in
the support and immobilization of the parts. At times, however, a better
effect is obtained by the application of a bandage placed firmly around
the chest, although, while this limits the motion of the ribs, it is
liable to render the respiration more labored.
If there is displacement, with much accompanying pain and evident
irritation of the lungs, the fracture must be reduced without delay.
The means of effecting this vary according to whether the displacement
is outward or inward. In the first case the bone may be straightened by
pressure from without, while in the second the end of it must be raised
by a lever, for the introduction of which a small incision through the
skin and intercostal spaces will be necessary. When coaptation has been
effected it must be retained by the external application of an adhesive
mixture, with splints and bandages around the chest.
FRACTURES OF THE BONES OF THE PELVIS.
These fractures will be considered under their separate denominations,
as those of the sacrum and the os innominatum, or hip, which includes
the subdivisions of the ilium, the pubes, and the ischium.
_The sacrum._--Fractures of this bone are rarely met with among
solipeds. Among cattle, however, it is of common occurrence, being
attributed not only to the usual varieties of violence, as blows and
other external hurts, but to the act of coition and violent efforts in
parturition. It is generally of the transverse kind and may be
recognized by the deformity which it occasions. This is due to the
dropping of the bone, with a change in its direction and a lower
attachment of the tail, which also becomes more or less paralyzed. The
natural and spontaneous relief which usually interposes in these cases
has doubtless been observed by the extensive cattle breeders of the
West, and their practice and example fully establish the inutility of
interference. Still, cases may occur in which reduction may be
indicated, and it then becomes a matter of no difficulty. It is effected
by the introduction of a round, smooth piece of wood into the rectum as
far as the fragment of bone and using it as a lever, resting upon
another as a fulcrum placed under it outside. The bone, having been thus
returned, may be kept in place by the ordinary external means in use.
_The os innominatum._--Fracture of the ilium may be observed either at
the angle of the hip or at the neck of the bone; those of the pubes may
take place at the symphysis, or in the body of the bone; those of the
ischium on the floor of the bone, or at its posterior external angle.
Or, again, the fracture may involve all three of these constituent parts
of the hip bone by having its situation in the articular cavity--the
acetabulum by which it joins the femur or thigh bone.
_Symptoms._--Some of these fractures are easily recognized, while others
are difficult to identify. The ordinary deformity which characterizes a
fracture of the external angle of the ilium, its dropping and the
diminution of that side of the hip in width, unite in indicating the
existence of the condition expressed by the term "hipped." An incomplete
fracture, however, or one that is complete without displacement, or even
one with displacement, often demands the closest scrutiny for its
discovery. The lameness may be well marked, and an animal may show it
but little while walking, though upon being urged into a trot will
manifest it more and more, until presently it will cease to use the
crippled limb altogether, and travel entirely on three legs. The acute
character of the lameness will vary in degree as the seat of the lesion
approximates the acetabulum. In walking, the motion at the hip is very
limited, and the leg is dragged; while at rest it is relieved from
bearing its share in sustaining the body. An intelligent opinion and
correct conclusion will depend largely upon a knowledge of the history
of the case, and while in some instances that will be but a report of
the common etiology of fractures, such as blows, hurts, and other
external violence, the simple fact of a fall may furnish in a single
word a satisfactory solution of the whole matter.
With the exception of the deformity of the ilium in a fracture of its
external angle, and unless there has been a serious laceration of
tissues and infiltration of blood, or excessive displacement, there are
no very definite external symptoms in a case of a fracture of the hip
bone. There is one, however, which, in a majority of cases, will not
fail--it is crepitation. This evidence is attainable by both external
and internal examination--by manipulation of the gluteal surface and by
rectal taxis. Very often a lateral motion, or balancing of the hinder
parts by pressing the body from one side to the other, will be
sufficient to render the crepitation more distinct--a slight sensation
of grating, which may be perceived even through the thick coating of
muscle which covers the bone--and the sensation may not only be felt,
but to the expert may even become audible. This external manifestation
is, however, not always sufficient in itself, and should invariably be
associated with the rectal taxis for corroboration. It is true that this
may fail to add to the evidence of fracture, but till then the simple
testimony afforded by the detection of crepitation from the surface,
though a strong confirmatory point, is scarcely sufficiently absolute to
establish more than a reasonable probability or strong suspicion in the
case.
In addition to the fact that the rectal examination brings the exploring
hand of the surgeon into near proximity to the desired point of search,
and to an accurate knowledge of the situation of parts, both pro and con
as respects his own views, there is another advantage attendant upon it
which is well entitled to appreciation. This is the facility with which
he can avail himself of the help of an assistant, who can aid him by
manipulating the implicated limb and placing it in various positions, so
far as the patient will permit, while the surgeon himself is making
explorations and studying the effect from within. By this method he can
hardly fail to ascertain the character of the fracture and the condition
of the bony ends. By the rectal taxis, as if with eyes in the finger
ends, he will "see" what is the extent of the fracture of the ilium or
of the neck of that bone; to what part of the central portion of the
bone (the acetabulum) it reaches; whether this is free from disease or
not, and in what location on the floor of the pelvis the lesion is
situated. By this method we have frequently been able to detect a
fracture at the symphysis, which, from its history and symptoms and an
external examination, could only have been guessed at. Yet, with all its
advantages, the rectal examination is not always necessary, as, for
example, when the fracture is at the posterior and external angle of the
ischium, when by friction of the bony ends the surgeon may discern the
crepitation without it.
Every variety of complication, including muscular lacerations with the
formation of deep abscesses and injuries to the organs of the pelvic
cavity, the bladder, the rectum, and the uterus, may be associated with
fractures of the hip bone.
_Prognosis._--The prognosis of these lesions will necessarily vary
considerably. A fracture of the most superficial part of the bone of the
ilium or of the ischium, especially if there is little displacement,
will unite rapidly, leaving a comparatively sound animal often quite
free from subsequent lameness. If there is much displacement, however,
only a ligamentous union will take place, with much deformity and more
or less irregularity in the gait. Other fractures may be followed by
complete disability of the patient, as, for example, when the cotyloid
cavity is involved, or when the reparatory process has left bony
deposits in the pelvic cavity at the seat of the union, which may, in
the case of the female, interfere with the steps of parturition, or
induce some local paralysis by pressure upon the nerves which govern the
muscles of the hind legs. This is a condition not infrequently observed
when the callus has been formed on the floor of the pelvis near the
obturator foramen, pressing upon the course or involving the obturator
nerve.
_Treatment._--In our estimation, the treatment of all fractures of the
hip bone should be of the simplest kind. Rendered comparatively
immovable by the thickness of the muscles by which the region is
enveloped, one essential indication suggests itself, and that is to
place the animal in a position which, so far as possible, will be fixed
and permanent. For the accomplishment of this purpose the best measure,
as we consider it, is to place the horse in a stall of just sufficient
width to admit him, and to apply a set of slings, snugly, but
comfortably. (See Plate XXXI.) This will fulfill the essential
conditions of recovery--rest and immobility. Blistering applications
would be injurious, though the adhesive mixture might prove in some
degree beneficial.
The minimum period allowable for solid union in a fractured hip is, in
our judgment, two months, and we have known cases in which that was too
short a time.
As we have said before, there may be cases in which the treatment for
fracture at the floor of the pelvis has been followed by symptoms of
partial paralysis, the animal, when lying down, being unable to regain
his feet, but moving freely when placed in an upright position. This
condition is owing to the interference of the callus with the functions
of the obturator nerve, which it presses upon or surrounds. By my
experience in similar cases I feel warranted in cautioning owners of
horses in this condition to exercise due patience, and to avoid a
premature sentence of condemnation against their invalid servants; they
are not all irrecoverably paralytic. With alternations of moderate
exercise, rest in the slings, and the effect of time while the natural
process of absorption is taking effect upon the callus, with other
elements of change that may be so operating, the horse in due time may
become able once more to earn his subsistence and serve his master.
FRACTURE OF THE SCAPULA.
This bone is seldom fractured, its comparative exemption being due to
its free mobility and the protection it receives from the superimposed
soft tissues. Only direct and powerful causes are sufficient to effect
the injury, and when it occurs the large rather than the smaller animals
are the subjects.
_Cause._--The causes are heavy blows or kicks and violent collisions
with unyielding objects. Those which are occasioned by falls are
generally at the neck of the bone, and of the transverse and comminuted
varieties.
_Symptoms._--The diagnosis is not always easy. The symptoms are
inability to rest the leg on the ground and to carry weights, and they
are present in various degrees from slight to severe. The leg rests upon
the toe, seems shortened, and locomotion is performed by jumps. Moving
the leg while examining it and raising the foot for inspection seem to
produce much pain and cause the animal to rear. Crepitation is readily
felt with the hand upon the shoulder when the leg is moved. If the
fracture occurs in the upper part of the bone, overlapping of the
fragments and displacement will be considerable.
The fracture of this bone is usually classed among the more serious
accidents, though cases may occur which are followed by recovery without
very serious ultimate results, especially when the seat of the injury is
at some of the upper angles of the bone or about the acromion crest. But
if the neck and the joint are the parts involved, complications which
are likely to disable the animal for life are liable to be present.
_Treatment._--If there is no displacement, a simple adhesive dressing to
strengthen and immobilize the parts will be sufficient. A coat of black
pitch dissolved with wax and Venice turpentine, and kept in place over
the region with oakum or linen bands, will be all the treatment
required, especially if the animal is kept quiet in the slings.
Displacement can not be remedied, and reduction is next to impossible.
Sometimes an iron plate is applied over the parts and retained by
bandages, as in the dressing of Bourgelat (Plate XXX); this may be
advantageously replaced by a pad of thick leather. In smaller animals
the parts are retained by figure-8 bandages, embracing both the normal
and the diseased shoulders, crossing each other in the axilla and
covered with a coating of adhesive mixture.
FRACTURES OF THE HUMERUS.
These are more common in small than in large animals, and are always the
result of external traumatism, such as falls, kicks, and collisions.
They are generally very oblique, are often comminuted, and though more
usually involving the shaft of the bone will in some cases extend to the
upper end and into the articular head.
_Symptoms._--There is ordinarily considerable displacement in
consequence of the overlapping of the broken ends of the bone, and this
of course causes more or less shortening of the limb. There will also be
swelling, with difficulty of locomotion, and crepitation will be easy of
detection. This fracture is always a serious damage to the patient,
leaving him with a permanently shortened limb and an incurable, lifelong
lameness.
_Treatment._--If treatment is determined on, it will consist in the
reduction of the fracture by means of extension and counter extension,
to accomplish which the animal must be thrown. If successful in the
reduction, then follows the application and adjustment of the apparatus
of retention, which must be of the most perfect and efficient kind.
Finally, this, however skillfully contrived and carefully adapted, will
often fail to effect any good purpose whatever.
FRACTURES OF THE FOREARM.
A fracture in this region may also involve the radius or the ulna, the
latter being broken at times in its upper portion above the radio-ulnar
arch at the olecranon. If the fracture occurs at any part of the forearm
from the radio-ulnar arch down to the knee, it may involve either the
radius alone or the radius and the cubitus, which are there intimately
united.
_Cause._--Besides having the same etiology with most of the fractures,
those of the forearm are, nevertheless, more commonly due to kicks from
other animals, especially when crowded together in large numbers in
insufficient space. It is a matter of observation that under these
circumstances fractures of the incomplete kind are those which occur on
the inside of the leg, the bone being in that region almost entirely
subcutaneous, while those of the complete class are either oblique or
transverse. The least common are the longitudinal, in the long axis of
the bone.
_Symptoms._--This variety of fracture is easily recognized by the
appearance of the leg and the different changes it undergoes. There is
inability to use the limb; impossibility of locomotion; mobility below
the injury; the ready detection of crepitation--in a word, the
assemblage of all the signs and symptoms which have been already
considered as associated with the history of broken bones.