observed, that the exact nature of the accident is often difficult to
detect; in all cases accurate and careful manipulation is required.
Displacement of one or other of the bones of the forearm almost
uniformly attends this fracture, sometimes rendering diagnosis obscure.
Fracture of the _olecranon_ process of the ulna is occasioned by
falls on the point of the elbow; or the bone may be snapped asunder
by powerful and sudden action of the triceps extensor cubiti, when
the arm is much and quickly bent. The injury is readily recognised;
there is inability to extend the forearm by its own muscular powers,
a considerable space is felt between the separated portions of the
bone, and the upper fragment is moveable as well as detached; these
marks of the injury are rendered more conspicuous by bending the joint.
Crepitation is produced by moving the limb when extended, and the
separated parts thereby approximated. Bloody swelling soon takes place,
large and extensive when bruising of the soft parts has been great—and
this is usually the case, in consequence of the injury being almost
always the result of direct violence. In some cases the process is
comminuted.
Compound fracture is rare, and likely to be productive of serious
consequences. I have treated and witnessed several cases. In one the
process was cut off by the patient falling out of bed on an earthenware
vessel, which broke under the limb. The joint is necessarily opened.
Violent inflammation soon commences, and can very seldom be kept
within moderate bounds. Discharge of increased and vitiated synovial
secretion takes place, followed by profuse and unhealthy suppuration.
The cartilages ulcerate, and then the bones. The cellular tissue
around becomes infiltrated, the parts swell and are discoloured,
and collections of matter form probably at more points than one;
perhaps there is a succession of abscesses. The condyles, and often a
portion of the shaft of the bone, are denuded by the suppuration, and
superficial necrosis results. Ultimately the patient grows hectic.
Amputation had to be resorted to in three of the cases which have come
under my observation, at the end of some weeks or months from the
receipt of the accident.
Union of the simple fracture will take place by bone, if the portions
be retained accurately and permanently in contact; but there is a risk
of the joint remaining stiff, and of re-separation being produced by
even slight violence. Union by ligament is as rapid as that by osseous
matter; and if the ligament is short, the arm is quite as useful.
Approximation of the broken surfaces is favoured by extension of the
elbow-joint, the triceps muscle being thus relaxed. The limb must not,
however, be but perfectly straight. The position is preserved by a
splint placed on the fore part of the limb, extending from the middle
of the arm to the lower part of the forearm, and retained by a roller
applied, not over-tight, from the fingers upwards. The application
of apparatus to the separated portion, with the view of forcing it
into contact with the shaft of the ulna, is useless. The figure of
8 bandage, and such like, are hurtful. Permanent relaxation of the
triceps, with prevention of motion, is sufficient. This is continued
for three or four weeks; by that time the fracture will in all
probability have united, and then gentle and gradual passive motion of
the joint is to be commenced.
In compound fracture the prognosis is always unfavourable. Means must
be taken to avert incited action—the limb must be properly placed
without delay, the edges of the wound accurately approximated, and
antiphlogistic measures pursued. Purulent collections must be opened
early. Rest of the joint is to be insured, and support afforded, by
bandaging and by the application of a splint. The patient will be
fortunate if he escape mutilation by the amputating knife; but when the
wound is trifling, and the parts not much lacerated or bruised, and
the treatment carefully conducted, a cure may be effected by the same
process as the simple fracture.
Fractures of the bones of the _forearm_, of one or both, are common;
generally simple. The _Radius_ may be broken at various points—at the
upper part—near its head—at the middle—most frequently near the distal
extremity. At the two first points the fracture will probably have
been produced by direct violence; but near the carpus, it is usually
the result of force applied to its extremity, as by falls in which the
weight of the body is thrown on the palm of the hand. The _ulna_ is
usually broken by force directly applied, as when the arm is brought in
contact with hard bodies in falls. By direct violence also, both bones
may give way about the middle, and at corresponding points: or, when
force is applied in the direction of the bones, the ulna may be found
broken near the wrist, and the radius near the elbow.
When one bone is broken, there is little displacement. The power of
motion is lost to a considerable degree, and there is some deformity,
but little or no shortening. The existence of fracture is ascertained
by tracing the bones with the fingers, and by gently rotating the limb;
the broken portions moving on each other produce distinct crepitation.
When the radius is broken near its middle, the forearm is kept
pronated, and the broken extremities are drawn towards the ulna; by
bringing the limb towards the supine position, the ends come together,
and the one bone is removed from the other. Fracture of the radius near
or through its distal extremity produces displacement of the wrist,
with great deformity; and this is increased by bloody effusion into
the sheaths of the tendons, and into the superficial cellular tissue.
In fracture of both bones, there is much deformity and shortening of
the limb; the power of moving the hand is lost; the muscles are bruised
and torn, and great swelling soon results.
There is little difficulty in remedying the slight displacement which
takes place when but one bone is broken, and in retaining the parts
in a favourable position. In children, occasionally, one of the bones
of the forearm is broken, the other being bent very considerably, so
as to cause great deformity.[62] When both have given way, slight
extension is required, and the forearm is placed in the middle state
between pronation and supination. Two pasteboard splints, softened in
hot water, and padded with tow, are applied, one on each aspect, from
a little above the elbow to over the fingers; the outer should extend
to the tips of the fingers, the inner need not pass the palm; they are
retained by a roller. In fracture of both bones, a wooden splint should
be retained on the outside of the limb for a few hours; but this
precaution is scarcely required when but one has suffered. Similar
treatment, along with attention to the wound, is required in compound
fracture.
The _metacarpal bones_ and _phalanges_ of the _fingers_ are subject to
fractures, both simple and compound. The metacarpal bone supporting
the little finger most frequently suffers from force applied to the
knuckle, as in pugilistic encounters. The other metacarpal bones are
occasionally broken from crushing of the hand, as by a heavy body
falling on it, or by its becoming entangled amongst machinery. The
injury is readily ascertained by moving the fingers, and pressing in
the course of the bone. On laying hold of the distal end of the bone
suspected to have given way, placing the fingers over the shaft, and
attempting slight motion, distinct crepitation is perceived. For the
cure, motion of the parts must be prevented for a sufficient time,
and inflammation warded off when threatened; there is a little or no
displacement, and consequently retentive apparatus can be almost wholly
dispensed with.
Simple fractures of the phalanges are recognised and treated by even
the most unlearned in the surgical profession. The deformity is so
striking as to render mistakes as to the nature of the accident
impossible; reduction is accomplished without difficulty; and the bones
are kept in their proper places by a small splint, either of wood or
pasteboard, placed on each side of the finger, and retained by a narrow
roller fixed by glue or starch.
Compound fractures of the phalanges are almost uniformly followed
by most violent inflammatory action in all the tissues, terminating
in disease of the joints, and in death of the tendinous and fibrous
tissues. The suppuration is profuse and unhealthy, and the infiltration
of the soft parts extensive. The diseased action not unfrequently
pervades the palm of the hand. In the great majority of cases,
necessity for amputation arrives sooner or later.
Fracture of the bones composing the _pelvis_ occasionally takes place,
but can be produced only by the application of great force, as by
a loaded vehicle passing over the body, or by a fall from a great
height. The accident is usually attended with serious injury of the
viscera contained in the pelvic cavity, or in that of the abdomen;
they may be either ruptured, or lacerated by sharp projecting spiculæ,
or merely bruised. The nature and extent of the injury is not easily
ascertained. There is great pain on motion of the body or of the limbs,
and usually extensive extravasation of blood in the soft parts; these
circumstances, along with the symptoms that may arise from internal
organs which have been injured, and a knowledge of the way in which the
injury was inflicted, lead to a strong suspicion of fracture of the
pelvis.
A portion of the crest of the ilium may be broken off, without serious
mischief ensuing, and may unite favourably. More extensive fractures,
deeper in the pelvis, as in the neighbourhood of the acetabulum, are
attended with excruciating pain on the least motion; in these the
existence of fracture may be suspected from the first, but the extent
of the injury is not fully known till after death. Fractures near the
symphysis, and of the rami, either of the os pubis or ischium, are
usually attended with injury to the bladder or to the urethra. Wound of
the bladder is almost necessarily fatal; extravasation of urine, with
all its fearful consequences, taking place in the loose cellular tissue
connecting the upper part of the viscus to the parietes of the pelvis,
and in the cellular tissue behind the peritoneum. The urethra may be
lacerated by the sharp edge of fractured bone, or it may be ruptured
by direct violence applied to itself. The latter case sometimes
accompanies partial diastasis of the symphysis, produced by the person
falling astride on a beam. Either injury separately is sufficiently
dangerous, and a patient with both is in a very precarious situation.
Great extravasation of blood takes place in the perineum, scrotum,
penis, and tops of the thighs, infiltration of urine quickly follows,
retention supervenes, abscesses form, and the patient perishes under a
train of symptoms already detailed when treating of the urinary organs.
The treatment is seldom satisfactory. Absolute rest must be procured,
and with this view the limbs are to be secured, and a broad band
passed round the pelvis. The state of the viscera must be attended
to; collections of matter must be evacuated; and all other untoward
symptoms must be actively met, and their consequences either adverted
or got over as far as possible.
Fracture of the _Sacrum_ is uncommon, as also detachment or fracture of
the _Coccyx_. The former accident happens in consequence of a fall from
a great height. There is little or no displacement whether the fracture
is transverse or longitudinal; sometimes there is splintering of the
bone. Acute pain is occasioned by motion of the limbs and of the trunk,
and by pressure over the injured part. Abscess is apt to follow, both
under the integument, and in the concavity of the bone, and the chief
duty of the surgeon is to prevent this if possible.
_Fractures of the Thigh._—On account of the thick muscular covering,
much attention is required to enable the surgeon to form an accurate
diagnosis regarding the effects of an injury of the upper part of
the femur. The necessity for ascertaining what the injury really is,
need not be insisted on. Consequences dreadful to the patient have
too often followed blunders in diagnosis. As in the accidents of the
shoulder-joint, some idea as to the exact injury may be formed by
ascertaining how the force was applied; but this, alone, may sometimes
mislead. Careful manipulation is to be chiefly trusted to.
Fracture within the capsule is met with most frequently in those
of advanced age, when the form of the neck of the bone has been
altered,—when it has become shorter, and attached less obliquely to the
shaft, as is sometimes the case; the bones, too, are then more brittle
than in earlier life. The accident often happens from slight force,
applied either to the farther end of the bone or to the trochanter, as
by a fall in going up or down stairs. Though the height often be not
great, yet the patient’s energies are weakened, he can make no effort
to break the fall, and the weight of the body is thrown on either the
fore or the back part of the trochanter. Though the fracture, in such
an accident, generally extends beyond the capsule, and the processes
are broken to a greater or less extent, yet occasionally the head of
the bone is separated by transverse break of the neck without farther
injury. This fracture occurs sometimes in those of middle life; and
even in children, separation of the head of the bone may on good
grounds be supposed occasionally to take place.
The marks of fracture within the capsular ligament are inability to
move the limb, pain about the joint on attempts being made to move it,
and shortening to a slight extent, as ascertained by comparison with
the sound limb; the patient being laid straight on his back, with the
crests of the ilia in a line, either the knees or the ankles are looked
to, and the comparative length of the limbs thereby observed. In some
cases, neither shortening nor deformity is apparent for some time after
the accident; there is merely want of power, and crepitation produced
by rotation; but retraction of the thigh would after a time inevitably
occur, and has done so when the nature of the injury was not at first
ascertained, nor proper treatment adopted. Most frequently there is
eversion of the toes, and to a considerable extent; sometimes there
is inversion, and this is owing to the limb either having been placed
in that position in falling, or having acquired it after the injury
has been inflicted. The rotators outward are the more powerful; the
limb naturally inclines outwards, and when in the recumbent posture,
the weight of the foot favours eversion. But in fracture the muscles
do not act as in a sound limb; and when the limb is once placed, the
patient will not by his own efforts alter the position. Thus it is that
inversion not unfrequently happens in this form of fracture, although
the opposite state is that which, from a consideration of the muscles
involved, is _à priori_ to be expected. In inversion the limb presents
somewhat of the appearance arising from the most common luxation; but
it possesses greater mobility, and has not the want of prominence
occasioned by displacement of the articulating extremity of the bone.
The facility of lengthening the member, and the crepitation felt on a
proper and more attentive manipulation, will remove all doubt.
On examining the injured hip, motion to some extent can be effected,
though with excruciating suffering to the patient. On stretching the
limb to its original length, and then rotating slightly, crepitation
can be felt by the hand, or heard by the ear, placed over the
trochanter major.
Fracture is much more frequently met with outside of the capsular
ligament, generally passing obliquely through the trochanters, and
communicating with fissures in various directions. Splinters are often
detached, and sometimes the small trochanter is broken off. Here, also,
there is inability to move the joint, violent pain on attempting it,
swelling and deformity of the member; there is shortening to a greater
extent than in the fracture within the capsule; there is free motion
in all directions; rotation, abduction, adduction, flexion, and often
extension, can be effected to an unnatural and unusual extent—the
degree of motion is no longer limited by the ligamentous attachments
of the head and neck of the bone. Here, also, the limb is most
frequently everted, but occasionally inverted; and that even when, from
the direction and extent of the fracture, neither the rotators outwards
nor the rotators inwards have been deprived of the power of acting.
In some cases of fracture, partly within and partly without the
capsule, all the usual marks of this injury are present, but it is
impossible to move the limb without employing considerable force. This
arises from the broken portions being jammed together, the neck of
the bone being, as it were, driven into and wedged in the cancellated
texture of the trochanter major, or of the upper part of the shaft.
The trochanter major is sometimes, though rarely, detached, without
separation of the neck of the bone from its shaft. In this injury there
is apparent lengthening of the limb, and flattening of the hip; the
patient is able to use the member, though not freely. Before swelling
has taken place, crepitation can be perceived on laying hold of the
trochanter whilst the limb is in motion; and the trochanter itself is
found to be in a slight degree moveable.
Fracture of the upper part of the shaft is attended with immediate and
great shortening; the limb is much misshapen, and lies on its outer
side, with the knee partially bent. The upper fragment of the bone
projects; the resistance to the action of the psoas and iliacus is in
a great measure done away with, consequently these muscles raise the
upper, whilst the lower end falls back and is drawn upwards behind
the other. In mismanaged cases, I have found on dissection the lower
end of the bone lying in the sacro-ischiatic notch, and a process
advancing very different from reparation—necrosis. The marks of this
accident are so conspicuous, that the surgeon is satisfied of what has
happened without enquiring for crepitation. Rapid and great swelling
takes place, if reduction and coaptation are not soon resorted to;
the bloodvessels are torn more and more by the ends of the bone, and
effusion of blood into the intermuscular cellular tissue is easy. Very
soon more extensive and dangerous swelling takes place, the result of
inflammatory action, accompanied with startings of the muscles and
greater retraction of the limb.
Fractures of the middle and lower thirds of the bone are not attended
with such great risk, and are more manageable in every way. There is
less disfiguration—the ends of the bone are not drawn by the action of
the muscles so far apart. The fracture is either oblique or transverse,
according to the direction of the force applied; and the bruising and
the degree of swelling are also dependent on the same circumstance.
From transverse fracture fissure sometimes extends, separating one or
other condyle.
[Illustration]
The reparation of injury in the upper part of the femur is opposed by a
variety of circumstances. Fractures of the neck of the bone are almost
uniformly met with in those whose powers of life have been nearly
exhausted. The whole injury is confined within the synovial capsule,
and the fibrous tissues which support that are unyielding, and but
slightly vascular; consequently, in fracture of the neck of the femur,
there occurs none of the swelling and increased vascularity of the
surrounding tissues, which follow fracture of other bones, or other
parts of this bone: no temporary callus can be formed; from this
cause, support of the disunited parts is deficient. The head and neck
of the bone are not so well supplied with bloodvessels as the other
parts; those arteries which pass along the ligamentum teres are the
chief support. And perhaps the influx of blood is not increased, in
consequence of injury, to such a degree as in other parts; in these,
when the surrounding parts are bruised or otherwise injured by fracture
in their immediate vicinity, their vascular action is soon excited,
the vessels ramifying on the periosteum are enlarged, and blood is
poured into the bone at all points. Instead of these salutary changes,
the secretion of synovia is increased, and a fluid, perhaps vitiated,
surrounds the bone, and is interposed betwixt its ends. There is also
difficulty in performing accurate adaptation of the broken ends, and
in securing retention so long as is necessary for union; the limb has
a tendency to retraction; in readjusting the apparatus, when become
loose, the broken surfaces are rubbed on each other, and thus any union
which may have been in progress is interfered with. In consequence of
all this, union seldom takes place by bone; it has occurred, and will
occur, in favourable cases, when the fibrous investment of the neck
of the bone does not happen to be torn, and under good treatment. Two
sketches which, through the kindness of Sir Astley Cooper, I am enabled
to introduce here, show the union complete: the patient from whom this
was taken had received other severe injuries, and very little attention
had been paid to that of the hip. But it is an undeniable fact, that
the circumstances which of a necessity follow fracture at this point
are inimical to its effective reparation. The broken ends are sometimes
united by fibrous tissue. Most frequently no union takes place, and the
broken surfaces gradually become smooth, polished like a bit of china,
and adapted to each other; a false joint is formed, but at the same
time the capsular ligament, and tissues exterior to it, are thickened
and strengthened, and so the unnatural motion is limited. The rough
and irregular portions of the bone are absorbed, and the neck of the
femur, from interstitial absorption, almost disappears; its diminished
head lies in and is attached to the cotyloid cavity, and is rubbed
upon by the opposed surface of the shaft. Shortening of the limb is
an inevitable result: at first the power of motion is slight, and the
support afforded to the body weak; in course of time the member becomes
strong and useful.