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OXFORD MEDICAL PUBLICATIONS
MANUAL OF SURGERY
BY
ALEXIS THOMSON, F.R.C.S.Ed. AND Eng.
_PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
SURGEON EDINBURGH ROYAL INFIRMARY
AND
ALEXANDER MILES, F.R.C.S.Ed.
SURGEON EDINBURGH ROYAL INFIRMARY
VOLUME SECOND
EXTREMITIES--HEAD--NECK
_SIXTH EDITION REVISED AND ENLARGED_
_WITH 288 ILLUSTRATIONS_
LONDON
HENRY FROWDE and HODDER & STOUGHTON
THE _LANCET_ BUILDING
1 & 2 BEDFORD STREET, STRAND, W.C.2
First Edition 1904
Second Edition 1907
Third Edition 1909
Fourth Edition 1912
" " Second Impression 1913
Fifth Edition 1915
" " Second Impression 1919
Sixth Edition 1921
PRINTED IN GREAT BRITAIN BY
MORRISON AND GIBB LTD., EDINBURGH
CONTENTS
PAGE
CHAPTER I
INJURIES OF BONES 1
CHAPTER II
INJURIES OF JOINTS 32
CHAPTER III
INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM 44
CHAPTER IV
INJURIES IN THE REGION OF THE ELBOW AND FOREARM 79
CHAPTER V
INJURIES IN THE REGION OF THE WRIST AND HAND 102
CHAPTER VI
INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH 122
CHAPTER VII
INJURIES IN THE REGION OF THE KNEE AND LEG 155
CHAPTER VIII
INJURIES IN REGION OF ANKLE AND FOOT 185
CHAPTER IX
DISEASES OF INDIVIDUAL JOINTS 201
CHAPTER X
DEFORMITIES OF THE EXTREMITIES 241
CHAPTER XI
THE SCALP 319
CHAPTER XII
THE CRANIUM AND ITS CONTENTS 328
CHAPTER XIII
INJURIES OF THE SKULL 361
CHAPTER XIV
DISEASES OF THE BRAIN AND MEMBRANES 373
CHAPTER XV
DISEASES OF THE CRANIAL BONES 406
CHAPTER XVI
THE VERTEBRAL COLUMN AND SPINAL CORD 411
CHAPTER XVII
DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD 431
CHAPTER XVIII
DEVIATIONS OF THE VERTEBRAL COLUMN 461
CHAPTER XIX
THE FACE, ORBIT, AND LIPS 474
CHAPTER XX
THE MOUTH, FAUCES, AND PHARYNX 496
CHAPTER XXI
THE JAWS, INCLUDING THE TEETH AND GUMS 507
CHAPTER XXII
THE TONGUE 528
CHAPTER XXIII
THE SALIVARY GLANDS 543
CHAPTER XXIV
THE EAR 553
CHAPTER XXV
THE NOSE AND NASO-PHARYNX 567
CHAPTER XXVI
THE NECK 582
CHAPTER XXVII
THE THYREOID GLAND 604
CHAPTER XXVIII
THE OESOPHAGUS 616
CHAPTER XXIX
THE LARYNX, TRACHEA, AND BRONCHI 634
INDEX 645
LIST OF ILLUSTRATIONS
FIG. PAGE
1. Multiple Fracture of both Bones of Leg 4
2. Radiogram showing Comminuted Fracture of both Bones of 5
Forearm
3. Oblique Fracture of Tibia; with partial Separation of 6
Epiphysis of Upper End of Fibula; and Incomplete Fracture
of Fibula in Upper Third
4. Excess of Callus after Compound Fracture of Bones of 9
Forearm
5. Multiple Fractures of both Bones of Forearm showing 11
Mal-union
6. Radiogram of Un-united Fracture of Shaft of Ulna 13
7. Excessive Callus Formation after Infected Compound 27
Fracture of both Bones of Forearm
8. Partial Separation of Epiphysis, with Fracture running 29
into Diaphysis
9. Complete Separation of Epiphysis 29
10. Partial Separation with Fracture of Epiphysis 29
11. Complete Separation with Fracture of Epiphysis 29
12. Os Innominatum showing new Socket formed after 41
Old-standing Dislocation
13. Oblique Fracture of Right Clavicle in Middle Third, 45
united
14. Fracture of Acromial End of Clavicle 46
15. Adhesive Plaster applied for Fracture of Clavicle 49
16. Forward Dislocation of Sternal End of Right Clavicle 51
17. Diagram of most common varieties of Dislocation of the 53
Shoulder
18. Sub-coracoid Dislocation of Right Shoulder 55
19. Sub-coracoid Dislocation of Humerus 56
20. Kocher's Method of reducing Sub-coracoid 57
Dislocation--First Movement
21. Kocher's Method--Second Movement 58
22. Kocher's Method--Third Movement 59
23. Miller's Method of reducing Sub-coracoid 60
Dislocation--First Movement
24. Miller's Method--Second Movement 61
25. Dislocation of Shoulder with Fracture of Neck of Humerus 64
26. Transverse Fracture of Scapula 68
27. Fracture of Surgical Neck of Humerus, united with 70
Angular Displacement
28. Impacted Fracture of Neck of Humerus 71
29. Ambulatory Abduction Splint for Fracture of Humerus 72
30. Radiogram of Separation of Upper Epiphysis of Humerus 73
31. "Cock-up" Splint 77
32. Gooch Splints for Fracture of Shaft of Humerus; and
Rectangular Splint to secure Elbow 77
33. Radiogram of Supra-condylar Fracture of Humerus in a 81
Child
34. Radiogram of T-shaped Fracture of Lower End of Humerus 83
35. Radiogram of Fracture of Olecranon Process 86
36. Backward Dislocation of Elbow in a Boy 89
37. Bony Outgrowth in relation to insertion of Brachialis 90
Muscle
38. Radiogram of Incomplete Backward Dislocation of Elbow 91
39. Forward Dislocation of Elbow, with Fracture of Olecranon 93
40. Radiogram of Forward Dislocation of Head of Radius, with 95
Fracture of Shaft of Ulna
41. Greenstick Fracture of both Bones of the Forearm 98
42. Gooch Splints for Fracture of both Bones of Forearm 99
43. Colles' Fracture showing Radial Deviation of Hand 103
44. Colles' Fracture showing undue prominence of Ulnar 103
Styloid
45. Radiogram showing the Line of Fracture and Upward 104
Displacement of the Radial Styloid in Colles' Fracture
46. Radiogram of Chauffeur's Fracture 107
47. Radiogram of Smith's Fracture 108
48. Manus Valga following Separation of Lower Radial 109
Epiphysis in Childhood
49. Radiogram showing Fracture of Navicular (Scaphoid) Bone 111
50. Dorsal Dislocation of Wrist at Radio-carpal Articulation 113
51. Radiogram showing Forward Dislocation of Navicular Bone 114
52. Extension Apparatus for Oblique Fracture of Metacarpals 117
53. Radiogram of Bennett's Fracture of Base of Metacarpal 118
of Right Thumb
54. Splints for Bennett's Fracture 119
55. Multiple Fracture of Pelvis through Horizontal and 123
Descending Rami of both Pubes, and Longitudinal Fracture
of left side of Sacrum
56. Fracture of Left Iliac Bone; and of both Pubic Arches 124
57. Many-tailed Bandage and Binder for Fracture of Pelvic 125
Girdle
58. Nelaton's Line 128
59. Bryant's Line 129
60. Section through Hip-Joint to show Epiphyses at Upper 130
End of Femur, and their relation to the Joint
61. Fracture through Narrow Part of Neck of Femur on Section 131
62. Impacted Fracture through Narrow Part of Neck of Femur 132
63. Fracture of Neck of Right Femur, showing Shortening, 133
Abduction, and Eversion of Limb
64. Fracture of Narrow Part of Neck of Femur 134
65. Coxa Vara following Fracture of Neck of Femur in a Child 136
66. Non-impacted Fracture through Base of Neck 137
67. Fracture through Base of Neck of Femur with Impaction 137
into the Trochanters
68. Non-impacted Fracture through Base of Neck 138
69. Fracture of the Femur just below the small Trochanter, 140
united, showing Flexion and Lateral Rotation of Upper
Fragment
70. Adjustable Double-inclined Plane 141
71. Diagram of the most Common Dislocations of the Hip 142
72. Dislocation of Right Femur on to Dorsum Ilii 143
73. Dislocation on to Dorsum Ilii 144
74. Dislocation into the Vicinity of the Ischiatic Notch 145
75. Longitudinal Section of Femur showing Fracture of Shaft 148
with Overriding of Fragments
76. Radiogram of Steinmann's Apparatus applied for Direct 150
Extension to the Femur
77. Hodgen's Splint 151
78. Long Splint with Perineal Band 152
79. Fracture of Thigh treated by Vertical Extension 153
80. Section of Knee-joint showing Extent of Synovial Cavity 156
81. Extension applied by means of Ice-tong Callipers for
Fracture of Femur 158
82. Radiogram of Separation of Lower Epiphysis of Femur, 160
with Backward Displacement of the Diaphysis
83. Separation of Lower Epiphysis of Femur, with Fracture 161
of Lower End of Diaphysis
84. Radiogram of Fracture of Head of Tibia and upper Third 163
of Fibula
85. Radiogram illustrating Schlatter's Disease 164
86. Diagram of Longitudinal Tear of Posterior End of Right 171
Medial Semilunar Meniscus
87. Radiogram of Fracture of Patella 173
88. Fracture of Patella, showing wide Separation of Fragments 175
89. Radiogram of Transverse Fracture of both Bones of Leg 178
by Direct Violence
90. Radiogram of Oblique Fracture of both Bones of Leg by 178
Indirect Violence
91. Box Splint for Fractures of Leg 180
92. Box Splint applied 181
93. Section through Ankle-joint showing relation of 186
Epiphyses to Synovial Cavity
94. Radiogram of Pott's Fracture, with Lateral Displacement 187
of Foot
95. Ambulant Splint of Plaster of Paris 189
96. Dupuytren's Splint applied to Correct Eversion of Foot 190
97. Syme's Horse-shoe Splint applied to Correct Backward 191
Displacement of Foot
98. Radiogram of Fracture of Lower End of Fibula, with 192
Separation of Lower Epiphysis of Tibia
99. Radiogram of Backward Dislocation of Ankle 195
100. Compound Dislocation of Talus 197
101. Radiogram of Fracture-Dislocation of Talus 198
102. Radiogram of Dislocation of Toes 199
103. Arthropathy of Shoulder in Syringomyelia 203
104. Radiogram of Specimen of Arthropathy of Shoulder in 204
Syringomyelia
105. Radiogram showing Multiple partially Ossified 205
Cartilaginous Loose Bodies in Shoulder-joint
106. Diffuse Tuberculous Thickening of Synovial Membrane of 206
Elbow
107. Contracture of Elbow and Wrist following a Burn in 207
Childhood
108. Advanced Tuberculous Disease of Acetabulum with Caries 210
and Perforation into Pelvis
109. Early Tuberculous Disease of Right Hip-joint in a Boy 212
110. Disease of Left Hip; showing Moderate Flexion and 213
Lordosis
111. Disease of Left Hip; Disappearance of Lordosis on 213
further Flexion of the Hip
112. Disease of Left Hip; Exaggeration of Lordosis 214
113. Thomas' Flexion Test, showing Angle of Flexion at 214
Diseased Hip
114. Tuberculous Disease of Left Hip: Third Stage 215
115. Advanced Tuberculous Disease of Left Hip-joint in a Girl 216
116. Extension by Adhesive Plaster and Weight and Pulley 220
117. Stiles' Double Long Splint to admit of Abduction of 221
Diseased Limb
118. Thomas' Hip-splint applied for Disease of Right Hip 222
119. Arthritis Deformans, showing erosion of Cartilage and 225
lipping of Articular Edge of Head of Femur
120. Upper End of Femur in advanced Arthritis Deformans 226
of Hip
121. Femur in advanced Arthritis Deformans of Hip and Knee 227
Joints
122. Tuberculous Synovial Membrane of Knee 230
123. Lower End of Femur from an Advanced Case of Tuberculous 231
Arthritis of the Knee
124. Advanced Tuberculous Disease of Knee, with Backward 233
Displacement of Tibia
125. Thomas' Knee-splint applied 236
126. Tuberculous Disease of Right Ankle 239
127. Female Child showing the results of Poliomyelitis 243
affecting the Left Lower Extremity
128. Radiogram of Double Congenital Dislocation of Hip in 249
a Girl
129. Innominate Bone and Upper End of Femur from a case of 250
Congenital Dislocation of Hip
130. Congenital Dislocation of Left Hip in a Girl 251
131. Contracture Deformities of Upper and Lower Limbs 255
resulting from Spastic Cerebral Palsy in Infancy
132. Rachitic Coxa Vara 258
133. Coxa Vara, showing Adduction Curvature of Neck of Femur 260
associated with Arthritis of the Hip and Knee
134. Bilateral Coxa Vara, showing Scissors-leg Deformity 260
135. Genu Valgum and Genu Varum 265
136. Female Child with Right-sided Genu Valgum, the result of 266
Rickets
137. Double Genu Valgum; and Rickety Deformities of Arms 267
138. Radiogram of Case of Double Genu Valgum in a Child 268
139. Genu Valgum in a Child. Patient standing 269
140. Genu Valgum. Same Patient as Fig. 139, sitting 270
141. Bow-knee in Rickety Child 271
142. Bilateral Congenital Club-foot in an Infant 274
143. Radiogram of Bilateral Congenital Club-foot in an Infant 275
144. Congenital Talipes Equino-varus in a Man 277
145. Bilateral Pes Equinus in a Boy 280
146. Extreme form of Pes Equinus in a Girl 281
147. Skeleton of Foot from case of Pes Equinus due to 282
Poliomyelitis
148. Pes Calcaneo-valgus with excessive arching of Foot 284
149. Pes Calcaneo-valgus, the result of Poliomyelitis 285
150. Pes Cavus in Association with Pes Equinus, the Result 286
of Poliomyelitis
151. Radiogram of Foot of Adult, showing Changes in the 286
Bones in Pes Cavus
152. Adolescent Flat-Foot 287
153. Flat-Foot, showing Loss of Arch 288
154. Imprint of Normal and of Flat Foot 290
155. Bilateral Pes Valgus and Hallux Valgus in a Girl 293
156. Radiogram of Spur on Under Aspect of Calcaneus 295
157. Radiogram of Hallux Valgus 296
158. Radiogram of Hallux Varus or Pigeon-Toe 298
159. Hallux Rigidus and Flexus in a Boy 299
160. Hammer-Toe 300
161. Section of Hammer-Toe 301
162. Congenital Hypertrophy of Left Lower Extremity in a Boy 302
163. Supernumerary Great Toe 303
164. Congenital Elevation of Left Scapula in a Girl: also 304
shows Hairy Mole over Sacrum
165. Winged Scapula 305
166. Arrested Growth and Wasting of Tissues of Right Upper 307
Extremity
167. Lower End of Humerus from case of Cubitus Varus 309
168. Intra-Uterine Amputation of Forearm 310
169. Radiogram of Arm of Patient shown in Fig. 168 310
170. Congenital Absence of Left Radius and Tibia in a Child 311
171. Club-Hand, the Result of Imperfect Development of Radius 312
172. Congenital Contraction of Ring and Little Fingers 314
173. Dupuytren's Contraction 315
174. Splint used after Operation for Dupuytren's Contraction 316
175. Supernumerary Thumb 317
176. Trigger Finger 318
177. Multiple Wens 324
178. Adenoma of Scalp 325
179. Relations of the Motor and Sensory Areas to the 330
Convolutions and to Chiene's Lines
180. Diagram of the Course of Motor and Sensory Nerve Fibres 333
181. Chiene's Method of Cerebral Localisation 336
182. To illustrate the Site of Various Operations on the Skull 337
183. Localisation of Site for Introduction of Needle in Lumbar 338
Puncture
184. Contusion and Laceration of Brain 343
185. Charts of Pyrexia in Head Injuries 348
186. Relations of the Middle Meningeal Artery and Lateral 353
Sinus to the Surface as indicated by Chiene's Lines
187. Extra-Dural Clot resulting from Haemorrhage from the 354
Middle Meningeal Artery
188. Depressed Fracture of Frontal Bones with Fissured 365
Fracture
189. Depressed and Comminuted Fracture of Right Parietal 365
Bone: Pond Fracture
190. Pond Fracture of Left Frontal Bone, produced during 366
Delivery
191. Transverse Fracture through Middle Fossa of Base of Skull 368
192. Diagram of Extra-Dural Abscess 374
193. Pott's Puffy Tumour in case of Extra-Dural Abscess 375
following Compound Fracture of Orbital Margin
194. Diagram of Sub-Dural Abscess 376
195. Diagram illustrating sequence of Paralysis, caused by 380
Abscess in Temporal Lobe
196. Chart of case of Sinus Phlebitis following Middle Ear 384
Disease
197. Occipital Meningocele 388
198. Frontal Hydrencephalocele 389
199. Naevus at Root of Nose, simulating Cephalocele 390
200. Hydrocephalus in a Child 391
201. Patient suffering from Left Facial Paralysis 402
202. Skull of Woman illustrating the appearances of Tertiary 408
Syphilis of Frontal Bone--Corona Veneris--in the Healed
Condition
203. Sarcoma of Orbital Plate of Frontal Bone in a Child at 409
Age of 11 months and 18 months
204. Destruction of Bones of Left Orbit, caused by Rodent 410
Cancer
205. Distribution of the Segments of the Spinal Cord 417
206. Attitude of Upper Extremities in Traumatic Lesions of 418
the Sixth Cervical Segment
207. Compression Fracture of Bodies of Third and Fourth 426
Lumbar Vertebrae
208. Fracture-Dislocation of Ninth Thoracic Vertebra 428
209. Fracture of Odontoid Process of Axis Vertebra 429
210. Tuberculous Osteomyelitis affecting several Vertebrae at 432
Thoracico-Lumbar Junction
211. Osseous Ankylosis of Bodies (_a_) of Dorsal Vertebrae, 434
(_b_) of Lumbar Vertebrae following Pott's Disease
212. Radiogram of Museum Specimen of Pott's Disease in a Child 435
213. Radiogram of Child's Thorax showing Spindle-shaped 437
Shadow at Site of Pott's Disease of Fourth, Fifth, and
Sixth Thoracic Vertebrae
214. Attitude of Patient suffering from Tuberculous Disease 441
of the Cervical Spine
215. Thomas' Double Splint for Tuberculous Disease of the 442
Spine
216. Hunch-back Deformity following Pott's Disease of Thoracic 443
Vertebrae
217. Attitude in Pott's Disease of Thoracico-Lumbar Region of 444
Spine
218. Arthritis Deformans of Spine 449
219. Meningo-Myelocele of Thoracico-Lumbar Region 454
220. Meningo-Myelocele of Cervical Spine 454
221. Meningo-Myelocele in Thoracic Region 456
222. Tail-like Appendage over Spina Bifida Occulta in a Boy 457
223. Congenital Sacro-Coccygeal Tumour 458
224. Scoliosis following upon Poliomyelitis affecting Right 463
Arm and Leg
225. Rickety Scoliosis in a Child 464
226. Vertebrae from case of Scoliosis showing Alteration in 466
Shape of Bones
227. Adolescent Scoliosis in a Girl 467
228. Scoliosis with Primary Curve in Thoracic Region 468
229. Scoliosis showing Rotation of Bodies of Vertebrae, and 469
widening of Intercostal Spaces on side of Convexity
230. Diagram of Attitudes in Klapp's Four-Footed Exercises for 473
Scoliosis
231. Head of Human Embryo about 29 days old 475
232. Simple Hare-Lip 476
233. Unilateral Hare-Lip with Cleft Alveolus 477
234. Double Hare-Lip in a Girl 478
235. Double Hare-Lip with Projection of the Os Incisivum 479
236. Asymmetrical Cleft Palate extending through Alveolar 480
Process on Left Side
237. Illustrating the Deformities caused by Lupus Vulgaris 483
238. Sarcoma of Orbit causing Exophthalmos and Downward 488
Displacement of the Eye, and Projecting in Temporal
Region
239. Sarcoma of Eyelid in Child 489
240. Dermoid Cyst at Outer Angle of Orbital Margin 490
241. Macrocheilia 492
242. Squamous Epithelioma of Lower Lip in a Man 493
243. Advanced Epithelioma of Lower Lip 494
244. Recurrent Epithelioma in Glands of Neck adherent to 495
Mandible
245. Cancrum Oris 497
246. Perforation of Palate, the Result of Syphilis, and Gumma 498
of Right Frontal Bone
247. Cario-necrosis of Mandible 510
248. Diffuse Syphilitic Disease of Mandible 512
249. Epulis of Mandible 513
250. Sarcoma of the Maxilla 515
251. Malignant Disease of Left Maxilla 516
252. Dentigerous Cyst of Mandible containing Rudimentary Tooth 517
253. Osseous Shell of Myeloma of Mandible 518
254. Multiple Fracture of Mandible 520
255. Four-Tailed Bandage applied for Fracture of Mandible 522
256. Defective Development of Mandible from Fixation of Jaw 526
due to Tuberculous Osteomyelitis in Infancy
257. Leucoplakia of the Tongue 531
258. Papillomatous Angioma of Left Side of Tongue in a Woman 538
259. Dermoid Cyst in Middle Line of Neck 539
260. Temporary Unilateral Paralysis of Tongue 541
261. Series of Salivary Calculi 545
262. Acute Suppurative Parotitis 546
263. Mixed Tumour of Parotid 550
264. Mixed Tumour of the Parotid of over twenty years' 551
duration
265. Acute Mastoid Disease showing Oedema and Projection of 565
Auricle
266. Rhinophyma or Lipoma Nasi 569
267. The Outer Wall of Left Nasal Chamber after removal of 571
the Middle Turbinated Body
268. Congenital Branchial Cyst in a Woman 584
269. Bilateral Cervical Ribs 586
270. Transient Wry-Neck 587
271. Congenital Wry-Neck in a Boy 589
272. Congenital Wry-Neck seen from behind to show Scoliosis 590
273. Recovery from Suicidal Cut-Throat after Low Tracheotomy 596
and Gastrostomy
274. Hygroma of Neck 599
275. Lympho-Sarcoma of Neck 600
276. Branchial Carcinoma 601
277. Parenchymatous Goitre in a Girl 606
278. Larynx and Trachea surrounded by Goitre 607
279. Section of Goitre shown in Fig. 278 to illustrate 607
Compression of Trachea
280. Multiple Adenomata of Thyreoid in a Woman 611
281. Cyst of Left Lobe of Thyreoid 612
282. Exophthalmic Goitre 614
283. Radiogram of Safety-Pin impacted in the Gullet and 620
Perforating the Larynx
284. Denture Impacted in Oesophagus 621
285. Radiogram, after swallowing an Opaque Meal, in a Man 626
suffering from Malignant Stricture of Lower End of Gullet
286. Diverticulum of the Oesophagus at its Junction with the 627
Pharynx
287. Larynx from case of Sudden Death due to Oedema of 637
Ary-Epiglottic Folds
288. Papilloma of Larynx 641
MANUAL OF SURGERY
CHAPTER I
INJURIES OF BONES
Contusions--Wounds--FRACTURES: _Pathological_; _Traumatic_;
_Varieties_--Simple fractures--Compound fractures--Repair of
fractures--Interference with repair--Gun-shot
fractures--SEPARATION OF EPIPHYSES.
The injuries to which a bone is liable are Contusions, Open Wounds,
and Fractures.
#Contusions of Bone# are almost of necessity associated with a similar
injury of the overlying soft parts. The mildest degree consists in a
bruising of the periosteum, which is raised from the bone by an
effusion of blood, constituting a _haematoma of the periosteum_. This
may be absorbed, or it may give place to a persistent thickening of
the bone--_traumatic node_.
#Open Wounds of Bone# of the incised and contused varieties are
usually produced by sabres, axes, butcher's knives, scythes, or
circular saws. Punctured wounds are caused by bayonets, arrows, or
other pointed instruments. They are all equivalent to compound,
incomplete fractures.
FRACTURES
A fracture may be defined as a sudden solution in the continuity of a
bone.
PATHOLOGICAL FRACTURES
A pathological fracture has as its primary cause some diseased state
of the bone, which permits of its giving way on the application of a
force which would be insufficient to break a healthy bone. It cannot
be too strongly emphasised that when a bone is found to have been
broken by a slight degree of violence, the presence of some
pathological condition should be suspected, and a careful examination
made with the X-rays and by other means, before arriving at a
conclusion as to the cause of the fracture. Many cases are on record
in which such an accident has first drawn attention to the presence of
a new-growth, or other serious lesion in the bone. The following
conditions, which are more fully described with diseases of bone, may
be mentioned as the causes of pathological fractures.
_Atrophy_ of bone may proceed to such an extent in old people, or in
those who for long periods have been bed-ridden, that slight violence
suffices to determine a fracture. This most frequently occurs in the
neck of the femur in old women, the mere catching of the foot in the
bedclothes while the patient is turning in bed being sometimes
sufficient to cause the bone to give way. Atrophy from the pressure of
an aneurysm or of a simple tumour may erode the whole thickness of a
bone, or may thin it out to such an extent that slight force is
sufficient to break it. In general paralysis, and in the advanced
stages of locomotor ataxia and other chronic diseases of the nervous
system, an atrophy of all the bones sometimes takes place, and may
proceed so far that multiple fractures are induced by comparatively
slight causes. They occur most frequently in the ribs or long bones of
the limbs, are not attended with pain, and usually unite
satisfactorily, although with an excessive amount of callus.
Attendants and nurses, especially in asylums, must be warned against
using force in handling such patients, as otherwise they may be
unfairly blamed for causing these fractures.
Among diseases which affect the skeleton as a whole and render the
bones abnormally fragile, the most important are rickets,
osteomalacia, and fibrous osteomyelitis. In these conditions multiple
pathological fractures may occur, and they are prone to heal with
considerable deformity. In osteomalacia, the bones are profoundly
altered, but they are more liable to bend than to break; in rickets
the liability is towards greenstick fractures.
Of the diseases affecting individual bones and predisposing them to
fracture may be mentioned suppurative osteomyelitis, hydatid cysts,
tuberculosis, syphilitic gummata, and various forms of new-growth,
particularly sarcoma and secondary cancer. It is not unusual for the
sudden breaking of the bone to be the first intimation of the presence
of a new-growth. In adolescents, fibrous osteomyelitis affecting a
single bone, and in adults, secondary cancer, are the commonest local
causes of pathological fracture.
_Intra-uterine fractures_ and fractures occurring _during birth_ are
usually associated with some form of violence, but in the majority of
cases the foetus is the subject of constitutional disease which
renders the bones unduly fragile.
TRAUMATIC FRACTURES
Traumatic fractures are usually the result of a severe force acting
from without, although sometimes they are produced by muscular
contraction.
When the bone gives way at the point of impact of the force, the
violence is said to be _direct_, and a "fracture by compression"
results, the line of fracture being as a rule transverse. The soft
parts overlying the fracture are more or less damaged according to the
weight and shape of the impinging body. Fracture of both bones of the
leg from the passage of a wheel over the limb, fracture of the shaft
of the ulna in warding off a stroke aimed at the head, and fracture of
a rib from a kick, are illustrative examples of fractures by direct
violence.
When the force is transmitted to the seat of fracture from a distance,
the violence is said to be _indirect_, and the bone is broken by
"torsion" or by "bending." In such cases the bone gives way at its
weakest point, and the line of fracture tends to be oblique. Thus both
bones of the leg are frequently broken by a person jumping from a
height and landing on the feet, the tibia breaking in its lower third,
and the fibula at a higher level. Fracture of the clavicle in its
middle third, or of the radius at its lower end, from a fall on the
outstretched hand, are common accidents produced by indirect violence.
The ribs also may be broken by indirect violence, as when the chest is
crushed antero-posteriorly and the bones give way near their angles.
In fractures by indirect violence the soft parts do not suffer by the
violence causing the fracture, but they may be injured by displacement
of the fragments.
In fractures by _muscular action_ the bone is broken by "traction" or
"tearing." The sudden and violent contraction of a muscle may tear off
an epiphysis, such as the head of the fibula, the anterior superior
iliac spine, or the coronoid process of the ulna; or a bony process
may be separated, as, for example, the tuberosity of the calcaneus,
the coracoid process of the scapula, or the larger tubercle (great
tuberosity) of the humerus. Long bones also may be broken by muscular
action. The clavicle has snapped across during the act of swinging a
stick, the humerus in throwing a stone, and the femur when a kick has
missed its object. Fractures of ribs have occurred during fits of
coughing and in the violent efforts of parturition.
Before concluding that a given fracture is the result of muscular
action, it is necessary to exclude the presence of any of the diseased
conditions that lead to pathological fracture.
Although the force acting upon the bone is the primary factor in the
production of fractures, there are certain subsidiary factors to be
considered. Thus the age of the patient is of importance. During
infancy and early childhood, fractures are less common than at any
other period of life, and are usually transverse, incomplete, and of
the nature of bends. During adult life, especially between the ages of
thirty and forty, the frequency of fractures reaches its maximum. In
aged persons, although the bones become more brittle by the marrow
spaces in their interior becoming larger and filled with fat,
fractures are less frequent, doubtless because the old are less
exposed to such violence as is likely to produce fracture.
Males, from the nature of their occupations and recreations, sustain
fractures more frequently than do females; in old age, however,
fractures are more common in women than in men, partly because their
bones are more liable to be the seat of fatty atrophy from senility
and disease, and partly because of their clothing--a long skirt--they
are more exposed to unexpected or sudden falls.
[Illustration: FIG. 1.--Multiple Fracture of both Bones of Leg.]
#Clinical Varieties of Fractures.#--The most important subdivision of
fractures is that into simple and compound.
In a _simple_ or subcutaneous fracture there is no communication,
directly or indirectly, between the broken ends of the bone and the
surface of the skin. In a _compound_ or open fracture, on the other
hand, such a communication exists, and, by furnishing a means of
entrance for bacteria, may add materially to the gravity of the
injury.
A simple fracture may be complicated by the existence of a wound of
the soft parts, which, however, does not communicate with the broken
bone.
Fractures, whether simple or compound, fall into other clinical
groups, according to (1) the degree of damage done to the bone, (2)
the direction of the break, and (3) the relative position of the
fragments.
(1) _According to the Degree of Damage done to the Bone._--A fracture
may be incomplete, for example in _greenstick fractures_, which occur
only in young persons--usually below the age of twelve--while the
bones are still soft and flexible. They result from forcible bending
of the bone, the osseous tissue on the convexity of the curve giving
way, while that on the concavity is compressed. The clavicle and the
bones of the forearm are those most frequently the seat of greenstick
fracture (Fig. 41). _Fissures_ occur on the flat bones of the skull,
the pelvic bones, and the scapula; or in association with other
fractures in long bones, when they often run into joint surfaces.
_Depressions_ or indentations are most common in the bones of the
skull.
The bone at the seat of fracture may be broken into several pieces,
constituting a _comminuted_ fracture. This usually results from severe
degrees of direct violence, such as are sustained in railway or
machinery accidents, and in gun-shot injuries (Fig. 2).
[Illustration: FIG. 2.--Radiogram of Comminuted Fracture of both Bones
of Forearm.]
_Sub-periosteal_ fractures are those in which, although the bone is
completely broken across, the periosteum remains intact. These are
common in children, and as the thick periosteum prevents displacement,
the existence of a fracture may be overlooked, even in such a large
bone as the femur.
A bone may be broken at several places, constituting a _multiple_
fracture (Fig. 1).
_Separation of bony processes_, such as the coracoid process, the
epicondyle of the humerus, or the tuberosity of the calcaneus, may
result from muscular action or from direct violence. _Separation of
epiphyses_ will be considered later.
(2) _According to the Direction of the Break._--_Transverse_ fractures
are those in which the bone gives way more or less exactly at right
angles to its long axis. These usually result from direct violence or
from end-to-end pressure. _Longitudinal_ fractures extending the
greater part of the length of a long bone are exceedingly rare.
_Oblique_ fractures are common, and result usually from indirect
violence, bending, or torsion (Fig. 3). _Spiral_ fractures result from
forcible torsion of a long bone, and are met with most frequently in
the tibia, femur, and humerus.
[Illustration: FIG. 3.--Showing (1) Oblique fracture of Tibia; (2)
Oblique fracture with partial separation of Epiphysis of upper end of
Fibula; (3) Incomplete fracture of Fibula in upper third. Result of
railway accident. Boy aet. 16.]
(3) _According to the Relative Position of the Fragments._--The bone
may be completely broken across, yet its ends remain in apposition,
in which case there is said to be _no displacement_. There may be an
_angular_ displacement--for example, in greenstick fracture. In
transverse fractures of the patella or of the olecranon there is often
_distraction_ or pulling apart of the fragments (Fig. 35). The broken
ends, especially in oblique fractures, may _override_ one another, and
so give rise to shortening of the limb (Fig. 2). Where one fragment is
acted upon by powerful muscles, a _rotatory_ displacement may take
place, as in fracture of the radius above the insertion of the
pronator teres, or of the femur just below the small trochanter. The
fragments may be _depressed_, as in the flat bones of the skull or the
nasal bones. At the cancellated ends of the long bones, particularly
the upper end of the femur and humerus, and the lower end of the
radius, it is not uncommon for one fragment to be _impacted_ or wedged
into the substance of the other (Fig. 28).
_Causes of Displacement._--The factors which influence displacement
are chiefly mechanical in their action. Thus the direction and nature
of the fracture play an important part. Transverse fractures with
roughly serrated ends are less liable to displacement than those which
are oblique with smooth surfaces. The direction of the causative force
also is a dominant factor in determining the direction in which one or
both of the fragments will be displaced. Gravity, acting chiefly upon
the distal fragment, also plays a part in determining the
displacement--for example, in fractures of the thigh or of the leg,
where the lower segment of the limb rolls outwards, and in fractures
of the shaft of the clavicle, where the weight of the arm carries the
shoulder downwards, forwards, and medially. After the break has taken
place and the force has ceased to act, displacement may be produced by
rough handling on the part of those who render first aid, the careless
or improper application of splints or bandages, or by the weight of
the bedclothes.
In certain situations the contraction of unopposed, or of unequally
opposed, groups of muscles plays a part in determining displacement.
For example, in fracture immediately below the lesser trochanter of
the femur, the ilio-psoas tends to tilt the upper fragment forward and
laterally; in supra-condylar fracture of the femur, the muscles of the
calf pull the lower fragment back towards the popliteal space; and in
fracture of the humerus above the deltoid insertion, the muscles
inserted into the inter-tubercular (bicipital) groove adduct the upper
fragment.
REPAIR OF INJURIES OF BONE
In a _simple fracture_ the vessels of the periosteum and the marrow
being torn at the same time as the bone is broken, blood is poured
out, and clots around and between the fragments. This clot is soon
permeated by newly formed blood vessels, and by leucocytes and
fibroblasts, the latter being derived from proliferation of the cells
of the marrow and periosteum. The granulation tissue thus formed
resembles in every particular that described in the repair of other
tissues, except that the fibroblasts, being the offspring of cells
which normally form bone, assume the functions of _osteoblasts_, and
proceed to the formation of bone. The new bone may be formed either by
a direct conversion of the fibrous tissue into osseous tissue, the
osteoblasts arranging themselves concentrically in the recesses of the
capillary loops, and secreting a homogeneous matrix in which lime
salts are speedily deposited; or there may be an intermediate stage of
cartilage formation, especially in young subjects, and in cases where
the fragments are incompletely immobilised. The newly formed bone is
at first arranged in little masses or in the form of rods which unite
with each other to form a network of spongy bone, the meshes of which
contain marrow.
The reparative material, consisting of granulation tissue in the
process of conversion into bone, is called _callus_, on account of its
hard and unyielding character. In a fracture of a long bone, that
which surrounds the fragments is called the _external_ or _ensheathing
callus_, and may be likened to the mass of solder which surrounds the
junction of pipes in plumber-work; that which occupies the position of
the medullary canal is called the _internal_ or _medullary callus_;
and that which intervenes between the fragments and maintains the
continuity of the cortical compact tissue of the shaft is called the
_intermediate callus_. This intermediate callus is the only permanent
portion of the reparative material, the external and internal callus
being only temporary, and being largely re-absorbed through the agency
of giant cells.
Detached fragments or splinters of bone are usually included in the
callus and ultimately become incorporated in the new bone that bridges
the gap.
In time all surplus bone is removed, the medullary canal is re-formed,
the young spongy bone of the intermediate callus becomes more and more
compact, and thus the original architectural arrangement of the bone
may be faithfully reproduced. If, however, apposition is not perfect,
some of the new bone is permanently required and some of the old bone
is absorbed in order to meet the altered physiological strain upon the
bone resulting from the alteration in its architectural form. In
overriding displacement, even the dense cortical bone intervening
between the medullary canal of the two fragments is ultimately
absorbed and the continuity of the medullary canal is reproduced.
The amount of callus produced in the repair of a given fracture is
greater when movement is permitted between the broken ends. It is also
influenced by the character of the bone involved, being less in bones
entirely ossified in membrane, such as the flat bones of the skull,
than in those primarily ossified in cartilage.
If the fragments are widely separated from one another, or if some
tissue, such as muscle, intervenes between them, callus may not be
able to bring about a bony union between the fragments, and
_non-union_ results.
Bones divided in the course of an operation, for example in osteotomy
for knock-knee, or wedge-shaped resection for bow-leg, are repaired by
the same process as fractures.
#Excess of Callus.#--In comminuted fractures, and in fractures in
which there is much displacement, the amount of callus is in excess,
but this is necessary to ensure stability. In fractures in the
vicinity of large joints, such as the hip or elbow, the formation of
callus is sometimes excessive, and the projecting masses of new bone
restrict the movements of the joint. When exuberant callus forms
between the bones in fractures of the forearm, pronation and
supination may be interfered with (Fig. 4). Certain nerve-trunks, such
as the radial (musculo-spiral) in the middle of the arm, or the ulnar
at the elbow-joint, may become included in or pressed upon by callus.
[Illustration: FIG. 4.--Excess of Callus after compound fracture of
Bones of Forearm.]
#Absorption of Callus.#--It sometimes happens that when an acute
infective disease, especially one of the exanthemata, supervenes while
a fracture is undergoing repair, the callus which has formed becomes
softened and is absorbed. This may occur weeks or even months after
the bone has united, with the result that the fragments again become
movable, and it may be a considerable time before union finally takes
place.
#Tumours of Callus.#--Tumours, such as chondroma and sarcoma, and
cysts which are probably of the same nature as those met with in
osteomyelitis fibrosa, are liable to occur in callus, or at the seat
of old fractures, but the evidence so far is inconclusive as to the
causative relationship of the injury to the new-growth. They are
treated on the same lines as tumours occurring independently of
fracture.
#Badly United Fracture--Mal-Union.#--Union with marked displacement of
the fragments is most common in fractures that have not been properly
treated--as, for example, those occurring in sailors at sea; and in
cases in which the comminution was so great that accurate apposition
was rendered impossible. It may also result from imperfect reduction,
or because the apparatus employed permitted of secondary displacement.
Restlessness on the part of the patient from intractability, delirium
tremens, or mania, is the cause of mal-union in some cases; sometimes
it has resulted because the patient was expected to die from some
other lesion and the fracture was left untreated.
Whether or not any attempt should be made to improve matters depends
largely on the degree of deformity and the amount of interference with
function.
When interference is called for, if the callus is not yet firmly
consolidated, it may be possible, under an anaesthetic, to bend the
bone into position or to re-break it, either with the hands or by
means of a strong mechanical contrivance known as an osteoclast. In
the majority of cases, however, an open operation yields results which
are more certain and satisfactory. When the deformity is comparatively
slight, the bone is divided with an osteotome and straightened; when
there is marked bending or angling, a wedge is taken from the
convexity, as in the operation for bow-leg. To maintain the fragments
in apposition it may be necessary to employ pegs, plates, bone-grafts,
or other mechanical means. Splints and extension are then applied, and
the condition is treated on the same lines as a compound fracture.
[Illustration: FIG. 5.--Multiple Fractures of both Bones of Forearm
showing mal-union.]
#Delayed Union.#--At the time when union should be firm and solid, it
may be found that the fragments are only united by a soft
cartilaginous callus, which for a prolonged period may undergo no
further change, so that the limb remains incapable of bearing weight
or otherwise performing its functions. The normal period required for
union may be extended from various causes. The most important of these
is general debility, but the presence of rickets or tuberculosis, or
an intercurrent acute infectious disease, may delay the reparative
process. The influence of syphilis, except in its gummatous form, in
interfering with union is doubtful. The influence of old age as a
factor in delaying union has been overestimated; in the great majority
of cases, fractures in old people unite as rapidly and as firmly as
those occurring at other periods of life.
_Treatment._--The general condition of the patient should be improved,
by dieting and tonics. One of the most reliable methods of hastening
union in these cases is by inducing passive hyperaemia of the limb
after the method advocated by Bier, and this plan should always be
tried in the first instance. An elastic bandage is applied above the
seat of fracture, sufficiently tightly to congest the limb beyond,
and, to concentrate the congestion in the vicinity of the fracture, an
ordinary bandage should be applied from the distal extremity to within
a few inches of the break. The hyperaemia should be maintained for
several hours (six to twelve) daily. An apparatus should be adjusted
to enable the patient to get into the open air, and in fractures of
the lower extremity the patient should move about with crutches in the
intervals, putting weight on the fractured bone. This method of
treatment should be persevered with for three or four weeks, and the
limb should be massaged daily while the constricting bandage is off.
Among the other methods which have been recommended are the injection
between the fragments of oil of turpentine (Mikulicz), a quantity of
the patient's own blood (Schmieden), or alcohol and iodine; the
forcible rubbing of the ends together, under an anaesthetic if
necessary; and the administration of thyreoid extract. If these
methods fail, the case should be treated as one of un-united fracture.
As a rule, satisfactory union is ultimately obtained, although much
patience is required.
#Non-Union.#--Sometimes the fragments become united by a dense band of
fibrous tissue, and the reparative process goes no further--_fibrous
union_. This is frequently the case in fractures of the patella, the
olecranon, and the narrow part of the neck of the femur.
_False Joint--Pseudarthrosis._--In rare cases the ends of the
fragments become rounded and are covered with a layer of cartilage.
Around their ends a capsule of fibrous tissues forms, on the inner
aspect of which a layer of endothelium develops and secretes a
synovia-like fluid. This is met with chiefly in the humerus and in the
clavicle.
_Failure of Union--"Un-united Fracture."_--As the time taken for union
varies widely in different bones, and ossification may ultimately
ensue after being delayed for several months, a fracture cannot be
said to have failed to unite until the average period has been long
overpassed and still there is no evidence of fusion of the fragments.
Under these conditions failure of union is a rare complication of
fractures. In adults it is most frequently met with in the humerus,
the radius and ulna (Fig. 6), and the femur; in children in the bones
of the leg and in the forearm.
[Illustration: FIG. 6.--Radiogram of Un-united Fracture of Shaft of
Ulna of fifteen years' duration.]
In a radiogram the bones in the vicinity of the fracture, particularly
the distal fragment, cast a comparatively faint shadow, and there may
even be a clear space between the fragments. When the parts are
exposed by operation, the bone is found to be soft and spongy and the
ends of the fragments are rarefied and atrophied; sometimes they are
pointed, and occasionally absorption has taken place to such an extent
that a gap exists between the fragments. The bone is easily penetrated
by a bradawl, and if an attempt is made to apply plates, the screws
fail to bite. These changes are most marked in the distal fragment.
The want of union is evidently due to defective activity of the
bone-forming cells in the vicinity of the fracture. This may result
from constitutional dyscrasia, or may be associated with a defective
blood supply, as when the nutrient artery is injured. Interference
with the trophic nerve supply may play a part, as cases are recorded
by Bognaud in which union of fractures of the leg failed to take place
after injuries of the spinal medulla causing paraplegia. The condition
has been attributed to local causes, such as the interposition of
muscle or other soft tissue between the fragments, or to the presence
of a separated fragment of bone or of a sequestrum following
suppuration. In our experience such factors are seldom present.
If the treatment recommended for delayed union fails, recourse must be
had to operation, the most satisfactory procedure being to insert a
bone graft in the form of an intra-medullary splint. In certain cases
met with in the bones of the leg in children, the degree of atrophy of
the bones is such that it has been found necessary to amputate after
repeated attempts to obtain union by operative measures have failed.
In the tibia we have found that with the double electric saw a rod of
bone can be rapidly and accurately cut, extending well above as well
as below the site of fracture but unequally in the two directions; the
rod is then reinserted into the trough from which it was taken _with
the ends reversed_, so that a strong bridge of bone is provided at the
seat of non-union.
CLINICAL FEATURES OF SIMPLE FRACTURES
In the first place, the _history of the accident_ should be
investigated, attention being paid to the nature of the
violence--whether a blow, a twist, a wrench, or a crush, and whether
the violence was directly or indirectly applied. The degree of the
violence may often be judged approximately from the instrument
inflicting it--whether, for example, a fist, a stick, a cart wheel, or
a piece of heavy machinery. The position of the limb at the time of
the injury; whether the muscles were braced to meet the blow or were
lax and taken unawares; and the patient's sensations at the moment,
such as his feeling something snap or tear, may all furnish
information useful for purposes of diagnosis.
_Signs of Fracture._--The most characteristic signs of fracture are
unnatural mobility, deformity, and crepitus.
_Unnatural mobility_--that is, movement between two segments of a limb
at a place where movement does not normally occur--may be evident when
the patient makes attempts to use his limb, or may only be elicited
when the fragments are seized and moved in opposite directions.
_Deformity_, or the part being "out of drawing" in comparison with the
normal side, varies with the site and direction of the break, and
depends upon the degree of displacement of the fragments. _Crepitus_
is the name applied to the peculiar grating or clicking which may be
heard or felt when the fractured surfaces are brought into contact
with one another.
The presence of these three signs in association is sufficient to
prove the existence of a fracture, but the absence of one or more of
them does not negative this diagnosis. There are certain fallacies to
be guarded against. For example, a fracture may exist and yet
unnatural mobility may not be present, because the bones are impacted
into one another, or because the fracture is an incomplete one. Again,
the extreme tension of the swollen tissues overlying the fracture may
prevent the recognition of movement between the fragments. Deformity
also may be absent--as, for instance, when there is no displacement of
the fragments, or when only one of two parallel bones is broken, as in
the leg or forearm. Similarly, crepitus may be absent when impaction
exists, when the fragments completely override one another, or are
separated by an interval, or when soft tissues, such as torn
periosteum or muscle, are interposed between them. A sensation
simulating crepitus may be felt on palpating a part into which blood
has been extravasated, or which is the seat of subcutaneous emphysema.
The creaking which accompanies movements in certain forms of
teno-synovitis and chronic joint disease, and the rubbing of the
dislocated end of a bone against the tissues amongst which it lies,
may also be mistaken for the crepitus of fracture.
It is not advisable to be too diligent in eliciting these signs,
because of the pain caused by the manipulations, and also because
vigorous handling may do harm by undoing impaction, causing damage to
soft parts or producing displacement which does not already exist, or
by converting a simple into a compound fracture.
It is often necessary for purposes of diagnosis to administer a
general anaesthetic, particularly in injuries of deeply placed bones
and in the vicinity of joints. Before doing so, the appliances
necessary for the treatment of the injury should be made ready, in
order that the fracture may be reduced and set before the patient
regains consciousness.
_Radiography in the Diagnosis of Fractures._--While radiography is of
inestimable value in the diagnosis of many fractures and other
injuries, particularly in the vicinity of joints, the student is
warned against relying too implicitly on the evidence it seems to
afford.
A radiogram is not a photograph of the object exposed to the X-rays
but merely a picture of its shadow, or rather of a series of shadows
of the different structures, which vary in opacity. As the rays
emanate from a single point in the vacuum tube, and as they are not,
like the sun's rays, approximately parallel, the shadows they cast are
necessarily distorted. Hence, in interpreting a radiogram, it is
necessary to know the relative positions of the point from which the
rays proceed, the object exposed, and the plate on which the shadow is
registered. The least distortion takes place when the object is in
contact with the plate, and the shadow of that part of the object
which lies perpendicularly under the light is less distorted than that
of the parts lying outside the perpendicular. The light and the plate
remaining constant, the amount of distortion varies directly with the
distance between the object and the plate.
To ensure accuracy in the diagnosis of fracture by the X-rays, it is
necessary to take two views of the limb--one in the sagittal and the
other in the coronal plane. By the use of the fluorescent screen, the
best positions from which to obtain a clear impression of the fracture
may be determined before the radiograms are taken. Stereoscopic
radiograms may be of special value in demonstrating the details of a
fracture that is otherwise doubtful.
Imperfect technique and faulty interpretation of the pictures obtained
lead to certain fallacies. In young subjects, for example, epiphysial
lines may be mistaken for fractures, or the ossifying centres of
epiphyses for separated fragments of bone. The os trigonum tarsi has
been mistaken for a fracture of the talus. In the vicinity of joints
the bones may be crossed by pale bands, due to the rays traversing the
cavity of the joint. In this way fracture of the olecranon or of the
clavicle may be simulated. The neck of the femur may appear to be
fractured if a foreshortened view is taken.
It is possible, on the other hand, to overlook a fracture--for
example, if there is no displacement, or if the line of fracture is
crossed by the shadow of an adjacent bone. In deeply placed bones such
as those about the hip, or in bones related to dense, solid
viscera--for example, ribs, sternum, or dorsal vertebrae--it is
sometimes difficult to obtain conclusive evidence of fracture in a
radiogram.
It is to be borne in mind also, and especially from the medico-legal
point of view, that, as early callus does not cast a deep shadow in a
radiogram, the appearance of fracture may persist after union has
taken place. The earliest shadow of callus appears in from fourteen to
twenty-one days, and can hardly be relied upon till the fourth or
sixth week. The disturbed perspective produced by divergence of the
rays may cause the fragments of a fracture to appear displaced,
although in reality they are in good position. If the limb and the
plate are not parallel, the bones may appear to be distorted, and
errors in diagnosis may in this way arise. In this relation it should
be mentioned that perfect apposition of the fragments and anatomically
accurate restoration of the outline of the bones are not always
essential to a good functional result.
* * * * *
As most of the remaining signs are common to all the lesions from
which fractures have to be distinguished, their diagnostic value must
be carefully weighed.
_Interference with Function._--As a rule, a broken bone is incapable
of performing its normal function as a lever or weight-bearer; but
when a fracture is incomplete, when the fragments are impacted, or
when only one of two parallel bones is broken, this does not
necessarily follow. It is no uncommon experience to find a patient
walk into hospital with an impacted fracture of the neck of the femur
or a fracture of the fibula; or to be able to pronate and supinate the
forearm with a greenstick fracture of the radius or a fracture of the
ulna.
_Pain._--Three forms of pain may be present in fractures: pain
independent of movement or pressure; pain induced by movement of the
limb; and pain elicited on pressure or "tenderness." In injuries by
direct violence, pain independent of movement and pressure is never
diagnostic of fracture, as it may be due to bruising of soft tissues.
In injuries resulting from indirect violence, however, pain localised
to a spot at some distance from the point of impact is strongly
suggestive of fracture--as, for example, when a patient complains of
pain over the clavicle after a fall on the hand, or over the upper end
of the fibula after a twist of the ankle. Pain elicited by attempts to
move the damaged part, or by applying pressure over the seat of
injury, is more significant of fracture. Pain elicited at a particular
point on pressing the bone at a distance, "pain on distal
pressure,"--for example, pain at the lower end of the fibula on
pressing near its neck, or at the angle of a rib on pressing near the
sternum,--is a valuable diagnostic sign of fracture. When nerve-trunks
are implicated in the vicinity of a fracture, pain is often referred
along the course of their distribution.
_Localised swelling_ comes on rapidly, and is due to displacement of
the fragments and to haemorrhage from the torn vessels of the marrow
and periosteum.
_Discoloration_ accompanies the swelling, and is often widespread,
especially in fracture of bones near the surface and when the tension
is great. It is not uncommon to find over the ecchymosed area,
especially over the shin-bone, large blebs containing blood-stained
serum. In fractures of deep-seated bones, discoloration may only show
on the surface after some days, and at a distance from the break.
Alterations in the relative position of _bony landmarks_ are valuable
diagnostic guides. Alteration in the _length_ of the limb, usually in
the direction of shortening, is also an important sign. Before drawing
deductions, care must be taken to place both limbs in the same
position and to determine accurately the fixed points for measurement,
and also to ascertain if the limbs were previously normal.
_Shock_ is seldom a prominent symptom in uncomplicated fractures,
although in old and enfeebled patients it may be serious and even
fatal. During the first two or three days after a fracture there is
almost invariably some degree of traumatic _fever_, indicated by a
rise of temperature to 99 deg. or 100 deg. F.
#Complications.#--_Injuries to large arteries_ are not common in
simple fractures. The popliteal artery, however, is liable to be
compressed or torn across in fractures of the lower end of the femur;
extravasation of blood from the ruptured artery and gangrene of the
limb may result. If large _veins_ are injured, thrombosis may occur,
and be followed by pulmonary embolism.
_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 prone 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 masses of callus, is
not uncommon, especially in the region of the elbow.
Wasting of the muscles and oedema 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 massage. 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 assistant 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 pronator 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.
_Massage 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 massage 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 massage and movement are commenced at
once, but circumstances 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 massage is applied by the surgeon or by a trained
masseur. 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 massage is repeated once each day; the sittings last from ten to
fifteen minutes. The sequence should be, first, massage; second,
passive movement; and third, active movement. At first massage
predominates, and more passive than active movement; gradually massage
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 massage and movement is
impracticable, and where movable splints are inconvenient, splints of
_plaster of Paris_, _starch_, or _water-glass_ 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, coarse
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 massage.
_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 circumstances 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, massage 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 assists 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 assume 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. Massage and movement should be commenced
after the wound is healed and the condition has become analogous 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 substitute
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 passed 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.
#Gun-shot Injuries of Bone.#--Fractures resulting from the impact of
bullet or fragments of shell are of necessity compound, and are
usually infected from the outset by organisms carried in by the
missile or by portions of clothing or other foreign material. Not
infrequently the missile lodges in the bone.
[Illustration: FIG. 7.--Excessive Callus Formation after infected
Compound Fracture of both Bones of Forearm--result of gun-shot wound.
Fusion of Bones across Interosseous Space.]
The extent of the injury to the bone varies infinitely, from a mere
chip or gutter-shaped wound to complete pulverisation of the portion
struck. The fracture is of the comminuted and fissured variety, the
cracks radiating from the point of impact and extending for a
considerable distance, sometimes even implicating the articular
surface of the bone some inches away. In comminuted fractures of the
shafts of long bones there is often a large wedge-shaped fragment
completely isolated from the rest, and in the presence of infection
this may form a sequestrum. Healing is often delayed by the separation
of sequestra, which takes place slowly, and union is attended with
excessive formation of callus. When a considerable section of the
shaft has been lost, want of union, fibrous union, or the formation of
a false joint may result.
The treatment is carried out on the same lines as in other forms of
compound fracture, except that mention should be made of the
irrigation method of Carrel, found to be the most potent means of
overcoming the associated infection.
SEPARATION OF EPIPHYSES[1]
[1] We do not employ the term "diastasis," which has been used in
different senses by different writers.
In young subjects before the bones are fully developed the epiphyses
may be separated from the diaphyses. The use of the X-rays has added
greatly to our knowledge of these lesions.
It is useful to remember that in the upper extremity the epiphyses in
the regions of the shoulder and wrist, and, in the lower extremity,
those in the region of the knee, are the latest to unite; and that it
is in these situations that growth in length of the bone goes on
longest and most actively (twenty to twenty-one years). Injuries of
these epiphyses, therefore, are most liable to interfere with the
growth of the limb.
An epiphysis is nourished from the articular arteries and through the
vessels of the periosteum.
_Pathological Separation of Epiphyses._--There are certain
pathological conditions, such as rickets, scurvy, congenital syphilis,
tubercle, suppurative conditions, and tumour growths, which render
separation of the epiphyses liable to occur from injuries altogether
insufficient to produce such lesions under normal conditions.
#Traumatic Separations.#[2]--Speaking generally, it may be said that
injuries which in an adult would be liable to produce dislocation, are
in a young person more apt to cause separation of an epiphysis.
Indirect violence, especially when exerted in such a way as to combine
traction with torsion,--for example, when the foot is caught in the
spokes of a carriage wheel,--is the commonest cause of epiphysial
separation. Direct violence is a much less frequent cause. Muscular
action occasionally produces separation of the epiphyses--for example,
the anterior superior iliac spine, the small trochanter of the femur,
or the upper end of the fibula.
[2] We desire here to acknowledge our indebtedness to Mr. John
Poland's work on _Traumatic Separation of the Epiphyses_.
[Illustration: FIG. 8.--Partial Separation of Epiphysis, with Fracture
running into Diaphysis.]
[Illustration: FIG. 9.--Complete Separation of Epiphysis.]
[Illustration: FIG. 10.--Partial Separation with Fracture of
Epiphysis.]
[Illustration: FIG. 11.--Complete Separation with Fracture of
Epiphysis.]
The majority of separations take place between the eleventh and the
eighteenth years, chiefly because during this period the injuries
liable to produce such lesions are most common. They do not occur
after twenty-five, because by that time all the epiphyses have united.
In females this form of injury is rare, and almost invariably occurs
before puberty.
The following are the most common seats of separation in the order of
their frequency: (1) the lower end of the femur; (2) the lower end of
the radius; (3) the upper end of the humerus; (4) the lower end of the
humerus; (5) the lower end of the tibia; and (6) the upper end of the
tibia.
_Morbid Anatomy._--In a true separation the epiphysial cartilage
remains attached to the epiphysis. As a rule the epiphysis is not
completely separated from the diaphysis, the common lesion being a
separation along part of the epiphysial line, with a fracture running
into the diaphysis (Fig. 8). It is not uncommon for more than one
epiphysis to be separated by the same accident--for example, the lower
end of the femur and the upper ends of the tibia and fibula.
Epiphysial separations, like fractures, may be _simple_ or _compound_.
Incomplete separations are liable to be overlooked at the time of the
accident, but there is reason to believe that they may form the
starting-point of disease. Strain of the epiphysial junction--the
_juxta-epiphysial strain_ of Ollier--is a common injury in young
children.
_Clinical Features._--The symptoms simulate those of dislocation
rather than of fracture. Thus, _unnatural mobility_ at an epiphysial
junction may closely resemble movement at the adjacent joint,
especially when the epiphysis is an intra-capsular one. The
relationship of the bony points, however, serves to indicate the
nature of the lesion. The degree of _deformity_ is often slight,
because the transverse direction of the lesion, the breadth of the
separated surfaces, and the firmness of the periosteal attachment
along the epiphysial line often prevent displacement. In many cases a
distinct, rounded, smooth, and regular ridge, caused by the projection
of the diaphysis, can be felt. The peculiar "muffled" nature of the
_crepitus_ is one of the most characteristic signs. The older the
patient, and the further ossification has progressed, the more does
the crepitus resemble that of fracture.
Of the subsidiary signs, _loss of power_ in the limb is one of the
most constant; indeed, in young children it is sometimes the first,
and may be the only, sign that attracts attention. _Pain_ and
_tenderness_ along the epiphysial line are valuable signs,
particularly when the lesion is due to indirect or muscular violence
and there is no bruising of soft parts. Localised _swelling_,
accompanied by _ecchymosis_, is often marked; and the adjacent joint
may be distended with fluid.
As distinguishing this injury from a dislocation, it may be noted that
in epiphysial separation there is no snap felt when the deformity is
reduced, the tendency to re-displacement is greater, and the amount of
relief given by reduction less than in dislocation. The use of the
Roentgen rays at once establishes the diagnosis.
_Prognosis and Results._--In the majority of cases union takes place
satisfactorily by the formation of callus in the spongy tissue of the
diaphysis and on the deep surface of the periosteum. In spite of the
favourable nature of the prognosis in general, however, the friends of
the patient should be warned that a completely satisfactory result
cannot always be relied upon.
Deformity, with stiffness and locking at the adjacent joint,
especially at the elbow, may result from imperfect reduction, or from
exuberant callus. Arrest of growth of the bone in length is a rare
sequel, and when it occurs, it is due, not to premature union of the
epiphysis with the shaft, but to diminished action at the ossifying
junction.
When the growth of one of the bones of the leg or forearm is arrested
after separation of its epiphysis while the other bone continues to
grow, the foot or hand is deviated towards the side of the shorter
one.
Partial separations may be overlooked at the time of the accident and
cause trouble later from bending of the bone, as in one variety of
coxa vara. The epiphysis at the lower end of the femur may be
displaced into the ham and press on the popliteal vessels.
_Treatment._--The general principles which govern the treatment of
fractures apply equally to epiphysial separations, the essential being
the accurate replacement of the epiphysis.
In _compound separations of epiphysis_, the end of the diaphysis may
be pushed through the skin. The entrance of sepsis may prove an
obstacle to any operative measure that would otherwise be indicated.