femur is not at right angles with the axis of its shaft; in other
words, the inner condyle is placed a little lower or beyond the
location of the outer. In this way sufficient angular arrangement of
the leg upon the thigh is permitted so that, with the upper ends of the
femora separated by the width of the pelvis, the knees and the ankles
may, under normal circumstances, be made to touch when the limbs are
fully extended. Thus a slight degree of angular deflection at the knee
is normal. When this is exaggerated to a degree not permitting the
ankles to touch when the knees are in contact the condition is known as
_genu valgum_, or _knock-knee_. When, on the other hand, the angle is
lessened or reversed so that the knees are more or less separated when
the ankles are in contact the condition is then known as _genu varum_,
or _bow-leg_. These two conditions constitute the typical and classical
types of knock-knee and bow-leg. Other conditions, however, which lead
to the same result occur through various and irregular curvatures or
irregularities of the femur or the tibia, or both, and there thus
may be produced atypical yet most pronounced instances of these same
deformities. These deformities may be apparent almost from birth, may
appear during early childhood, or not until adolescence. As a rule they
are not manifested until young children are learning to walk. Whenever
they appear before this time they are expressions of infantile rickets,
which should be recognized as such and corrected by mere manipulation
while the bones are still flexible, the correction being maintained,
and by suitably feeding and medicating the patient. (See the general
subject of Rickets.)
[Illustration: FIG. 261
Rachitic changes in limbs. (Lexer.)]
In fact rickets supplies the explanation for the great majority of
these deformities; incomplete ossification and calcification of the
bones accounting for the comparative ease with which they yield to
pressure or other deforming influences. Rickety children always
manifest a tendency to defective ossification at epiphyseal lines,
and it is here that the change usually takes place. Nevertheless
marked instances of curvature are seen in all the bones of the lower
extremity. As deformity in any given direction becomes more pronounced
the tendency to its exaggeration becomes greater. Finally these changes
involve not only the bones proper but the ligaments and the other joint
structures, which yield where pressure is abnormal and greatest, thus
completely changing their shape and internal relations. Along with
other changes in knock-knee there is a tendency to external rotation,
perhaps even to spiral curvature of the tibia; the patella lies outside
of its normal position, the tendons are more or less displaced, while,
at the same time, there may be inflection of the feet as an effort at
compensation (Fig. 261).
With the exception of spinal curvatures and torticollis there is
perhaps no more conspicuous deformity than that produced by these
abnormalities at the knee-joint. While at first gait is not seriously
affected, it is in time, especially in cases of double knock-knee. When
these knees are bent to a right angle the angular deformity disappears
and all that remains is the rotation of the tibia. Hence it follows
that all correction of these deformities, either slow or operative,
should be applied to the fully extended leg. In advanced cases there
is frequently a complication with flat-foot, which may or may not be
painful. The condition is rarely produced by paralytic affections, and
should be differentiated from mere atrophy of wasted and contracted
legs. A form of knock-knee is occasionally seen in the adult, which
is of traumatic origin and is due to improper care or neglect in the
treatment of the injury.
=Treatment.=--_The treatment of this condition is either mechanical or
operative._ Mechanical treatment varies between the gentlest expedients
and the use of more or less extensive and cumbersome apparatus.
When a young and growing child begins to show evidence of either of
these deformities it is usually sufficient to supply shoes which are
reasonably stiff, and raise one or other border of the sole and heel,
according as we wish to influence the growth of the limb, _i. e._, in
knock-knee the inner border of the foot is to be raised, in bow-leg
the outer. The consequence of even slight influence thus constantly
maintained when the child is upon its feet is usually sufficient to
rectify slight degrees of these deformities. When, however, the case is
pronounced more radical measures should be applied. Massage has been
recommended along with manipulation, but should be gently performed.
The different forms of apparatus in use afford various methods of
making pressure against that condyle which is too prominent. It is
possible to make them efficient, but only when they are both well
planned and well made in the first place and intelligently applied and
watched. The special forms of apparatus sold in the instrument stores
are of little value. Too often it happens that when efficient they
cannot be tolerated, and that when tolerated they are inefficient.
Much speedier and more satisfactory results are achieved by operative
methods, so that, in general, they may be regarded as the more
desirable.
_Operative treatment_ consists in some modification either of
osteoclasis or osteotomy.
_Osteoclasis_ has to do with the forcible stretching, bending, or
even breaking of those parts which show the greatest effects of the
deformity or are known to be its primary seat. In young children with
tender and still somewhat flexible bones this may be accomplished by
the hands alone, the patient being under an anesthetic. Manual power
failing a simple instrument known as the _osteoclast_, which affords a
means of applying powerful pressure by the agency of a screw at just
the desired point, is used. Pressure is then applied and carried to
the necessary degree, even with partial or complete fracture of the
bone at fault. In this way is inflicted a simple fracture which permits
of the immediate redressing of the limb, with such overcorrection of
the deformity as seems desirable. The limb thus treated is completely
encased in a suitable plaster-of-Paris splint, and should be held in
the desired position until the plaster is completely hardened and not
likely to yield. Osteoclasis, though it often appears an exceedingly
barbarous procedure, is one of the most beneficent when properly
managed, and is rarely followed by an undesirable result.
_Osteotomy_ is performed by the use of the chisel and mallet, the
former being introduced through a small incision made in the skin,
passed down to the bone with its cutting edge parallel to the bone
axis until the bone itself is reached, after which it is turned at
right angles to it and the mallet used until the chisel has been driven
partly or completely through the shaft of the bone or the portion which
it is intended to attack. The chisel should be partly withdrawn and
its position changed if it is necessary to continue its use. Thus by a
partial division of the bones of the young it is possible usually to
so weaken them that, without undue force, and by manual power, they
are fractured at the desired point. The operation should be done with
the most complete aseptic protection. The procedure recommended by
Macewen is now universally accepted. The incision is made at the inner
side of the thigh just above the tubercle for the adductor magnus,
and the osteotome (as the chisel especially made for this purpose
is called) is passed through it, down to the bone, turned at right
angles, and made to cut nearly through the shaft. Lest it become too
firmly wedged it may be moved a little laterally after each blow of
the hammer. The operation, if properly done, is practically bloodless;
the small opening made for the chisel is sealed at the moment of its
withdrawal, the deformity corrected with the least amount of handling
or disturbance, and the plaster-of-Paris bandage immediately applied,
with the leg in exactly the position which it is desired should be
maintained. Such a dressing may be left for three or four weeks before
being changed. One change is usually sufficient, and in from six to
seven weeks the patient is allowed to slowly regain use of the member.
A special set of osteotomes, after Macewen’s pattern, is furnished by
the instrument dealers for those who practise osteotomy. It consists
of a set of three straight chisels, consecutively numbered, the first
being a little thicker and the third the thinnest of the three, and
thus made with the intent to use the thickest first in order that in
the notch made by it the thinner instruments can be subsequently more
easily manipulated.
BOW-LEGS.
_Bow-legs_ are nearly always of rachitic origin, occurring with less
angular deformity, and as the result of the warping or bending of bones
which are not sufficiently rigid to sustain the weight they are made to
carry. Most cases of bow-legs have their origin within the very early
years of childhood. Other cases are seen in infancy and before children
have ever borne much weight upon their feet. The deformity must be
accounted for by muscle tonus, mere muscle activity serving to place
enough stress upon the bones to swerve them from their normal axes. The
bones probably bend outward because the muscles on the inner side are
the stronger. Children thus affected walk not so much with a limp as
with a waddle, with the feet rather apart, and some inversion of the
toes. Double and complicated curves occur in many of these cases, both
femurs and tibias participating, and having an anterior as well as a
lateral bowing. Such complications materially increase the difficulty
of any treatment.
=Treatment.=--The _treatment_ of bow-leg is generally considered
simpler than that of knock-knee. Occurring in _young_ and growing
children it can be overcome, if taken early, by the expedient already
mentioned, elevating the outer border of the sole of each shoe. The
more mechanical and the purely operative methods of treatment are
essentially the same as those just described for knock-knee, based
on similar but reversed principles. In the very young manual force
will often serve the purpose of a more formal osteoclasis, but the
osteoclast may be used whenever it seems indicated. In those cases
where the bowing is due to abrupt and almost angular deformity,
_osteotomy is indicated_. This is made on exactly the same principles
as mentioned above. In all instances spiral curvatures should be
overcome so far as possible during the process of forcible correction
and dressing in the plaster-of-Paris bandages ordinarily used. Here,
as previously, all treatment should be addressed to the limbs in their
fully extended position. If the rings of the ordinary osteoclast be
sufficiently padded and protection afforded in this way, the skin
rarely sloughs, and the damage, which is, at least, theoretically done
to the tissues, is quickly repaired. Failure in union after any of
these operations is exceedingly rare.
CLUB-FOOT; TALIPES.
In general the term talipes is applied to any malformations of the
foot by which it is more or less misshaped and its function impaired.
The commonest of these is that known and described below as talipes
equinovarus. Of these various deformities there are four principal
types, according as the foot is inverted, everted, hyperflexed, or
hyperextended. More particularly they are:
1. Talipes equinovarus, the commonest type, the ordinary club-foot;
2. Talipes valgus, or flat-foot;
3. Talipes equinus;
4. Talipes calcaneus.
These forms may be variously blended, as well as seen in varying
degrees from the slightest possible deviation to the most pronounced
form. Statistics show that about one child in every five hundred is
born with some form of club-foot.
Club-foot may be either of acquired or congenital origin. Acquired
club-foot is essentially always of paralytic nature, following usually
infantile paralysis or those injuries by which nerves have been divided
or caught in callus or in tumors. As the result of such loss of nerve
or muscle power, in certain muscle groups, malpositions of the feet are
caused which simulate those of congenital origin.
1. =Congenital Club-foot; Talipes Equinovarus.=--This consists
anatomically in an inward dislocation at the metatarsal joint of the
anterior part of the foot, in consequence of which the relations
of all of the other component parts of the foot are deranged; the
scaphoid is swerved on to the inner and lower side of the astragalus
to such an extent as to touch the internal malleolus; the cuneiforms
follow the scaphoid and the metatarsals follow the cuneiforms; the
cuboid is shifted to the inner side and does not articulate squarely
with the calcis. In infants these bones are cartilaginous, but as
the individuals grow and these miniature bones develop and ossify
they take similar and abnormal shapes and positions. The calcis is
drawn into a more vertical position than normal by drawing up the
heel, and is even somewhat rotated on its own vertical axis; thus its
anterior articulating surface is made to look obliquely inward. This
displacement of bones causes dislocation of tendons, the anterior
group being drawn mostly to the inner side. The patient walks more
and more on the outside of the foot, and as he does this adventitious
bursæ develop on the outer border, which become very thick and form in
time large callosities. In the most pronounced cases there occurs, in
connection with all this, curvature or spiral inward rotation of the
tibia, and even of the femur of the affected limb, while the contracted
muscles become overdeveloped and those which are disused underdeveloped
(Fig. 262).
[Illustration: FIG. 262
Talipes equinovarus.]
Among the causes of club-foot heredity seems to play a considerable
part, as it often happens that two or three club-footed children are
born of one mother. The deformity has been ascribed to abnormal or
exaggerated posture _in utero_, with compression. This theory is at
least attractive and has the force of argument from antiquity, for
Hippocrates thus believed. Unquestionably the normal intra-uterine
position of the fetus includes a certain degree of equinovarus. Yet if
this were the real cause the condition would occur apparently much more
frequently. It has been ascribed also to disparity in strength between
opposing groups of muscles, that group which causes the deformity being
naturally the stronger, it being at the same time unimportant whether
one group is relatively too strong or the other relatively too weak.
Most monstrosities or seriously defective infants have also club-foot,
from which some argue that the central nervous system has something
to do with it; yet it has been shown in over 1200 cases of club-foot
that only twice did such defect of the central nervous system as spina
bifida occur. The embryologists and comparative anatomists regard it as
an expression of arrested development, while evolutionists consider it
an atavistic reversion to an earlier anthropoid arrangement. None of
these theories really satisfactorily explains the deformity. Therefore
we should hold that either there are different and variable causes or
that we have not yet found the true one.
=Treatment of Congenital Club-foot.=--There being in these cases no
tendency to spontaneous improvement, mechanical or operative treatment,
or both, are required. If these be afforded early the prospects of
restoration, practically to the normal, are good, but treatment should
be begun early and conducted with great care and patience. It is not so
difficult to correct the deformity, but correctional supports should
be worn for a relatively long time, while the older the case the more
difficult become all the features, both mechanical and durational.
Parents are often eager at first, but later become inattentive or
careless. The main objects are to be attained by correction of position
by force or by division of contracted or shortened tissues, or
retention in position, with the addition of any other features which
may influence growth and development according to normal standards.
Of these we will speak first of rectification: (_a_) bloodless, as
by purely mechanical force, or by means of certain apparatus, and
(_b_) operative, as by subcutaneous tenotomy, aponeurotomy, etc., or
by open incision, through which are performed osteotomy, excision,
astragalectomy, tarsectomy, etc., as the operator may see fit.
In all of these the anterior part of the foot is to be forced outward
as well as raised, two distinct features, which should be combined but
not confused.
In the young infant gentle force applied many times a day, with the
persuasion of a strip of adhesive plaster, applied beneath the foot
and over its outer border, and spirally upward to the inside of the
leg, can be made effective in mild cases; but overstretching of the
tendo Achillis is a necessary part of this maneuver every time it is
practised. The more positive method consists of fixation of the foot
in overcorrected position within a plaster or starch bandage, the same
extending above the knee, which should be slightly flexed, the dressing
to be renewed every two or three weeks, and correction increased until
it has become overcorrection.
In well-marked and in resistive cases an anesthetic should be given,
while by the use of sufficient force, which may be relatively great,
but which should be gently applied, the resisting tissues are so
stretched, if necessary to the point of something yielding, that but
slight pressure is required to hold the foot in an overcorrected
position. When the knife is required the tendo Achillis should
always, and the plantar tendons and fasciæ usually, be subcutaneously
divided, under aseptic precautions. The foot is then enveloped in
suitable dressings and put up in overcorrected position for two or
three days, in a rigid dressing at first of starch, but after this
in plaster of Paris; this is the writer’s plan of procedure. The
insertion of the point of the tenotome sufficiently deep to divide all
resistive ligaments and tissues (_e. g._, the astragaloscaphoid or
the calcaneocuboid) nowise complicates this method, but makes it more
efficient.
Cases which are resistant are best submitted at once to _open
operation_ (that is, after vigorous stretching of the contracted
tissues), always under strict asepsis. After decades of milder
ineffectual methods it remained for A. M. Phelps, of New York, to show
the benefits of this method by which all contracted tissues on the
concave aspect of the foot are exposed and divided. Incision is made
here from the top of the inner malleolus to the inside of the first
tarsometatarsal joint. With a little care the artery can be avoided,
but I have never seen any harm come from its division. Everything
which proves resistant is divided, even the inner osseous ligaments.
Sometimes the incisions can be made in wedge-shape, or obliquely, so
that the wound does not remain so widely open. No attempt is made to
close this wound. The operation may be done bloodlessly, under the
Martin rubber bandage, but whether this be used or not any vessel
which can be recognized as such should be tied; otherwise the wound
is snugly packed with gauze (upon which I like to use Peru balsam).
An ample surgical dressing is applied over it. This is covered with
gutta-percha tissue, to prevent too free access of air to the blood
which will ooze into the dressing, and the whole is then covered with a
starch bandage, in overcorrected position; this is left, according to
circumstances, for from three days to a week--the longer the better.
Then everything is removed, fresh gauze placed in the wound, which will
be found already largely filled up; fresh dressings are applied, and
the foot put up in plaster of Paris, with or without a fenestrum or any
provision by which the region of the wound may be easily uncovered for
necessary renewal of dressing.
It is in the most pronounced types of cases only, with marked bone
deformity, or those in which previous operations have failed, that
the still more radical division or removal of some part of the tarsus
is necessary. As to this no universal rule can be applied save this:
take out sufficient to correct deformity. In some cases it will be
sufficient to excise the astragalus (_astragalectomy_). In other cases
it is better to remove a wedge-shaped piece of the tarsus, without
reference to the name of the bones attacked (_tarsectomy_). I have
never found it necessary to touch the external malleolus, though this
has been suggested, nor to do osteotomy of the calcis or of the leg
bones above the ankle, as a few have done.
[Illustration: FIG. 263
Park’s club foot brace.]
These operations are usually practised, _after a preliminary
stretching_, through a curved incision on the outer aspect of the foot,
through which, at the same time, the thickened bursæ may be removed, or
the callosities included in the incision. The chief convexity of the
incision should be over the os calcis at its anterior portion. As the
dissection is made the tendons are drawn aside and spared. If it be
necessary to divide one or more of them it should be re-united later.
According to the density of the structures a strong knife may be used,
and strong scissors, or an osteotome manipulated either by hand or with
the hammer. After sufficient V-shaped or wedge-shaped bone has been
removed the defect should be held together, if practicable, by buried
tendon sutures or wire; it is rarely necessary to use drainage. The
external wound may be loosely closed with buried sutures, a suitable
dressing applied, and the foot put up in a rigid splint; this should
permit of removal, or at least inspection of the wound after a few
days, for renewal of those dressings which are saturated with blood and
for application of new dressings. After this the foot and leg should be
put up in overcorrected position in plaster of Paris.
In aggravated cases of club-foot Wilson believes combined operation
to give better functional results than can be obtained by any other
method. The astragaloscaphoid joint is exposed by an incision over
the prominence of the scaphoid, and, being cleared, is opened with
chisel or bone forceps, while sufficient of the articular surfaces is
removed to destroy them as such and to take out a sufficiently large
wedge-shaped piece from either bone so that the desired arch of the
foot is restored, or even exaggerated. Then the tendon of the extensor
proprius hallucis is exposed and divided just above the great toe, the
upper end of the tendon being drawn out through the first incision.
To this end is attached a strong silk ligature. The scaphoid is then
perforated with a bone drill at some distance from its superficial
aspect and at such an angle, with the foot in correct position, that
the canal thus made shall be in line with the action of the tendon. The
drill is then withdrawn and the tendon passed through the opening by
means of its attached silk. One inch beyond the bony canal the tendon
is cut off and split in halves, each half being turned in opposite
direction and fastened to the periosteum of the scaphoid with fine
silk, while the foot is held in overcorrected position, so that the
tendon is sewed in its new place under moderate tension. The foot is
then dressed in this overcorrected position in plaster of Paris, the
splint extending nearly to the knee, and the wound area being exposed
by a fenestrum cut in the splint before it is hard.
The location of the incision over the dorsum or outer aspect of the
foot may be varied to suit the needs of the case and the method of the
attack. In a general way a flap of soft tissues is raised and tendons,
so far as possible, are held outward. This is usually practicable,
and it is rarely necessary to divide the latter. After operation of
any type and recovery from the same it will be necessary for a long
time to have the patient wear a corrective appliance. This should be
applied as early as possible, and should be worn continuously, _i. e._,
night and day; inasmuch as growth is continuous there should also be
continued correctional influences. Many types of apparatus have been
devised. That which the writer has found effective and has adopted for
a number of years is illustrated in Fig. 263. It may be made single
or double, as occasion requires. A part of the appliance is a spiral
spring and a provision for a constant outward pressure is made upon
the foot, by which inversion is more easily overcome, as well as any
inward spiral twist of the bones of the leg. No such apparatus can
be made effective unless connected suitably with a waist-band. This
is, therefore, included in the shoe shown in Fig. 263. Furthermore
the appliance should be so made as to permit adjustment commensurate
with the rapid growth of the patient, and in order that it need not be
too often renewed. Some degree of mechanical ability is required for
its application and management. The principles are, however, easily
mastered and most parents can soon learn to manage it.
2. =Talipes Valgus.=--This condition is known also as _talipes planus_,
or, more briefly, _pes planus_, the common names being _flat-foot_,
_splay-foot_, or _pronated foot_. A particularly painful variety has
been often spoken of as _pes planus dolorosus_.
This type of deformity is rarely of congenital origin. It is
characterized by abduction and pronation of the foot, on whose inner
border there often appear two prominences, one the head of the
astragalus the other the head of the scaphoid. The bones show much less
alteration in actual shape than in club-foot. The scaphoid is deflected
somewhat to the outer side and the astragalus turned a little outward
and downward. A prominent feature is that the arch of the foot is more
or less obliterated, while its inner border becomes convex instead of
remaining concave. This is due in large measure to relaxation of the
ligaments binding the foot to the calcis, especially that extending
from the astragalus (Fig. 264).
=Etiology.=--The common cause of the condition is lack of sufficient
strength of the parts to carry the weight of the superimposed body.
It is produced often by ill-fitting shoes, accompanied by excessive
strain or rapid growth and gain in weight. It is sometimes complicated
by a certain shortening of the gastrocnemius (Shaffer), which prevents
flexion to its complete degree and compels some degree of eversion
of the foot in completing a step. In some instances it is induced by
previous morbid conditions, such as rickets, paralysis, diseases of
the spinal cord, and postgonorrheal arthritis. Ill-fitting footwear is
the most common cause, as it compresses the front part of the foot and
prevents adaptation of the foot to the position it should assume when
the weight of the body is thrown upon it. The effect of this weight is
to necessitate a greater divergence of the toes than such shoes permit
and gradually causes the patient to walk on the inside of the foot.
_Flat-foot is seldom seen in those who habitually go barefooted._
The condition is best relieved by making a graphic record of each case.
This is done by making the barefooted patient step first on smoked
glass or on wet dusted paper, and then upon a piece of plain paper. If
such a print be compared with the print similarly obtained from the
normal foot it will be seen how different are the points of contact
and how differently distributed is the body weight. A non-graphic but
sufficient inspection may be afforded by having the patient stand
upon a stool whose top is made of glass and by using a mirror beneath
the feet. In any event it will be shown that the inner border of the
foot is at least nearly straight or even convex, whereas it should be
neither.
[Illustration: FIG. 264
Talipes valgus.]
There are tender points over the astragaloscaphoid joints, at the base
of the first and fifth metatarsals, in front of the internal malleolus,
as well as often beneath the heel. Patients who thus suffer find that
the feet perspire very easily. In walking the feet are everted, and
when tenderness is very great it is because too much weight is borne on
the inner borders of such everted feet. Inspection of the shoes will
also show wearing of the inner border and over the inner malleolus.
Spontaneous cure of such cases does not occur, except perhaps after
long confinement in bed from other causes, but patients occasionally
become tolerant after a time, though many of them grow steadily worse
and avoid using the feet more than is absolutely necessary.
=Treatment.=--Mild cases will be benefited, often practically cured, by
simply raising the inner border of the sole and heel of the shoe. This
causes more weight to be borne on the outer border than in the natural
attitude of the foot. It will be sufficient usually to make from ³⁄₈
inch to ⁵⁄₈ inch difference in the level between the inner and the
outer borders of the sole and heel. Shoes may be so constructed that
this difference is made invisible, or suitably bevelled narrow strips
of leather may be sewed beneath the sole along the inner side, or laid
in between its upper and lower layers.
While this suffices for the milder cases it is not sufficient for the
more severe cases, which require forcible correction, and often under
an anesthetic. The best way to accomplish this, after having patients
thoroughly relaxed with chloroform, is to make a thorough manipulation
of the foot, trying especially to so loosen its outer ligaments that it
may be more easily put in proper position and finally overcorrected.
The foot is then put up in plaster of Paris in this much overcorrected
position. Such splints are worn for five or six weeks, after which
suitable shoes should be provided, either with their inner borders
elevated or with metal flat-foot plates inserted, or both. These plates
are now in general use, and may be procured from instrument dealers and
in shoe stores. In particular cases it is advisable to make a mold of
the lower aspect of each foot, to have this cast in iron, and then over
the iron model to have a suitable metal plate hammered so that it shall
exactly fit the individual for whom it is intended.
Only in extreme cases, rebellious to other treatment, has it been shown
necessary to resort to such treatment as division, by osteotomy, of the
neck of the calcis or of the astragalus.
Most of these cases may be benefited subsequently by gymnastics and
massage, _i. e._, by stretching the contracted gastrocnemius, if
necessary, with some mechanical device, and improving the general
condition of the leg muscles by suitable massage.
=Metatarsalgia; Morton’s Disease.=--Under this name has been described
a peculiar painful affection of the third and fourth or the fourth and
fifth toes, which gives rise to constant sensitiveness and sometimes
attacks of acute pain, especially when the foot is shod, and which is
often only relieved by immediately removing the boot or shoe. These
affection’s are more common in the upper walks of society, especially
among women who are disposed to cramp their feet in shoes which are too
small for them. Aside from the location of the pain there will often be
found a tender spot at the point of greatest complaint. As these cases
become worse pain radiates farther and farther up the leg, and may even
assume the type of a sciatica.
[Illustration: FIG. 265
Talipes equinus.]
Careful inspection usually reveals either a mild degree of flat-foot,
or of distortion by which the anterior part of the foot is broadened
and held in a depressed position--or else the dorsal part of the foot
is depressed behind the anterior part; there is also usually limitation
of dorsal flexion of the foot and plantar flexion of the toes.
Morton, who first described the affection as having a peculiar type
of its own, thought it due to entanglement of the external plantar
nerve between the heads of the fourth and fifth metatarsal bones,
and recommended for its relief excision of the head of the fourth of
these. The etiology of the affection is not always apparent, but it is
sometimes due to what has been described as a non-deforming type of
club-foot, while in practically all other instances it is in some way
connected with the use of badly fitting footwear.
=Treatment.=--Without proper treatment it does not subside. A really
weak and pronated foot should be supported with a proper plate and
elevation of its inner border, while a short gastrocnemius should be
stretched. Only in extreme cases or when these milder measures have
failed need resort be had to Morton’s suggestion and excise the head of
the fourth metatarsal.
3. =Talipes Equinus.=--In this condition the _equinus_ position is
simulated, and the patient walks upon the anterior part of the foot
only, perhaps even upon the ends of the metatarsal bones. While the
congenital form is extremely uncommon the acquired form is that which
commonly occurs. Appearing thus in all possible degrees it may in
mild cases cause merely a slight limp, while the extreme cases cause
a pronounced deformity and alteration in gait. The actual condition
is one of shortening of the tendo Achillis through contraction of its
component muscles, with corresponding change in shape of the bones
of the foot. There is also more or less shortening of the plantar
aponeurosis, and depression of the astragalus, which is drawn down upon
the calcis (Fig. 265).
=Causes.=--Perhaps the most common cause is paralysis, either of
infantile or cerebral and spastic type, of the anterior muscles of the
leg, the condition being simulated sometimes in hysteria. The spasm
which follows disease of the ankle-joint may also produce it. It may be
the result of muscle contraction after fractures or even after certain
fevers, the foot dropping naturally into this position and remaining
there altogether too long. Hence may be seen the necessity for putting
the foot in the right-angle position whenever the lower limb is dressed
in plaster or other rigid dressings after fracture. Talipes equinus
may also be due to injury to and loss of power in the anterior muscles
of the leg, or it may be compensatory, as when one leg is longer than
the other. In any of these events the body weight is borne on the ball
of the foot, and some degree of arching of the foot, which may be
excessive, is sure to occur.
=Treatment.=--In the milder cases, when seen early, it may be
sufficient to thoroughly and repeatedly stretch the sural muscles,
but, in the more severe forms, tenotomy of the tendo Achillis, with
subcutaneous or perhaps open division of the plantar structures,
will be needed. In paralytic cases tendon grafting (_q. v._) will be
required, probably with one or more of the measures mentioned above.
In some instances nerve grafting might be profitably employed. After
recovery from operation, braces adapted to each particular case will in
all probability be required, at least for a time.
4. =Talipes Calcaneus.=--In this deformity the anterior part of the
foot is drawn upward by its anterior flexors and a little to the outer
side, while the sural muscles are relaxed; thus the patient walks upon
the heel. The condition is often more or less combined with talipes
valgus. It is rarely of congenital origin, but is generally due to
paralysis of the distal muscles following injury or poliomyelitis. It
is sometimes of hysterical origin, and it may occur as the result of
muscle spasm following bone or joint disease (Fig. 266).
[Illustration: FIG. 266
Talipes calcaneus.]
[Illustration: FIG. 267
Pes cavus, hollow clawfoot.]
Those forms due to infantile paralysis are to be treated mainly by
tendon grafting or some similar expedient, and this to be followed by a
suitable shoe containing a sole plate with an upright attachment and a
joint opposite the ankle. Other forms must be treated, each on its own
merits, but according to general principles already enunciated.
=Pes Cavus.=--Here the anterior part of the foot is drawn backward and
the plantar arch made much more prominent. It may even be converted
into a Gothic arch. Extremes of this type are seen in the feet of
Chinese women. One form is due to contraction of the peroneus longus,
owing to paralysis of the sural muscles, by which the long flexors
are permitted to work to extra advantage; and yet another form is
often of congenital origin, having its explanation in paralysis of the
interossei and other small intrinsic muscles of the foot (Fig. 267).
When an ordinary metal sole plate fails to give relief a subcutaneous
or open division of the contracted structures may be practised.
CONGENITAL MISPLACEMENT (DISLOCATION) OF THE HIP.
Perhaps a more proper name for this congenital deformity would be
“misplacement” rather than dislocation. It is seen much oftener in
females than in males. It may be either unilateral or bilateral. The
displacement is usually upward and backward upon the dorsum of the
ilium. In rarer instances it is anterior and sometimes the head of the
femur lies not far away from the anterior superior spine of the ilium.
Regarding its cause absolutely nothing is known. It represents
defective development rather than arrest, and is a condition of
intra-uterine life. The acetabulum is usually found incomplete, but
whether this is the cause of the misplacement or whether it fails to
develop because of the absence of the head of the femur from this
cavity it is not easy to decide. The influence of heredity in these
cases is undeniable, for it is known to have prevailed in certain
families. Thirty years ago but little was known in regard to the
affection, and nothing could be done to atone for it. Of late years it
has been the subject of special study by numerous investigators (Figs.
268 and 269).
[Illustration: FIG. 268
Double congenital displacement of the hip. Buffalo Clinic. (Skiagram by
Dr. Plummer.)]
[Illustration: FIG. 269
Skiagram of coxa vara; deformity most marked at the epiphyseal
junction. This illustrates the mechanical limitation of abduction
caused by the deformity, and the compensatory tilting of the pelvis.
(Whitman.)]
[Illustration: FIG. 270
Congenital misplacement, with consequent atrophy and shortening.
(Calot.)]
Pathological changes are noted in the capsule itself, as well as in the
bony components of the joint. Thus the capsule is usually elongated
and stretched out of shape, while its lower portion may be adherent to
the margin of the acetabulum or may be shut off into a small cavity
by itself, this cavity having but a small connection with the balance
of the capsule and affording irresistible obstacles to reduction. With
changed joint relations the muscular arrangements are also changed,
some being lengthened, others shortened, as would naturally follow
from the approximation or separation of their points of origin and
insertion. Conspicuous change is seen in the upper end of the femur,
which is often atrophied, while the neck is shorter than normal, its
angle lessened, and the head of the bone often altered in shape. A
secondary acetabulum is in time formed and is usually found upon the
side of the ilium. This is shallow and insufficient to ensure firm
support for the head of the femur, even were this well developed.
Aside from these changes the pelvis is usually poorly developed on the
affected side, its inclination increased, the sacrum forced forward and
downward, the pelvic outlet widened, while a considerable degree of
lumbar lordosis is present (Fig. 270).
The condition is rarely noted until a growing infant begins to learn
to walk. The condition is one which has _no symptoms, only signs_, and
these do not at first attract attention. Sometimes it will have been
noted that there is an abnormality about the hip, with too free play,
or a snapping sound about the joint. When the condition is unilateral
there is a marked limp which increases with the age of the child.
With each step the femoral head is pushed upward on the side of the
ilium, and, in consequence, the pelvis is tilted toward the outside,
as well as twisted downward and forward. The limb being thus actually
shortened, the limp or waddling gait is easily accounted for. Along
with it there is usually flattening of the tibia, while the trochanter
may be felt and often seen on a level considerably above that where it
properly belongs. Motility in the joint is abnormally free, and with a
child on its back, by alternately pulling and pushing, the abnormally
free play of the upper end of the femur may be easily demonstrated,
either with the limb in its extended or the flexed position.
When the misplacement is _bilateral_ the individual is more
symmetrically deformed. The lordosis is increased, the abdomen
protrudes, the thighs are separated more widely than is normal, leaving
perhaps a considerable space in the perineum; the gait is of a peculiar
waddling character, which makes locomotion apparently difficult,
although it is free from pain. In these cases abnormal mobility of the
hip may be demonstrated on each side.
As these patients grow through adolescence into maturity they sometimes
improve, but usually suffer more and more difficulty in locomotion,
while the abdominal protrusion and the lordosis become more and more
pronounced.
Three varieties of congenital misplacement are described as _backward_,
_upward_, and _forward_. It is in those instances where the head of
the bone rests well back or well forward upon the ilium that the gait
is most pronounced, but in all instances the great trochanter will be
found above Nélaton’s line.
=Diagnosis.=--The diagnosis offers few difficulties. The peculiar
waddling gait may be seen in extreme cases of bow-legs, but then the
hip-joints will be normal. Extreme lordosis may be seen in cases of
lumbar spinal caries, but here again the hip-joints will be normal,
while the spinal muscles will be rigid and the patient disinclined
to walk. Traumatic dislocations and the results of hip-joint disease
will be indicated by a history to correspond, as will also early acute
joint affections following the exanthems. The diagnosis is to be made
principally from _coxa vara_, considered below, and the various defects
following infantile palsy. In coxa vara there is no corresponding
abnormality of motion, while in the paralytic cases there will often be
failure in muscle power, which is not present in cases of congenital
misplacement. Finally in instances which offer difficulties the Röntgen
rays now afford a method of diagnosis.
=Treatment.=--For a long time after this condition was recognized its
treatment was unsatisfactory, and it was not until Hoffa, about fifteen
years ago, advanced his operative method of relief that surgeons felt
at all like advising operation in well-marked cases. Then came Paci and
Lorenz, first with improvements on the Hoffa operation, and then with a
method of so-called “bloodless” reposition, which has been under severe
test and testimony. Last of all come Bradford and Sherman with their
improved methods of operation, which seem to me the most promising of
all as well as the most scientific.
[Illustration: FIG. 271
A plaster bandage applied by Lorenz, illustrating the extreme thickness
of the pelvic portion and discoloration of the adductor region.
(Whitman.)]
Lorenz was doubtless correct when he stated that the principal
obstruction to reduction is the narrowed part of the capsule, just
at the upper part of the acetabulum, and that if this could be torn
here sufficiently to permit the passage of the head, reduction
could be accomplished by manipulation alone, and maintained if the
acetabulum were sufficiently deep. An almost insuperable difficulty
in most cases is, however, this narrowed capsule, and the number of
accidents, including not only fractures of the femur and the pelvis,
but various other injuries which have resulted from too great violence,
is altogether too large and too disturbing to justify the use of such
force as has often been used. Of more than one hundred children upon
whom Lorenz operated when making a tour through the United States,
but little over 10 per cent. have given anything like ideal results;
while the danger from fracture and laceration of muscles and nerves,
as well as of bloodvessels, is fully as great as that pertaining to
any open operation. It may therefore be maintained that the percentage
of success from the use of manual force without incision does not
justify the risks of the method. Sherman argues that if we may open a
knee-joint without hesitation to take out a small piece of cartilage,
we need not fear to open a hip-joint in order to clear away a small
obstacle. The patient is thereby saved from many dangers and exposed to
so few that it seems more humane and desirable in every respect.
Sherman’s method is to make traction upon the limb, drawing the
femoral head down to a point just below the anterior superior crest,
where it can easily be felt, and to here make an incision over it
in the direction of muscular fibers so that they are not divided.
After division of the capsule the head of the bone is exposed and
retractors substituted by long loops of suture, put in on either
side of the opening in the capsules. In many cases a tenotomy of the
adductor tendons close to the pubis will also be of advantage. The leg
is next released from traction and the head of the bone allowed to
glide upward, while the finger is slipped into the capsule and down
toward the acetabulum. Upon this finger as a guide a long, straight,
probe-pointed bistoury is passed, and with it the narrower portion
of the capsule is cut through, down to the bone, taking care to not
cut off the ileopsoas tendon. The incision must be large enough to
give free access to the acetabulum. Traction is then again made with
sufficient manipulation so that the femoral head may be forced into
its proper cavity. When the head is in the acetabulum the retracting
sutures are tied together so as to close the upper part of the capsule,
and other sutures are introduced, as needed, to close the wound,
leaving space for a cigarette drain. The limb is then put into a
position of abduction of from 50 to 90 degrees, rotated in or not, as
needed, and a comprehensive plaster-of-Paris spica applied. In this
both limbs or only one may be included. The drain should be removed in
two days and the dressing left otherwise undisturbed for three months.
Bradford has added somewhat to our methods by showing not only the
arrangement of the capsule, but the fact that the acetabulum is often
filled with dense fibrous tissue which sometimes obliterates it, and
that this tissue can be curetted out, but that if it could be utilized
to aid in retaining the reduced head of the femur it would be a great
benefit. He operates as follows: The hip is subjected to preliminary
forcible stretching of all soft parts which can be stretched by manual
or mechanical force. A posterior incision is then made, which, without
dividing muscles, permits free opening into the capsule and affords a
channel to the deepest portion of the acetabulum. The posterior wall
of the capsule is then split, after which all constricting and other
obstacles at any point are carefully divided. These may be detected
by the finger, and can also be seen by a small electric light passed
down inside of a sterilized glass test tube. The capsular wound is then
retracted by deep retaining silk sutures, placed at the lower rim of
the acetabulum, thus affording a pathway for the reduction of the head.
After this has been accomplished as described above, the sutures are
tied closely around the femoral neck, and these retain it in position.
The other portions of the split capsule are then sewed around the head
and neck, to the trochanter and fascia, in such a way as to retain the
bone where it has been placed.[37]
[37] American Journal of Orthopedic Surgery, October, 1905.
The earlier the operation is done the better. It is necessary to always
maintain the limb in a position of well-marked abduction, and for a
long time, nor can patients be released from this at the expiration of
the first dressing period, usually twelve to fifteen weeks, although
the abduction can usually be reduced with each dressing until at last
the limbs are permitted to come together after the expiration of nine
to eighteen months. Even after the lapse of this length of time it
may be necessary to provide some form of apparatus by which too much
rotation in either direction may be prevented, or by which pressure
may still be made over the trochanter, in order that it may be kept
constantly pushed into the acetabulum (Figs. 271 and 272).
[Illustration: FIG. 272
Unilateral congenital dislocation, showing the fixation bandage. A
shoe with a cork sole about two inches in height should be worn on
the operated side, while the attitude of exaggerated abduction is
maintained. (Whitman.)]
[Illustration: FIG. 273
Coxa valga, with defective development of the right femur. (Albert.)]
COXA VARA AND VALGA.
This term is applied to an _abnormality in the shape of the neck of the
femur_, consisting of a downward curvature or bending of the femoral
neck, which is thus displaced until it stands almost at a right angle
with the shaft instead of at the normal obtuse angle. At the same time
there is often posterior curvature, or sometimes an anterior curve,
of the neck, which causes a corresponding rotation of the axis of the
whole limb. The pelvic side of the hip-joint is unaffected, the change
occurring usually solely in the upper end of the femur, the joint
not being involved. It may appear in congenital form and then may be
attributed either to intra-uterine pressure or to antenatal rickets or
osteomalacia. The acquired form is usually due to a non-inflammatory
softening, or to structural changes which permit of yielding, as above
described. Doubtless different cases have different causes, and they
are not to be included in one brief sentence. The condition corresponds
to those abnormalities at the knee which produce knock-knee and
bow-leg. Were the bone as easily examined at the upper end of the femur
as at the knee the condition would be more easily recognized. Therefore
the term has reference not so much to the results of active disease as
to deformities of congenital or acquired character. Fully three-fourths
of the cases are met with in male subjects, and the majority of
these occur only on one side. Thus of 190 quoted by Whitman, 85 were
unilateral, while only 26 occurred in females.
The more nearly the angle of fixation of the neck of the femur
approaches a right angle the further above Nélaton’s line will the
trochanter appear, and the more conspicuous this change the greater the
difficulty in abduction. Moreover, to shortening may be added internal
or external rotation, with consequent tilting of the pelvis and
compensatory alteration of the spinal curves.
The disease is by no means often of traumatic origin, although
traumatisms may produce an arthritis deformans, even in juvenile cases,
and that this may simulate a non-symptomatic coxa valga is now well
established (Fig. 273).
=Symptoms.=--Coxa vara produces certain symptoms, among them pain in
the joint, radiating down the front and inside of the thigh. If the
deformity be very marked, joint function is impaired. Tenderness is
rarely present. When pain or tenderness occur they may lead to the
mistaken diagnosis of rheumatism or neuralgia. The condition may arise
as the result of an acute ostitis, in which case patients will be
confined to bed for some time. Actual shortening may vary from one
to one and a half inches, while the limb will be found adducted, the
gluteal region flattened, with a deep curve between the trochanter and
the gluteal muscles.
=Diagnosis.=--The diagnosis is to be made mainly between this condition
and hip-joint disease or misplacement. When abnormalities in the
shape or position of the limbs in the young occur in a comparatively
short time, coxa vara may be suspected, especially in the absence of
that disability which coxitis usually produces. The patient should be
examined in both the upright and horizontal position. Coxa vara may
have an abrupt onset, but it never produces abscess. It is practically
self-limited and will be followed, sooner or later, by spontaneous
cessation of all acute features, while coxitis is progressive, with a
destructive tendency. In coxa vara we do not have the starting pains
nor muscle spasms of coxitis, while the actual shortening is much more
marked. In doubtful cases the cathode rays may be employed and will
often greatly facilitate diagnosis. The condition may be bilateral,
but will still fail to show the muscle atrophy so significant of
tuberculous disease.
As between coxa vara and that senile form of coxitis already described
in the chapter on Joints as arthritis deformans, it should be
remembered that the latter is a disease of advanced life, while the
former occurs rather in its earlier periods. Moreover, in the former
there is no tendency to change in the femorocervical angle, no matter
what changes may occur in other respects about the joint. When in
the senile disease shortening really occurs it results from actual
absorption of bone.
Coxa vara tends usually to _spontaneous cessation_, which may be
considered recovery. Acute symptoms after a time subside, and function
is regained to the full extent permitted by whatever changes have
occurred in the shape of the bone. If symptoms are at all severe they
demand physiological rest in bed, with traction, and the limb should
not be used until pain has entirely subsided. Conspicuous deformity
may call for correction by subcutaneous osteotomy made just below the
trochanter. Only in exceedingly serious cases is exsection of the joint
necessary.
DEFORMITIES CAUSED BY INFANTILE PALSIES.
Deformities induced by more or less acute affections of the cord and
brain, or by hemorrhages, have assumed an ever-increasing importance
in orthopedic work. Most of them resolve themselves into those due to
acute anterior poliomyelitis and those due to cerebral hemorrhages.
[Illustration: FIG. 274
Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing
quadrupedal locomotion. (Gibney.)]
=Anterior Poliomyelitis.=--Anterior poliomyelitis is an acute
inflammation manifested especially in the gray matter of the anterior
cornua of the spinal cord, involving both the neuroglia and the cells,
producing atrophy of the same and consequent paralysis of muscles
supplied by the motor nerves. It may assume an acute febrile type,
with rapid onset of paralysis, or it may be of slower development.
Usually conceded to be of infectious origin, it still lacks the minute
explanation for many of its attendant phenomena. It may appear with
acute symptoms, febrile and convulsive, paralysis appearing more or
less promptly. With the subsidence of other serious symptoms this
paralysis remains. There may then be a period of partial improvement
in the muscular condition, with disappearance of some of the most
pronounced phenomena. Finally with the growth and development of
the child more expressions of damage remain, and produce various
distortions and deformities, varying with the muscle groups affected.
Not only do deformities result, but there is more or less arrest of
development, with disproportion in size between the limbs involved and
those which have been spared. It is the early paralytic features which
may permit diagnosis to be made in the early days of the acute febrile
attack.
=Cerebral Palsies.=--The cerebral palsies, so called, are the result
of hemorrhages or acute disorganization of the brain. The former are
usually unilateral and give rise to a corresponding hemiplegia, with
either paralysis or spastic rigidity, and usually with atrophy. The
paralysis may not be complete, but is rather of the paretic type,
involving the entire limb, the reflexes being increased and the muscles
stiffened rather than flaccid, with loss of electrical reactions.
_A paraplegia points rather to lesion in the spinal cord and hemorrhage
than to cerebral lesion._ Transverse myelitis is rare in children.
Multiple neuritis may produce somewhat similar effects, as may also
the toxic paralyses due either to drugs (especially lead or arsenic)
or that following diphtheria, in which case it is the muscles of the
throat and neck which are likely to be involved. Figs. 274 and 275
portray extreme types which are rare, but instances of minor degree of
affection are frequent.
[Illustration: FIG. 275
Anterior poliomyelitis. Duration seven years. Showing atrophy and
slight lateral curvature of the spine; two and a quarter inches of
shortening. (Whitman.)]
=Treatment.=--As two cases of this kind are seldom alike, treatment
should be planned to meet the indications. Massage, electricity,
hot-air baths, and similar non-operative measures find here a large
field of usefulness, but, save in the milder cases, are insufficient.
In no class of cases do tendon grafting and nerve grafting find a wider
range of applicability, while tenotomy, myotomy, aponeurotomy, and
occasionally osteotomy will permit of atonement for deformity which has
not been treated. These operative measures have been considered.
CHAPTER XXXIV.
FRACTURES.
The term _fracture_ is, in surgery, applied to such injury of bone
and cartilage as effects break in continuity. This injury is effected
instantly, and it is rarely that fracture is produced by any slowly
acting cause, although this latter may so affect or disintegrate
bone as to permit fracture upon the application of a mild degree of
force. Fractures are variously classified and grouped for convenience
of description; thus we speak of _traumatic_ and _pathological
fractures_, implying by the former those which occur by violence in
normal conditions of health, and by the latter those which are produced
only because of some previous disease in the bone. The difference
is that in the former case there is no preëxisting disease, whereas
in the latter it is an essential feature of the case. Fractures
are also classified as _complete_ or _incomplete_, the former term
implying injury to the whole thickness of the bone, while the latter
are separately classified: (_a_) _Fissure_, in which there is a line
of fracture by which there is no complete separation of fragment, it
being essentially a crack; (_b_) the _green-stick fracture_, such as
occurs in the young, where the bone is not thoroughly calcified, but is
capable of bending to some extent, while a portion of it breaks; (_c_)
_depressed fracture_, which is generally produced by direct violence,
and occurs in a flat bone, _i. e._, the skull, the scapula, etc.;
(_d_) _detachment_ of a fragment or separation of an epiphysis; (_e_)
_partial fractures_, corresponding much to the green-stick, but without
deformity or change in shape or position.
[Illustration: FIG. 276
Impacted fracture of the shaft of the femur produced by a fall upon
the knee in a man aged eighty-three years. Illustrating impaction.
(Bryant.)]
Fractures are also described by means of the following adjectives,
which practically explain themselves, for instance:
_A._ _Complete_, _transverse_, _oblique_, _longitudinal_, _dentated_,
etc. _Spiral_ fracture is also described and occasionally seen. It
involves only the long bones, and not only implies a considerable
degree of violence, but is itself regarded as exceedingly serious.
_B._ In number they are _single_, _multiple_, or _comminuted_, as when
there are a number of fragments.
_C._ They are often _impacted_, which means that one fragment is
driven into and more or less embedded in the other. This impaction or
interlocking of fragments occurs usually in the neck of the femur and
the lower end of the radius. In the former locality it is advisable not
to interfere with it; in the latter it should always be dislodged in
order to restore the fragment to its proper position (Fig. 276).
_D._ As to their nature and location, fractures are referred to as
_pathological_, _gunshot_, _intra-articular_, or _extra-articular_,
etc., the latter terms referring to involvement of a joint. If blood
can escape from the site of the fracture into a joint cavity, or if
synovial fluid can escape from the latter into the former, then the
fracture is called _intra-articular_.
_Pathological fractures_ imply preëxisting disease. This may be
constitutional, as in the case of the fragilitas ossium, already
described in the chapter on the Bones, or it may be due to some
secondary deposit of cancer or a primary sarcoma. In adults, especially
those with a cancerous history, any spontaneous fracture, or even
one occurring with trifling violence, should lead to suspicion of a
metastatic focus in the bone at the site of its yielding. The atrophic
changes which notably occur in various bones as old age comes on lead
also to a condition which is pathological, _i. e._, it permits of
fracture from what would appear to be a trifling injury.
_Gunshot fractures are practically always comminuted_, save perhaps
some of those inflicted with the modern military weapons. A Mauser
bullet will frequently make an almost clean perforation, but the
gunshot fractures met with in civil practice are almost invariably
comminuted, especially those of the skull (Fig. 277).
_E._ The term _compound_ is applied to any fracture in which there is
wound of the soft tissues and so located as to permit access of air
to the injured bone. There is a distinction between a compound and a
complicated fracture. A fracture of the femur accompanied by a gash
or extensive wound, so long as air cannot come in contact with the
broken bone, would be described as a fracture of the femur complicated
by a lacerated wound. On the other hand, if through the slightest
puncture of the skin, even at a distance from the fracture, air can
even theoretically enter and come in contact with bone surfaces at the
site of the fracture, such an injury constitutes a compound fracture.
This distinction is not a trifling one, for upon the exclusion of air,
which to a certain extent means the exclusion of germs, depends very
much the rapidity and perfection of recovery. _Compound fractures
are all dangerous in proportion as they permit of infection_, and
while air infection is not necessarily the most serious of any, it
nevertheless is often sufficiently so to set up sepsis and interfere
with consolidation, even if it does not prevent it. Fractures are
made compound by _direct violence_ from the outside or by _indirect
violence_, as where a bone end perforates soft parts and the skin. Even
if a sharp point of bone thus protruded from within is quickly drawn
back again it is enough, since both the skin and the air in contact
with it are sources of germ activity. Thus it may happen that a slight
and apparently trivial injury of this kind is more serious than one
which is extensive.
[Illustration: FIG. 277
Skiagram of compound comminuted (gunshot) fracture of elbow, inflicted
with a Dumdum bullet. Illustrating the extreme of comminution. (Lexer.)]
_F._ _Epiphyseal separations_ constitute a somewhat distinct form of
injury, having at the same time the importance and dignity of fractures
in the truer sense of the term. In the chapter on Diseases of the
Joints will be found a table of the ages at which epiphyses unite. In
childhood and youth a fracture near the joint is most likely to partake
of this character, and it is of importance that it should be recognized
as such when it occurs. Injuries occurring beyond the ages mentioned in
the table are not likely to be of this character unless ossification is
delayed by some morbid process.
By virtue of their occupations and habits men suffer fractures more
frequently than women. Fractures are, moreover, ten times as frequent
as are dislocations. The aged, by virtue of their atrophic changes,
are more subject to fractures than others. Fracture in the vicinity of
certain joints predisposes as well to dislocation of these joints,
and it often happens that the treatment for the dislocation is
reduction and treatment of the fracture. So far as the external causes
of fracture are concerned they are frequently referred to as (_a_)
fracture by external violence, and (_b_) fracture by muscle activity.
The former are easily explained; the latter occur from excessive muscle
action, as in violently throwing a ball, or, as in one case with which
the writer was conversant, where a colored preacher in the vehemence
of his gesticulations fractured his own humerus. Obviously the long
or large bones are more liable to fracture than those which are short
and irregular. Certain bones, especially the clavicle, are peculiarly
exposed.
_Intra-uterine fractures_ have not as yet been mentioned. These occur
during the intra-uterine life of the fetus; this term does not include
such fractures as may be inflicted during delivery with or without
instruments. In a fetus already affected with congenital rickets it
may not require any severe contusion upon the abdomen of the mother to
inflict a fracture. Starvation (_i. e._, scurvy, syphilis, and struma)
in the mother may so disturb nutrition as to weaken the osseous system
of her offspring.
Such previous conditions as ensue from osteomyelitis (_i. e._, caries
and necrosis) may often weaken the bone. Nevertheless with distinct
necrosis there is usually so much new bone formation as to strengthen
rather than weaken the part. Bones may also become fragile as the
result of syphilis, especially when gummas develop within them.
Fractures frequently produce certain _deformities_ which are more
or less conspicuous and easily recognized. They are designated as
_angular_, _lateral_, or _axial_ (_i. e._, when the axes of bone
are considerably displaced, even though they may be more or less
parallel), _longitudinal_ (when ends overlap), _rotary_, etc.; while
by the interposition of muscles and other soft tissues more or less
wide _separation_ may be produced, the same result occurring when the
olecranon or the upper half of the patella is widely separated from the
main bone or portion by muscle pull.
DIAGNOSIS OF FRACTURES.
Fractures give rise to subjective symptoms and objective signs. In
diagnosis the history is also of value, especially in those cases
where it is a question of some constitutional affection and a minimum
or absolute absence of violence. The apparent immunity which the
intoxicated enjoy is in large measure due to the fact that by virtue of
their condition one of the predisposing causes of fracture is avoided.
There can be no doubt but what _muscle tension_, due to voluntary or
instinctive efforts to avoid harm, is a contributing factor in the
separation of many bones or their processes. A patient stupidly drunk
will not make these efforts, and will fall in a relaxed condition,
in which violence will probably be much less extensive, and the
consequences less disastrous than if he made an effort to save himself
from falling.
_Pain and tenderness_ are evidences of injury, and will often serve for
its location; even the reference of pain is somewhat suggestive. It
is stated as a universal rule that when pressure is applied laterally
or in the long axis of a bone and evokes pain, referred to a distance
from the point where pressure is made, it will indicate fracture at the
point to which it is referred. There is always _impairment_, usually
_loss of function_, while effort to move a thus injured limb will give
rise again to localized pain and tenderness. The pain of contusion is
usually diffuse, and that of fracture is referred to a limited area.
The tenderness produced by handling or examination will vary with the
stolidity, the age, and the character of the patient, as well as the
nature of the injury.
Objective signs are _crepitus_, _mobility_, _deformity_, _ecchymosis_,
_redisplacement_. _Crepitus_ means the sensation of grating or rubbing
produced when fractured bone surfaces are moved upon each other. It is
recognized by the sense of touch, sometimes by that of hearing. Its
presence is pathognomonic, but its absence is a negative sign, and
an effort should be made to obtain it. To repeat the demonstration,
especially to demonstrate it to others, means superfluous manipulation,
which is not to the best interest of the patient. Crepitus, then,
should be carefully sought for; once detected it should be sufficient.
_Abnormal mobility_ is explained only by fracture. It is easy to
detect it in the shaft of a long bone, but when near the joint it
is confusing. Its determination by manipulation is not seen in
green-stick or impacted fracture unless these are further broken up
by manipulation. When evident it should serve as a caution against
unnecessary or rough handling, for if it be easily recognizable
crepitus need not be sought.
_Deformity_ is a striking and pathognomonic feature of fracture. It
may be imitated by hematoma or sudden swelling of the soft parts or
of joints. It may consist of shortening or of angular, lateral, or
rotary displacement, or perhaps of depression or indentation. Careful
inspection, then, and palpation should precede other methods of
examination, as they are often sufficient to indicate the location, the
nature, and sometimes even the character of the active causes.
_Inspection of the injured part alone is not always sufficient._
Careful comparison between the two sides of the body should be made
in order that actual measurement or comparative examination may
reveal what mere inspection would not. In connection with inspection
it should be ascertained whether the individual has ever received
previous injuries. The writer recalls a case where a physician claimed
a recovery after fracture of the femur, treated by incompetent method,
yet with ideal result, inasmuch as he said there was absolutely no
shortening. A personal question, however, to the patient revealed the
fact that he had had the other thigh broken some years previously, and
that an apparently similar amount of shortening followed in each case.
The ordinary indications of fracture are frequently followed by
_ecchymosis_. This will appear at a date corresponding with the depth
of the injury beneath the skin (it may occur within an hour or three
or four days). The blood will follow the fascial planes and work its
way to the surface along them. The sign is of the greatest value in the
diagnosis of basal fractures of the skull and certain fractures of the
hip and pelvis. When it occurs after an interval it is a confirmatory
rather than a promptly available sign.
_Redisplacement_ implies that the parts when properly put into
apposition quickly fall out of it unless mechanically supported--that
is, they _do not stay reduced_. This sign is not universally
applicable. It applies especially to the fractures of the long bones of
the extremities, and particularly to the humerus, the femur, or double
fractures of the radius and ulna in the forearm or both bones of the
leg.
=Diagnostic Aid Afforded by the Fluoroscope and the Skiagram.=--Since
Röntgen’s memorable discovery the _cathode or x-rays_ have been of
greater and greater use in the diagnosis and portrayal of injuries and
morbid conditions in the osseous system. To such an extent is this
now true that well-equipped hospitals have ample conveniences for
fluoroscopic and photographic work, while many medical men are doing it
in their private practice. There can be no question but that diagnosis
and methods of treatment have been made more perfect since this new
method of investigation has been made available. On one hand, however,
it has led perhaps to something of neglect of the methods previously in
vogue, which necessitated anatomical knowledge and logical reasoning.
On the other hand, the knowledge thus obtained has been sometimes a
two-edged sword, since the display of skiagrams, or _x_-ray pictures,
in court has too often worked harm or discredit to the surgeon or the
institution with which he was connected. Moreover, even this method of
diagnosis, with its apparent certainties, is not always reliable, and
disappointments have sometimes followed.
=Intra-articular Fractures= are subject to peculiar complications which
enhance the difficulty of treatment and jeopardized the result. Among
the more common of these are the following:
1. Too wide separation of fragments by hemorrhage or distention, with
failure in resorption of fluid before fixation in bad position has
resulted.
2. Complete or partial rotary displacement, preventing proper
apposition of bone surfaces.
3. Interposition of soft or fibrous tissues between fragments by which
bony union is prevented. This is conspicuously common in fractures
of the olecranon and patella, and is of itself sufficient reason to
justify operation in otherwise suitable cases.
4. Separation of a fragment within a joint capsule, by which its blood
supply is cut off, making it essentially a foreign body. This occurs
especially at the anatomical necks of both the humerus and femur.
5. Exuberance of callus with consequent limitation of motion.
6. Insufficient amount or absence of callus, which, when bone ends are
bathed in joint fluids, is not often thrown out.
All of these are _immediate consequences_. The following are among the
more undesirable _remote consequences_ of the same injuries:
1. Exuberant callus, which may be the result of too early attempt to
move the parts, or may result from other causes; it offers more or less
mechanical obstruction to joint movements.
2. Separation of fragments to an extent precluding the possibility of
repair, and interfering with function.
3. Pseudo-ankylosis, as a result of condensation and organization of
blood clot between joint surfaces.
4. Adhesion of tendons to surrounding callus or within their own
sheaths.
5. Displacement and distortion of bone ends with vicious union, for
which the medical attendant is _sometimes_ responsible. Unfortunate
consequences of this kind are generally seen at the elbow after
fractures of the condyles; at the wrist, after incomplete reduction of
Colles’ fracture; at the hip, when insufficient traction has been made;
at the ankle, after the complete form of Pott’s fracture.
6. Exostoses and osteophytic outgrowths, which often complicate
fractures.
7. Absorption of bone, which is usually seen after fractures of the
neck of the femur.
8. Involvement of nerves by pressure of callus, most often seen about
the elbow.
9. Thrombosis leading to obliteration of the deeper and enlargement of
the more superficial veins.
10. Edema, also the result of venous obstruction by pressure of callus.
11. Chronic hydrarthrosis.
12. Arthritis deformans traumatica. This is usually a remote result of
fractures, and manifests itself by slow changes in shape and position,
with deformity and disability. It occurs most often in the aged.
13. Necrosis, which may be the result of failure in the process of
repair and will probably necessitate operation.
14. Malignant changes. These have to do with the occurrence of sarcoma
in bone callus, a complication which is known to occasionally arise.
(See Sarcoma.) It also refers to primary sarcoma, by which bone is
weakened, or secondary carcinoma, which produces the same result.
15. Syphilis. Chronic syphilitic disease is well known to weaken bones
by atrophic processes as well as by the deposition of gumma. It is
known also to delay, or sometimes almost prevent, the process of callus
formation, ossification, and later absorption. Syphilitic patients with
fractures need to be kept under antispecific medicines.
REPAIR OF FRACTURES.
The immediate consequence of a fracture is outpour of blood both from
the broken-bone surfaces and from whatever other tissues may have been
lacerated. This produces, first, a hematoma, which is followed by a
certain degree of local edema, perhaps even of general edema of the
distal parts. The latter will subside with a rapidity proportionate
to the promptness of suitable treatment and the nature of the injury.
The blood begins to coagulate within a short time, while with the
disappearance of the more fluid portion granulations begin to form from
the periosteum, as well as bone surfaces, externally and internally,
and even from the marrow. The clot loses its original characteristics
and is permeated more or less rapidly by granulations. With the site
of the injury wrapped in a mass of granulation tissue we speak of the
so-called _provisional callus_, whose amount will depend upon the
severity of the injury and the accuracy of the replacement of the
parts. If laceration has been but trifling and the bones are accurately
apposed the amount of callus will be small, otherwise it may be
large; so large, in fact, as to be easily palpated and even to cause
edema and pain by pressure. Repair of the fracture is effected by the
gradual conversion of this callus into cartilaginous tissue and then
into bone. So much of it, at least, as lies on the outer side of the
bone and is known as _external callus_ goes through this change. The
_internal callus_, _i. e._, that within the marrow cavity, undergoes a
more direct transformation, which amounts to immediate ossification.
The internal callus usually ossifies completely, and then forms a
_medullary plug_ that serves as an internal splint and affords support
and strength. In time it completely disappears, this time varying in
different cases.
The external callus is converted into bone by passing through the
intermediary condition of cartilage. Between the broken-bone ends
granulation occurs more slowly, and repair at this point is delayed,
partly because of poor circulation and nutrition; but the internal
callus acting as a bobbin within, and the external callus acting as a
solder on the outside, give sufficient support and strength to effect a
final and absolute ossification of all the interfragmentary granulation
tissue. When the time comes when callus is no longer necessary it
begins to disappear by absorption. When everything proceeds normally
callus is absorbed in a proportion commensurate with its loss of
utility. When bone ends have badly united considerable callus remains
permanently. When apposition has been ideal it almost completely
disappears, even the medullary cavity being restored.
Fragments which are completely detached may be reunited by practically
the same primary process, but fragments of considerable size usually
become surrounded by granulation tissue, by which they are nourished
and may be finally reunited, with more or less departure from their
original shape and location. It is in this way that a comminuted
fracture may heal. Fragments that are separated sometimes necrose and
have to be removed.
[Illustration: FIG. 278
FIG. 279
Compound fractures resulting from arm being caught in belting and wound
around shafting. End of radius united to ulna and lower end of ulna to
the radial fragment. Pseudarthrosis of humerus, thrice operated, the
third time in the Buffalo Clinic. (Skiagram by Dr. Plummer.) (Arch.
Phys. Therap., May, 1905.)]
The repair of the flat bones is effected by a similar process, which
is referred to as callus formation. In the skull it is brought about
chiefly through the agency of the diploë, whose powers in this
direction are somewhat limited. Cancellous bone tissue usually throws
out but little callus. Its repair occurs from within. _Cartilage_
heals by a very similar process, though it is not now ossific tissue
but _fibrous_ which reunites the fractured surfaces. Instances of both
kinds can be seen when a fracture has crossed a joint surface.
In a compound fracture much will depend upon the existence or absence
of septic complications. In a clean wound, whence blood and fluid
may have escaped, there will be little but granulation tissue.
Should this wound suppurate the exposed bone surfaces will undergo
at least a superficial necrosis, necrotic particles being removed
by the same granulation tissue which will later bind the bone ends
together. Here, too, the internal callus plays the largest role in the
process of repair. The bone tissue first formed is always coarse and
soft. Complete calcification and restoration of original density and
vascularity occur slowly. Neither cartilage nor bloodvessels alone
appear capable of forming bone; the latter is produced only under the
influence of the _osteoblasts, which penetrate from the periosteum and
the bone itself_ along the course of the bloodvessels.
The process is one of conversion of blood clot into provisional callus,
which then changes into granulation tissue or into cartilage, both of
these materials undergoing subsequent conversion into bone through the
medium of the osteoblasts and osteoclasts (or giant bone cells), the
neighboring bone itself undergoing a rarefying ostitis, to change back
into its original condition with the final changes of the callus.
Repair of intra-articular fractures has already been described as
influenced by the presence of synovial fluid and cartilage. The latter
does not proliferate, and the line of fracture usually appears as a
groove on its surface. At epiphyseal junctions union is usually rapid
and satisfactory, for the changes taking place at this point are in the
direct line of what is needed for repair.
DELAYED UNION; NON-UNION.
The above description refers to the process which is supposed to take
place in normal bone repair. When, however, this is disturbed, as it
may be from a variety of causes, there may be _delayed union_; when it
completely fails we have _non-union_. General conditions have bearing
on these local failures. Whatever makes a strain upon the system may
interrupt the process, _e. g._, pregnancy, lactation, exhausting
hemorrhages, acute diseases, starvation. Again, failure may result from
purely local conditions, such as marked displacement, and particularly
the intervention of some of the soft tissues, or any foreign body.
_Suppuration_ will also frequently cause great disappointment. The
humerus is the bone most often troublesome in this direction; next
the bones of the leg, the femur, and the bones of the forearm. It is
necessary to distinguish between delayed union and absolute non-union.
In the former normal processes may be simply retarded. _When thus
delayed they may be stimulated_ by rough handling, rubbing the bones
together, or by perforating the callus with the point of a drill, from
several directions. This method of drilling was introduced by Brainard,
of Chicago. The existence of syphilis has much to do with delay, and
should be combated by free use of antispecifics. Many patients will be
found to have _phosphaturia_, _i. e._, to be eliminating phosphates
which should go to repairing the bone. Such patients should be given
phosphoric acid, with some of the phosphates, preferably of calcium,
in order to make up for loss in this direction. Much can be done also
by massage, and by everything which stimulates nutrition and general
health (Fig. 280).
[Illustration: FIG. 280
Vicious union with great deformity after fracture, requiring extensive
operation. (Buffalo Clinic.)]
In _non-union_ efforts at repair are at a standstill; the bone ends
become rounded off, the marrow cavity is plugged on either side, while
in time the surrounding granulation or connective tissue undergoes
condensation, as well as organization, and a _capsule_ is formed in
which a certain amount of fluid resembling true synovia collects,
and thus is formed sometimes an almost perfect _pseudarthrosis or
false joint_, whose perfection as a joint must be admired, although
its presence is so deplored. The causes of non-union are now better
understood than formerly, and consist largely in the interposition
of fibrous and muscular tissues, that act as a barrier and keep the
granulation tissue or the callus on one side from coalescing with that
on the other.
_Treatment_ of these cases will vary with their causes. In _delayed
union_ patients should be encouraged to use the parts, thereby causing
greater activity, but in the presence of an actual _false joint_ no
method is of avail except that of actual exposure, by incision, with
removal of all intervening fibrous tissue, and freshening of the bone
surfaces by saw or chisel, the endeavor being to so shape them that
they may lie in contact, and then be so maintained, by some mechanical
expedient, such as a wire nail or suture, an ivory peg, a chromicized
tendon, a bone ring, a small metal brace fastened with screws, or by
any other expedient which may suggest itself to the ingenuity and
the means of the operator. There are, however, occasions when one
deliberately endeavors to secure a pseudarthrosis, as after ankylosis
of the shoulder-joint, if in making powerful effort to break up
adhesions the neck of the humerus should snap it would be better to
prevent union rather than favor it, as in this way something resembling
the original joint, so far as function is concerned, would be obtained.
At the hip, also, after such an accident, the same principles may be
adhered to or more deliberately secured by a subcutaneous osteotomy, as
is sometimes done for relief of deformity.
_Fibrous union_ implies such organization of granulation tissue as
converts it into simple fibrous or ligamentous tissue, the change
stopping here and not going on to formation of cartilage or bone.
There are three localities especially where fibrous union is sometimes
the best that can be obtained and often proves sufficient of itself;
these are the olecranon, the patella, and the neck of the femur.
Even though the halves of the patella be separated by two inches of
ligamentous tissue the patient may still have reasonable use of the
limb. A separation of half an inch to one inch at the olecranon does
not materially disable the arm, while at the hip-joint two or three
inches of ligamentous tissue between the main end of the bone and the
fragment will not totally interfere with locomotion, except so far as
it permits an equivalent amount of shortening of the leg. There are,
then, occasions especially when the hip is involved in elderly and
decrepit people, when ligamentous union is the best that can be hoped
for or attained.
TREATMENT OF FRACTURES.
In principle the treatment of fractures is very simple. It consists
in _putting the parts in apposition and maintaining them there_ for
sufficient time to permit of complete repair. That which is so simple
in theory is often very difficult and sometimes even impossible in
practice, made so by the nature of the injury or the disposition of the
patient. In the aged, who cannot lie long in one position for fear of
pulmonary stasis; also in the insane, in the epileptic, and in those
suffering from delirium tremens, will be met difficulties which are
insuperable. In such instances the first indication is to preserve the
life of the patient, the second is to get a good result, the third
is to do the best we can. Good management is not the least important
feature of such treatment. This will include suitable nutrition,
provision for elimination, prevention of bed-sores or pressure-sores,
and many other less important features.
Diagnosis having been made, the surgeon should study how he may best
carry out the fundamental principle of putting the parts in apposition
and so maintaining them.
The greatest obstacle to reduction and maintenance in position is
_muscle pull_. After an injury of this kind there will be more or less
muscle spasm, the more powerful groups displacing bones in the natural
direction of their pull. In the humerus and femur especially all arm
or thigh muscles will coöperate to produce shortening. As indicated
in the chapter on Joint Affections, nothing so thoroughly overcomes
chronic muscle spasm as _traction_. The principle underlying treatment
by traction is exceedingly simple, but there are numerous ways and
mechanical expedients for effecting it. In the lower limb, whether this
shall be done by anterior suspension, by weight and pulley, by elastic
contraction, or by some of the more complicated splints, matters little
so long as it be efficiently made. Of all these methods it may be said
in general the simplest is the best. In the upper extremity traction
may be made by similar methods with the patient in bed, or the patient
may be allowed to rise and be about with a weight hanging from the
elbow or some simple expedient of this kind.
The method of traction is one to be combined usually with further
protection, by which not only longitudinal but lateral displacement
maybe overcome. This suggests the use of _splints_ in addition to mere
traction methods.
It is not always possible to put in operation at first that method
which we may prefer a little later, as _swelling_ is usually so
pronounced as to make it advisable only to put the parts at rest and
hasten absorption. The same is true of hemorrhage. In rarer instances
it may be a question as to whether the distal parts may undergo
gangrene from the disturbance of circulation. These are matters to be
duly regarded before the later and more complete dressing. _Mechanical
aids_, usually in the shape of splints, are therefore necessary. The
physiological rest which it is so necessary to ensure will lead to a
certain wasting of muscles and stiffening of joints, which are only
temporary, but which by no means lessen disability when splints are
removed. _That splint is best for a given case which best fits it and
permits the surgeon to carry out its peculiar indications._ The writer
is opposed to manufactured splints, as they seldom fit the part. This
can be obviated by packing cotton or other compressible material into
the splint. For temporary purposes they will frequently suffice. For
fixed dressing, however, it is preferable to make a splint which shall
fit the limb to which it is affixed. Immobilization is difficult of
accomplishment and at many points impossible. Thus in fracture of the
ribs or clavicle it is impossible to avoid a certain amount of motion
with each respiratory effort, even though an uncomfortably tight
dressing be applied.
Splints are made of various materials, metal, wood, various
compositions hardened in molds, plaster of Paris, or some of its
substitutes, _i. e._, glue, soluble glass, or a composition like one
made of equal parts of powdered starch and fine isinglass, added to a
solution of potassium silicate, this being allowed to stand for several
days, after which a little fine boric acid powder is added; when this
is painted over gauze dressings it solidifies and forms a light and
rigid splint. There is one objection to all methods which comprise a
solution that hardens slowly--that is, that during the time required
for the purpose redisplacement may occur. It is not advisable to dress
a recent fracture in a wet pasteboard splint or in such a composition
as that mentioned above. Later, when a certain amount of consolidation
has already occurred they may serve a useful purpose.[38]
[38] Jenkins’ packing, such as is used on some engines, has been
recommended by Spotswood as a substitute for plaster-of-Paris
bandages, its advantages being that it is not affected by any
antiseptic washes as a plaster dressing would be, that it is lighter,
and that by placing it in hot water it can be molded to assume the
shape of the limb.
There are two methods of using plaster of Paris: one is gauze bandages
sprinkled with it, rolled, and kept ready for use, to be placed in
water at the time of their employment. A limb may be enveloped in
these, after being covered with a layer of wadding or some other
protective material, by which the plaster shall not come in actual
contact with the skin. It is also a good plan to place a strip of tin
or pasteboard along the exposed surface of the limb, over which the
surgeon cuts to remove the splint. Thus one may avoid any danger of
injuring the skin with the point of the knife. It is also a good plan
to make at least a part of this cut before the plaster has sufficiently
hardened, _i. e._, to do most of the work, leaving perhaps a layer or
two of gauze to be cut through some time later. It is necessary to
impress the fact that when a quickly hardening fixed dressing is used
approximation should be ensured by the greatest attention, maintaining
it until the splint is so hardened that redislocation is impossible.
Another method of using plaster of Paris is by sopping strips of
surgeons’ lint, ordinary canton flannel, or almost any other similar
material, in plaster-of-Paris cream, then molding these to the injured
limb, maintaining the same rigid precaution as to the proper position
of the same while the splint hardens. In this way a splint can be
adapted to the part, and, at the same time, made removable, permitting
as frequent access to it as may be desired.
COMPOUND FRACTURES AND THEIR TREATMENT.
As already stated, it is the communication of fractured bone surfaces
with the external air which makes a fracture compound in the strictly
surgical sense. This may occur through a minute and tortuous opening
or through a large and extensive wound. Although the communication is
with the atmosphere the danger comes not so much from germs floating
in the air as from those on the surface of the body and within the
pores of the skin, or else from foreign material admitted through the
external wound. Obviously the great danger is of septic infection.
Whether the tissues may prove more or less susceptible, and thus
resist or break down, cannot at the outset be foretold. This leaves
but one imperative ride to follow, _to act in every instance as though
serious injection had occurred and to take precautions accordingly_.
Even a small puncture made by a spicule of bone may permit germs to
be withdrawn into the tissues as the bone is replaced. If, then, the
surgeon seals such a puncture he necessarily takes the chances and must
abide the result. Whether he shall do this or not will depend upon the
patient and the injury. At all events, the site of puncture should be
carefully cleansed and disinfected and the case so dressed that it
may be carefully watched. Complete sterilization of every particle of
exposed tissue is absolutely necessary, and for this purpose hydrogen
dioxide or some of its later substitutes will prove effective. A
protruding splinter of bone should be removed with cutting forceps,
unless the wound must be enlarged as a part of the treatment of the
fracture. In most instances it will be safer to pursue this course,
_i. e._, to extend the wound which makes the fracture compound, to a
degree permitting thorough exploration and cleansing. Not infrequently
fragments of bone will be found, which when nearly or completely
detached should be removed. Such a free opening permits also of wiring,
or other means of fastening together bone ends, by which apposition may
be more perfectly secured. _A compound fracture which has been long
unattended may be safely assumed to be septic._ Here free incision,
with cleansing and ample drainage, will be a far safer course than
non-compliance with the general rule.
_Compound fractures of the skull_ are nearly always depressed
fractures, and practically always call for operation. Their proper
treatment will be dealt with when considering Injuries to the Head. A
fracture of the ribs may be made compound by penetration of a sharp
bone end, and such injury to the lung as may permit air to escape into
the pleural cavity. Such a pneumothorax may be followed by a hemothorax
and hydrothorax, and these perhaps by empyema. Compound fractures of
the pelvis are not infrequently complicated by perforation of the
bladder or bowel, or rupture of the urethra, or some other serious
visceral injury which may determine their fate. Compound fractures
are difficult of treatment because they entail frequent changes of
dressing and prevent the use of desirable splints. These fractures
are also sometimes so serious as to necessitate amputation, which may
be necessitated either by such comminution of bone as to make repair
impossible, or such injury to vessels as may determine gangrene. If
the circulation can be shown to be sufficient, either at the time or
perhaps by delay of a few hours or a day, a limb may be saved by the
resection of one or both bones, which in pre-antiseptic days would have
required amputation.
The surgeon does not always see these cases in their recent or
fresh state. He may be called to a case complicated by suppuration,
cellulitis, and sepsis. Here though amputation may be required he may
still delay it, hoping to improve local conditions, and thus to make it
more promising, or he may have to resort to various expedients, such as
suspension with constant irrigation, or temporary packing with yeast,
in order to justify any further attack upon the parts already involved.
In the treatment of compound as of simple fractures we should never
lose sight of the _dangers of too tight bandaging and of pressure
sores_. I have seen both these lead to gangrene, with its necessary
mutilation, in cases where the attendant has forgotten the proneness of
injured parts to swell, and has either not allowed for this within the
dressings or has not atoned for it in time when it has already occurred.
In the treatment of all these cases the operator should never forget
the medicolegal aspects of such a case nor the necessity for constant
attention and caution on his part. He should remember that his minutest
precautions will often be disobeyed. He may, however, be cheered
by the fact that only in cases of carelessness will he incur legal
responsibility.
SPECIAL FRACTURES.
Fractures of the skull and of the vertebræ will be considered under the
respective headings of Injuries to the Head and to the Spine.
FRACTURES OF THE NOSE.
The nose is the most frequently broken of all the bony parts about the
face. One nasal bone or both may be broken, and each may be separated
from its bony supports as well as from the other. The fracture may be
compound in either direction, most frequently so into the nasal cavity,
as a result of which infection may as easily take place from within as
from without. The cartilages may also participate in the injury.
The injury would be easy of recognition were it not for the amount
of swelling that often accompanies it. The signs are mobility and
crepitus, with more or less deformity. So long as the nose can be
grasped between the fingers recognition of fracture is easy. If
swelling prevents this an instrument or the finger can be passed into
one nostril and combined manipulation practised. There is generally
more or less bleeding from the nose, and sometimes considerable
emphysema. Swelling and ecchymosis are also often pronounced. This
will all subside under cool and soothing applications. The most
important indication is to replace the nose and hold it where it should
remain. The difficulty is increased by the efforts which the patient
instinctively makes to dislodge clot or secretion. The importance
of accurate reposition is in some cases sufficient to justify an
anesthetic and instrumental help. This will permit of the application
of such force as may be necessary to elevate or to shift fragments,
while a gutta-percha splint may be molded upon the outside, or a
sterilized pin or needle made to transfix the nose from one side to
the other (Mason), passing behind the fragments and through the septum
in such a way as to keep it from dropping backward. A good plan is to
introduce a tube into each nostril, perhaps a piece of silk catheter,
around which a certain amount of gauze can be packed, and which can
thus be used as an internal splint, while on either side and externally
a little roll of gauze is held in place by adhesive plaster crossing
the cheeks. The operator should take as much pains to see that the
septum is in its original position as in attending to outside and
cosmetic effects. The septum can be controlled by a pair of forceps.
A nose properly held in place will heal within a few days, to a point
requiring little if any support. A transfixion pin should not be
needed, if used, for more than four or five days. An internal splint
should be removed each day, so that the nose may be sprayed with
cleansing solution (Dobell’s) and retained secretions removed.
The disfigurement resulting after this injury is dropping in at the
root of the nose, constituting the so-called _saddle-nose_ defect.
Such disfigurement as results can be later atoned for by subcutaneous
injection of paraffin. (See chapter on Surgery of the Face.)
FRACTURES OF THE SUPERIOR MAXILLA, WITH OR WITHOUT OTHER BONES OF THE
FACE.
The more protected portions of the upper jaw are rarely fractured,
save by extreme violence. The _alveolar process_, with one or several
teeth, may be partially or completely detached. Such fractures are
compound, and after replacement need antiseptic mouth-washes as well as
other attention. Usually the teeth in the fragment can be utilized for
the purpose of fastening it back into place by means of the uninjured
teeth, retention being secured by wire or waxed silk. Extensive
detachment may necessitate sutures through drill holes. The lower jaw
can usually be utilized as a splint for the upper by binding the jaws
firmly together and feeding the patient on fluid food. When one or two
teeth are loosened or displaced it will often be possible, if they
can be promptly secured, to successfully _reimplant_ them in their
sockets. Both the sockets and the teeth should be thoroughly cleansed.
After replacement it will be necessary only to ensure absolute rest and
retention in position.
In regard to other _facial bones_ there is no injury which may not
occur, as the result of direct violence. The _zygoma_ and the _malar
bone_ may be broken away, or the entire collection of facial bones may
be loosened from their connection with the bones of the skull proper.
The margins of the _orbit_, or its walls, may also be injured, and the
sinuses opened, with perhaps more or less entrance of foreign material.
These fractures are generally compound and are accompanied sometimes by
injuries to the soft tissues. It becomes then a question not merely of
cosmetic result, but of avoiding infection and saving life. The latter
is the more important, and measures should first be directed to that
object. Satisfactory results can be attained by drilling and holding
bone fragments together with tendon or other sutures, and by neatly
trimming and cleaning wounded surfaces and bringing them together.
Subcutaneous sutures should be used for this purpose.
FRACTURES OF THE INFERIOR MAXILLA.
This bone is broken nearly as often as the nose, and almost invariably
by direct violence. Here, as in the upper jaw, there may be trifling or
serious fractures of the _alveolar process_, which should be treated
on the same principle as above set forth. Fractures of the rami occur
more often in those parts which are occupied by teeth, or from which
teeth have dropped out by senile changes, the jaw being weakened at
these locations. The most frequent seat of fracture is near the middle
line. Fractures of the _ascending ramus_ and of the upper processes
are rare. Double fractures are not infrequent, the lines of separation
being rarely symmetrical. The gum and the skin are often torn and the
majority of these fractures are compound. The bone is considered to
be weakened at the dental foramen; at all events it often yields in
this vicinity. By fracture with much displacement posterior to this
opening the inferior dental nerve may be injured or torn. The condyle,
after extreme violence, has been known to have been driven up into the
cranial cavity through the base of the skull. _Gunshot fractures_ are
nearly always comminuted (Figs. 281, 282 and 283).
[Illustration: FIG. 281
Use of silver wire in fixation of fragments by utilizing the teeth.]
[Illustration: FIG. 282
FIG. 283
Bandage and splint for fracture of lower jaw. (Bryant.)]
The _signs_ of fracture of the lower jaw are unnatural mobility,
crepitus, displacement, pain, and loss of function. No bone in the
body is more easily investigated by sight and touch, and recognition
of these fractures is usually easy. Pain is provoked by attempting to
move the jaw, even in talking, and depends on the extent to which the
inferior dental nerve is injured. Irregularity in the line of the teeth
will sometimes permit recognition. These fractures furnish excellent
illustrations of the effect of muscles in producing displacement. Those
of the tongue and the floor of the mouth, as well as the anterior
muscles of the neck, will pull the fragments in various directions,
according to the direction of the line of fracture and its location.
This displacement may be trifling or serious. These fractures are
often compound, internally or externally, such injuries constituting
an unpleasant complication, but affording occasionally an opportunity
for fastening fragments by drill or wire suture, which would
otherwise require an opening to be made. In every instance antiseptic
mouth-washes should be frequently used.
=Treatment.=--The treatment is simplified when the dentition is good
and regular so that the fragments may be fastened together with wire
or waxed silk ligature around the adjoining teeth, and then fixation
accomplished with a simple molded gutta-percha or plaster-of-Paris
splint, by which the lower jaw is held firmly against the upper. Such
a dressing is held in position by a four-tailed bandage (Fig. 283). A
silk or wire loop, used for the purpose just mentioned, should include
two teeth on either side of the fracture, for by constant tension the
nearest tooth will soon loosen, and if this were next to the break
the effect of such displacement would be injurious (Fig. 281). When
the line of fracture is oblique there is often greater difficulty in
adjustment.
While the simplest means by which the fragments may be kept in position
are the best, there should be no hesitation in serious cases to resort
to operative measures having for their purpose the insertion of wire
sutures or their equivalent. These are inserted after drilling the bone
at suitable points, and are introduced with a view to their subsequent
removal, the ends being left projecting in order to facilitate this. In
clean cases, where the incision is made in unbroken skin, the ends may
be twisted short and turned in, previously to closing the wound. Such
operative treatment is required when there has been a double fracture,
the central fragment being badly displaced by groups of muscles which
tend to pull it downward and backward.
A dentist should be consulted, as he may be able to make a mold and
then construct a plate or _interdental_ splint, by which a more perfect
reposition may be effected.
Swelling, emphysema, ecchymosis, etc., may be treated in the usual way.
Irritation is likely to provoke free secretion of saliva; this may be
combated by small doses of belladonna. Patients should be fed by fluid
or thin semifluid food, and mouth-washes should be frequently used.
FRACTURES OF THE HYOID BONE.
The hyoid may be broken by direct violence, either locally applied or
by forcing the head backward. Fracture of the bone itself is not so
serious as the lesions which accompany or follow it, either hemorrhage
or inflammation, with _edema of the larynx_, which may impede
respiration or cause strangulation. Fracture produces difficulty in
breathing, swelling, and pain on talking. It is doubtful if bony union
is attained, but fibrous union answers equally well. The treatment
consists essentially of physiological rest. Edema may necessitate
tracheotomy, and dysphagia feeding by an esophageal tube or by the
rectum. Should the fracture be compound, or should a fragment be
displaced so as to be detected, it may be removed through suitable
incision.
FRACTURES OF THE LARYNX.
This may be fractured by injuries of the same character as those which
fracture the hyoid, except that it is more exposed to the direct
violence of a blow, as from a baseball. In elderly people in whom
calcification of the laryngeal cartilages has occurred fracture is
more dangerous than in the young. Injuries which produce these lesions
are of a serious nature, as prompt swelling, either from hemorrhage
or edema, occurs and threatens respiration. For illustration a death
occurred on the baseball field within a few minutes after reception of
a blow upon the front of the neck with laryngeal fracture; the cause of
death was suffocation due to swelling, which might have been averted if
tracheotomy could have been performed. In the milder injuries of this
kind much can be done with sprays of cocaine and adrenalin, to quiet
laryngeal irritation and reduce vascularity.
FRACTURES OF THE STERNUM AND RIBS.
Fracture of the _sternum_ in childhood is exceedingly rare. In adults
it may occur in connection with other injuries or as a solitary lesion.
Such a fracture, of itself, would indicate in most cases excessive
violence. It is usually more or less transverse, the periosteum being
rarely so torn as to permit of much escape of blood. Cases are recorded
in which it has been broken in straining during the act of parturition.
It is most commonly injured by compressing and crushing injuries.
Sternal fractures are followed by much pain, aggravated by deep
respiration and made worse by pressure. Sometimes displacement can
be made out, while crepitus may be detected with the stethoscope.
Occasionally there is sufficient deformity to make the injury apparent
at a glance.
Displacement should be reduced and apposition then maintained by a
plaster-of-Paris jacket or other suitable apparatus. It is advisable in
some cases to anesthetize the patient and to make a sufficient opening
that instruments may be used by which fragments may be lifted or pried
into place. This should be done under aseptic precautions.
_Diastases or separations of ribs or cartilages_ from the sternum
or from each other have essentially the dignity of fractures, are
recognized by the same general signs, and are treated in the same
general way. A cartilage may snap in the young, and in the old, when
calcified, may break as would a bone or even a pipe-stem.
_The ribs_ are usually broken in their lateral aspects, but rarely
between the head and angle. They may be fractured by muscle action or
by external violence, examples of the former being violent efforts at
lifting or sneezing. Violence may be applied in so many ways that it
is not necessary to specify them. Fractures may pertain to one or to
several ribs in proportion to the extent and violence of the exciting
injury. In some crushing injuries an entire section of the chest wall
may be broken loose and depressed, this corresponding to a depressed
fracture of the skull. Rib fractures are usually of themselves
innocent, but may be made serious by _complications_, as when the
pleura is torn, or an intercostal artery bleeds profusely, or when a
jagged fragment of bone first scratches and then perforates a lung.
This will lead first to the outpour of blood and then of pleuritic
fluid, by which in a short time the lung will be separated from the
chest wall. Should infection occur through the injured lung, _i. e._,
entrance of germ-ladened air, then empyema may seriously complicate
matters and later necessitate operation. Even the heart has been
injured, in several reported cases, by projecting fragments of bone.
Gunshot fractures of the thoracic wall imply those features pertaining
to every compound fracture, plus the injury possibly done to the lungs,
heart, or mediastinal contents, such as hemothorax or pneumothorax.
The first and second ribs are so protected and the eleventh and twelfth
so movable that by far the greater proportion of rib fractures pertain
to the eight intervening ribs.
=Symptoms.=--These are often vague, when but a single rib has been
cracked through and not displaced, and comprise pain on pressure,
as well as that provoked by deep breathing, coughing, and certain
other movements. Should this pain be limited, or constant and
made worse by pressure, fracture of the rib may be suspected. If
auscultation crepitus can be heard, diagnosis is at once made. When
abnormal mobility is unmistakable, or when by any means crepitus is
elicited, the signs are positive. Sometimes the patient himself will
recognize crepitus. This may be learned either by auscultation or by
pressure with the flat hand over the affected area. _Emphysema_ is an
unmistakable evidence of fracture with perforation, while the signs of
the presence of fluid in the chest cavity will also indicate fracture.
=Treatment.=--Fracture of one or two ribs with displacement is
ordinarily a matter of trivial import, the adjoining ribs acting as
splints. It necessitates practically nothing but physiological rest,
which may be best afforded by keeping the patient in bed, with _firm
compression_ around the chest, made either with a binder of strong
cloth or a broad piece of adhesive plaster carried nearly around the
body, or in more aggravated cases by a plaster-of-Paris jacket. In thin
individuals the formation of callus can be recognized by the sense of
touch. So soon as this is fairly formed displacement is less likely
to occur and uncomfortable compression may be relaxed. Should there
be external angular displacement this may be corrected by pressure. A
projecting fragment which threatens to perforate should be cut away
with bone forceps through a small incision, taking pains to permit as
little air as possible to enter. If there be a _traumatic pneumothorax_
the air should be removed with an aspirating needle. When it is evident
that there is serious injury to the chest wall and that air has already
separated the lung from it (traumatic atelectasis) the parts should be
freely exposed, to permit the rounding off of bone ends, the seizure
of intercostal vessels, the cleansing out of the pleural cavity, with
perhaps later wiring of fragments or else their complete removal and
closure of the external wound with or without drainage, as may be
required. If blood or air has already escaped into the pleural cavity
the blood should be speedily removed. The same plan is advisable
in fractures of the cartilages. Sedatives to check cough, _e. g._,
heroine, are also indicated.
FRACTURES OF THE CLAVICLE.
The clavicle and the radius are the two bones most frequently broken,
the former more often in the young, the latter in the elderly; the
clavicle yields both to direct violence, as by blows on the shoulder,
and that which is transmitted through the arm from the elbow or hand.
For convenience of description the bone is divided into thirds, the
most common location for fracture being near the junction of the middle
and outer third. Save for epiphyseal separations the extremities of the
bone are seldom broken. In spite of its subcutaneous position and its
proximity to large vessels, compound injuries or other complications
are quite uncommon.
The clavicle is the brace which keeps the shoulder proper from falling
upon and around the thorax. _Consequently when it is broken the
shoulder tends to drop downward, forward, and inward_, except in a
green-stick fracture, while even then there may be some displacement in
these directions. Deformity is usually easily recognized, one or other
fragment projecting beneath the skin in such a way as to be easily
palpated. There is enough spasm of cervical muscles to draw the head
over toward the affected side, while there is loss of function in the
affected arm. Pain is made worse by pressing the shoulder inward as
well as by moving it in any direction.
In young children the bone is often broken with a minimum of
displacement. Fracture of both clavicles is not so very rare. Trouble
may occur later in the course of the case from pressure of exuberant
callus upon nerves and even vessels. This is to be prevented by
foresight and by careful attention to maintenance of parts in proper
position.
=Treatment.=--The multiplicity of dressings which have been suggested
for fractures of the clavicle attest the fact that so long as primary
indications are observed the treatment can be made very simple. These
indications are to _keep the shoulder upward, outward, and backward_,
as it tends to drop in the opposite way. The action of three muscles is
of great importance in considering the proper treatment of these cases,
_i. e._, the sternomastoid and the trapezius, because they tend to pull
fragments upward, and the pectoralis major because advantage can be
taken of its arrangement to overcome upward displacement. It was Moore,
of Rochester, who taught many years in Buffalo, who showed how this
could be done. The fibers of the great pectoral which arise highest,
_i. e._, from the clavicle, are those which are inserted lowest along
the bicipital groove of the humerus, because of the semi-revolution
made by the tendon of this muscle as it passes to its insertion. By
putting the arm in such a position that these fibers are pulled upon
the operator may counteract the upward pull of the other muscles just
mentioned. This is the underlying feature of Moore’s suggestion; to
force the elbow far backward, into a position which is for the time
being uncomfortable, in order thus to pull down fragments which jut
up beneath the skin. Any dressing which permits this position to be
maintained will be equally serviceable. Moore suggests for this purpose
what he calls a double figure-of-eight, which is shown in Figs. 284 and
285. It is put on as follows: A strip of cloth, sheeting, or anything
of the kind, about two yards in length and folded sufficiently to make
a strong strip eight inches wide, is held near its middle over the
surgeon’s hand. This hand is placed beneath the elbow of the injured
side, so that the strip crosses the under surface of the flexed forearm
at the elbow. One end, which should be the longer, lying to the inner
side, is passed upward and in front of the arm, carried over the
shoulder across the back and under the opposite axilla, then over in
front of the sound shoulder, meeting on the back the other end, which
is carried up first over the outside of the forearm, then behind the
shoulder and across the spine. This bandage should be pulled tightly,
while an assistant holds the elbow as far backward and upward as the
patient can tolerate it, as the more the position is exaggerated the
more are the clavicular fibers of the muscle pulled upon and the
better are the fragments held in place. This dressing not only meets
the three primary indications laid down, but gives the added advantage
just described. By it the shoulders are drawn backward and fixed to
each other. The _elbow should be lifted_ as the dressing is applied, so
as to lift the shoulder. Most of the cloth materials used for such a
dressing are more or less elastic, and it may need to be tightened once
or twice a day during the time that it is worn. After a few days, when
consolidation should have occurred, it may be changed for some other
less irksome form of dressing. The hand should be supported in a sling.
This dressing is useful in dislocations of the clavicle, especially of
its outer end, and in every kind of injury in which the indication
is to hold the shoulder upward and backward. In simple cases without
much displacement the primary indications may be more simply met by a
dressing of adhesive plaster, known in the East as Sayre’s and in the
West as Freer’s. It consists of two strips of plaster of about the
width of the arm itself. One of them is wound around the upper end of
the arm, close to the shoulder, in such a way that, as it is passed
around the back and brought over the chest, the arm and shoulder are
pulled backward. The other strip passes from beneath the elbow of the
injured side obliquely up and over the opposite shoulder. When it is
applied the elbow should be _firmly lifted_. After the completion of
either of these dressings the injured shoulder should appear at least
one inch higher than the well one. Should the patient’s arm and chest
be hairy they should be shaved before the application of the plaster
strips. Like other material, plaster will stretch and slip, and these,
like other dressings, should be readjusted every day or two, _for the
shoulder should be kept elevated for at least a week_.
[Illustration: FIG. 284
Moore’s apparatus (back view).]
[Illustration: FIG. 285
Moore’s apparatus (front view).]
When the case is complicated by other injuries necessitating
confinement in bed it is sufficient to keep the patient flat upon
the back and without a pillow. In this position the shoulder falls
naturally in the direction desired, and perhaps no other attention will
be required. Many other methods are combined with a figure-of-eight
bandage, crossing the back and forming a loop over each shoulder, so as
to keep it from dropping forward.
While the results of treatment are nearly always good, if one is
insistent upon a minimum of deformity, confinement upon the back on
a hard bed is the surest way to obtain satisfactory results. Cases
in which there is little or no tendency to deformity need only the
simplest support by which rest may be ensured.
Epiphyseal separations are to be treated as fractures.
FRACTURES OF THE SCAPULA.
The most frequent fracture of the scapula is that of the _acromion_;
this is usually the result of direct violence, such as a fall upon the
tip of the shoulder. Detachment of this fragment permits a peculiar
flattening of the shoulder, but without dislocation. The fragment
can be easily felt, while the deltoid is displaced and its rounded
contour lost. Treatment consists solely in _forcing the arm upward_, by
dressings applied beneath the elbow, thus lifting the fragment into its
place; fibrous union occurring here much more often than osseous, the
latter is possible only in case a good apposition be maintained. Any
form of dressing, then, by which the elbow is crowded upward and rest
maintained will be appropriate.
The _surgical neck_ is occasionally detached, sometimes with and
sometimes without the coracoid process. As the humerus is attached
to it by the capsular ligament the arm drops with the fragment when
the patient is in the upright position, and the elbow will be found
lower than that of the injured side. The arm is unduly mobile, and the
fragment can usually be seized and crepitus obtained within the axilla.
Here it is necessary to hold the arm up, as it controls the position of
the fragment. It is usually sufficient to lift the elbow up and bind
the arm firmly to the side, the scapula being immobilized by broad
straps of adhesive plaster.
The _coracoid process_ is occasionally detached, usually by muscular
violence, _i. e._, it is pulled off by the coracobrachialis and
the coracoid head of the biceps which arise from it. The injury is
recognized by failure to detect the process in its proper place, and
usually by discovery of the fragment at a point below its normal
position, to which it has been drawn out by the muscles arising from
it. Ligamentous union can be secured by relaxing these muscles, which
is done by placing the hand over the opposite shoulder and dressing the
arm firmly against the chest. I have seen paralysis of the arm result
from excessive callus after fracture of the coracoid.
The _spine_, _body_, and the _angles_ of the scapula are occasionally
broken by severe violence. In the aged comminution may occur. Crepitus
can be nearly always obtained. It may be necessary to distinguish
the scapular fracture from one of the ribs beneath it. The treatment
consists in simply fixing the shoulder-blade upon the chest, to which
it is naturally adapted, by firm bandages, which shall immobilize not
only it but the arm as well.
FRACTURES OF THE HUMERUS.
At the _upper end_ of the humerus we deal with fracture of the
processes, _i. e._, the _tuberosities_, which may be torn off by
violent action of the muscles therein inserted; of the _anatomical
neck_, which is rare and occurs most often in the aged; of the
_surgical neck_, which is the most common; or, in the young,
_epiphyseal separation_, which is the equivalent of the last named.
Separation of the tuberosities is diagnosticated mainly by exclusion,
possibly by _x_-rays. The _anatomical neck_ lies within the capsule,
and should the head be thus detached it might remain as a foreign body
in the joint, having no means of securing nutrition. Fractures of
the _head of the bone_ are not classical and are usually the result
of gunshot injuries or extreme violence. In all of these injuries
there will be swelling, loss of function, while crepitus is sometimes
obtained, but is very difficult to locate, even under an anesthetic.
The diagnosis is to be made mostly by exclusion.
The _surgical neck_ is the most frequently broken; the line of fracture
passing below the tuberosities and above the muscles inserted along the
bicipital groove. Therefore the pectoralis and the latissimus muscles
will both conspire to pull the upper end of the shaft toward the thorax
to such an extent that it can be felt in the axilla. This gives its
axis a different direction, while all the muscles extending from the
shoulder to the forearm will tend to produce shortening. Deformity
is usually distinct, crepitus is easily obtained, and undue mobility
is well marked. The head of the bone can be detected in its proper
place beneath the deltoid, but does not rotate with the shaft. In rare
instances a certain amount of impaction may make this evidence of
fracture obscure. _Epiphyseal separation_ will give the same signs and
symptoms.
=Treatment.=--The primary indication here is to overcome muscle pull
by traction in a direction toward the crest of the pelvis of the same
side. At the same time, with a certain degree of coaxing of the upper
end of the shaft outward and a little forward, it may be possible to
so re-apply broken surfaces to each other, and so affix the arm to
the thorax, as to be effective. When serious difficulty, however, is
encountered the writer advises traction, applied to the arm alone, if
the patient be able to be upright, or to the arm and forearm, if he be
confined in bed. It will take considerable stretching to overcome the
combined action of all the muscles which tend to produce displacement.
Along with such treatment a coaptation splint should be applied, the
best being that which can be carefully molded to the parts and adapted
to their needs. For this purpose a molded plaster-of-Paris splint is
preferable to one of metal made to some standard size. In the dressing
it is necessary to include not only the shoulder and arm but also the
forearm, otherwise the principle of physiological rest would not be
enforced. Fig. 286 illustrates the common tendency to displacement in
these injuries.
_Fracture_ of the surgical neck is occasionally combined with
_dislocation_ of the head of the humerus, by which such an injury is
seriously complicated. Reduction may be attempted by manipulation.
Until recently it was generally advised to wait for a week or ten days,
and until consolidation had occurred, and then to make the attempt at
reduction; but Porter and McBurney have shown that it is advisable
to cut down upon the dislocated upper fragment, and, fixing it with
forceps or with an instrument shaped like a corkscrew or hook, to
force it back into place again. If this be done under the strictest
precautions it lends no serious features to the case, while, in most
respects, such a procedure would greatly simplify it, the wound being
closed with or without drainage, and the usual fracture dressing being
applied.
In cases of _old fracture and dislocation_ the head of the bone should
be exsected, the functional result thus obtained being excellent.