Fig. 287, from Moore, shows how the periosteum is not necessarily
entirely detached, but is stripped up to form a hinge, the fragment
displaced forward, and its outer aspect often turned upward. This
makes traction in an outward direction an essential feature of the
replacement of the fractured surfaces, the manipulation being combined
with fixation of the fragment so far as it can be seized through the
axilla. If the epiphysis is properly slipped over upon the end of the
humerus the case assumes ordinary features, and is to be dressed as
usual.
[Illustration: FIG. 286
Fracture of the surgical neck of humerus. (Hoffa.)]
[Illustration: FIG. 287
Separation of the upper epiphysis of the humerus; displacement forward
of the lower fragment. (Moore.)]
The shaft of the bone is frequently broken, lines of fracture
running in all directions and occurring at all levels. A variety of
displacement may take place. The evidences of fracture are usually
recognizable and diagnosis is not difficult. The brachial artery and
the musculospiral nerve are occasionally involved, either in callus
or by primary injury from a spicule of bone. These fractures are more
liable to delay in union or even to non-union than almost any others.
These occur often without evident cause, while more or less absorption
of bone has been known, by which complications are produced.
In the _treatment of fractures of the shaft_ posture is necessary to
observe, the fragments not only being held in position, but the axis
of the bone being maintained. An external splint, extending up to and
rounded over the shoulder, and an internal splint molded to the inner
side of the arm, taking in the elbow and forearm, and placed at a right
angle, and then the immobilization of the entire arm by its fixation to
the body will give the best result. The writer prefers to make these
of plaster of Paris, by molding strips of surgeons’ lint sopped in
plaster cream, and maintaining the limb in the desired position while
they harden. Should comminution be extreme, or shortening difficult
to overcome, a few days’ confinement in bed, with traction upon the
forearm, either extended or included in the above dressing, by the
usual method, with weight and pulley, will give the best result. So
soon as callus has bound the ends of the bone together the patient may
be released from bed and the arm left in the right-angle position, in
plaster, as above. Or over such a splint as has been described, made
of molded plaster, may be hung by a bandage at the elbow sufficient
weight (a bag containing shot) to maintain constant traction upon the
lower fragment, while the patient is in the upright position, and to
influence for good any overlapping or displacement of any kind during
the critical period when the bone ends are being united by callus.
The _epicondyles_ are occasionally chipped off from the condyles,
the internal being the more frequently injured. These detachments
are extra-articular and are relatively unimportant, the fragments
being kept from displacement by their fibrous investments. If such an
injury should be compound any fragment completely loosened should be
removed. It is sufficient to dress such an injured elbow with cold
wet compresses in the flexed position. _Supracondyloid_ fracture, or
its equivalent in the young (an _epiphyseal separation_) are somewhat
similar, the latter occurring nearer to the articulation than the
former. In each of these injuries the arm is flexed and shortened,
the fragment lying usually in front of the shaft and the olecranon
protruding posteriorly. The more the arm is extended the more prominent
the deformity, while by flexion it is much diminished. Hence the
advantage of dressing it in the position of overflexion sometimes
called Jones’ position.[39] Injury to the vessels at the bend of the
elbow may occur in these fractures. If not dressed in this position
the elbow should be put at a right angle, while a weight is slung over
the elbow, as already mentioned above. Joint function will be greatly
hampered if complete extension and reduction be not effected (Fig. 288).
[39] In supracondyloid fractures there is almost always posterior and
upper displacement of the lower fragment. When the parts are found
in this position, and especially when the skiagram shows the line of
fracture in the usual location (from above downward and forward), the
fracture should be treated by flexion of the arm in the so-called
Jones’ position. By this the fragment is best restored to its proper
position, being pried there by the muscular cushions of the forearm
and arm. (Ashhurst.)
[Illustration: FIG. 288
Supracondyloid fracture or epiphyseal separation. (Lejars.)]
In considering fractures about the elbow no greater aid can be obtained
than by a study of the relations of the three prominent or salient
anatomical points to each other. These are the internal and external
condyles and the tip of the olecranon. They afford a key to nearly
all the displacements which may be produced after fracture or even
dislocation, and the only conditions under which they cannot be made
available are those where there has been tremendous swelling before the
case is seen by the surgeon. A fourth prominent feature, the head of
the radius, is also of much assistance, but is less often available,
especially in muscular or swollen forearms. When a normal arm is
flexed to a right angle and viewed from behind the three points above
mentioned constitute the angles of a nearly equilateral triangle.
When seen from the side the point of the olecranon is just below the
external condyle and in the same plane; when the arm is completely
extended and viewed from behind these three points are practically in
the same line. By a careful study of the variations from the above
relations which are produced by injury diagnosis can be greatly
facilitated.
[Illustration: FIG. 289
T-fracture of humerus. (Helferich.)]
[Illustration: FIG. 290
T-shaped fracture of lower epiphysis of humerus.]
[Illustration: FIG. 291
Intracondyloid fracture of humerus. Almost perfect functional result.
(Parmenter.)]
[Illustration: FIG. 292
Gunstock deformity after fracture of internal condyle, illustrating
neglect of precautions mentioned in text. (Beatson.)]
The _condyles_ may each be broken loose by itself, or they may be _both
broken_ at the same time. Fig. 291 illustrates what is known sometimes
as a T-fracture, where the lower extremity is not only separated
from the shaft but is broken into halves; such fractures imply great
violence, and are particularly difficult to treat. Should the condyles
be detached in such a way as to leave the lower end of the humerus in
pointed wedge shape it may perforate or do much harm to the soft parts
(Fig. 290). In these _intercondyloid_ fractures the writer would advise
dressing in the extended position, with a molded plaster-of-Paris
anterior splint and a gentle degree of traction, the patient being
confined to bed for a few days. In applying such a splint the surgeon
should give extreme care to holding the fragments in proper position
while the splint hardens, and in preserving the “carrying function”
(Fig. 291). (See below.)
[Illustration: PLATE XXXIX
Supracondyloid Fracture. (Child, nine years old.) Union with deformity,
fragment so joined to lower end of shaft of humerus at an angle that
when forearm is completely flexed upon this fragment it yet is only at
right angle with the arm. Operation indicated. (X-ray picture.)]
The _external condyle_ when fractured is displaced by muscle pull;
when the _internal condyle_ is broken the tendency is to backward
displacement of the fragment and widening of the joint.
_Fracture of the internal condyle_ is often an exceedingly serious
matter, because it is so often associated with more or less dislocation
and with permanent deformity, as a result of inattention to the
anatomical relations of the bones. The ulna sustains peculiar relations
to the inner condyle; at its upper end it is wrapped around the
process, holding it much as a monkey-wrench can be made to seize an
ordinary object, and being held to it by the internal lateral ligament.
Herein lies the secret of success or failure in treatment, for the
fragment, being so fixed to the ulna, should be controlled by it, _i.
e._, the position of the ulna is the most essential feature of the
treatment of the fracture. The forearm makes an angle with the arm
proper, by which a considerable degree of divergence is maintained.
This has been alluded to by Allis and others as the “carrying
function.” It can _only be estimated in the extended position, and be
accurately judged by comparison with the other arm._ If the arm be
flexed all possibility of estimating it is lost; therefore to _dress
such a fracture in the right-angle position is bad practice_ (Fig.
292). The only position in which the carrying function can be preserved
is the extended, or one a little short of it for the purpose of
comfort. If the ulna is put in the proper position the fragment will be
held equally so or as nearly as possible (Fig. 294).
[Illustration: FIG. 293
Fracture of external condyle. (Lejars.)]
In the _treatment of fractures of the inner condyle_ the patient, if
a child, should be anesthetized, the upper part of the body exposed,
both arms extended, and the injured arm made to correspond exactly with
the other so far as concerns the angle of divergence. Upon the arm so
placed an anterior plaster-of-Paris molded splint should be carefully
applied, extending from axilla to wrist, and then lightly secured with
bandages, the surgeon holding the arm in the proper position _until
the plaster is sufficiently hardened to permit no displacement._ The
arm should be kept in this position for at least ten days, after which
the splint may be removed and gentle motion practised. It may then
be reapplied for two or three days, after which we may begin to flex
the arm, applying either a new plaster splint or any other that seems
suitable, and in such a way that at the expiration of another week the
forearm is brought to a comfortable position of right angle, where it
may be maintained with a light splint or simply with a sling, according
to the age and tractability of the patient. Fig. 294 illustrates the
splint and the position, which is the only one in which the surgeon
maintains his own security and can properly estimate the carrying
function. The mistake has been in dressing this fracture, like most
others at the elbow, in the right-angle position.
In _fractures of the outer condyle_ these anatomical conditions do
not prevail, and these may be dressed in whatever position best meets
the indications of comfort and accurate reduction. _Intercondyloid
fractures_ are subject to the same conditions as those of the
_internal condyle_, plus others which are added, and should therefore
be dressed in the _same position_.
[Illustration: FIG. 294
Molded plaster splint for entire arm, and especially for fractures of
the internal condyle, showing proper position for dressing same.]
_Epiphyseal separations_, as well as supracondyloid fractures, should
be dressed either with traction in a somewhat extended position, or in
that of extreme flexion, called also Jones’ position, according as the
fragments may best fall into place in one or the other.
[Illustration: FIG. 295
Molded plaster splint for arm.]
[Illustration: FIG. 296
Molded plaster splint for forearm.]
The writer has for his own purposes discarded almost all other splint
material for the upper extremity in favor of the plaster-of-Paris
splints already mentioned. Figs. 294, 295 and 296, may illustrate
the method and purpose of their use; many other modifications can be
devised as may be demanded. It is customary, after such a splint is
hard and firm, to remove it for a few moments, trim it, smooth the
edges, line it with a fresh piece of soft lint or its equivalent,
and then reapply it to the arm with a roller or starch bandage, the
arm meantime not having been disturbed, but maintained in its proper
position, and being restored to the splint and made to take its
previous position. Such a splint fits accurately the individual for
whom it is made. It is worthless for anyone else; nor should it ever
be used again, the _intent being to mold a splint for each case which
shall serve its individual purpose and none other_.
Too early passive motion with the intent to regain mobility is
inadvisable and often dangerous. A fractured joint should be kept at
rest until the bone is consolidated. If callus be thus reduced to the
minimum, and consolidation be undisturbed, the patient will, in due
time, recover motion, often to the extreme limit. In fractures of the
humerus five or six weeks are required for the attainment of perfect
union. In spite of precaution callus formation will sometimes be
excessive and interfere with motion. Absorption of exuberant material
then is most desirable. This can be encouraged by constant but gentle
pressure. Thus when callus in front of the lower articular surface of
the humerus obstructs the coronoid process of the ulna and prevents
complete flexion the patient should wear for several hours at a time an
elastic sling, made with a piece of Martin rubber bandage sufficiently
long to make a loop around the neck, into which the hand is passed. It
should be made so tight as to exert gentle but constant pressure; the
result of this will be to cause rapid disappearance of the callus upon
which it is made. Conditions may be reversed when necessary, and the
patient may have some weight affixed to the hand by which, when the arm
hangs down, reversed pressure shall be made, or when desirable these
measures may be alternated. One should not, however, be tempted into
resorting to them too early, since much is done, even in unfavorable
cases, by purely natural processes, this being especially true of
children who are growing rapidly.
FRACTURES OF THE FOREARM; THE ULNA.
At the upper end of the _ulna_ the most frequent fracture is that
of the _olecranon_, whose separation by direct or indirect violence
corresponds to fracture of the patella. The fragment is pulled upward
along the back of the arm by the triceps muscle, and the power of
extension is almost lost. There is rarely any difficulty in diagnosis,
except in conditions of extreme swelling, which of itself would be
suspicious, as under hardly any other circumstances could a joint be so
distended (Figs. 297 and 298).
[Illustration: FIG. 297
Fracture of olecranon. (Erichsen.)]
[Illustration: FIG. 298
Fracture of ulna, upper end. (Lejars.)]
[Illustration: FIG. 299
Fracture of olecranon with fibrous union. (Park.)]
=Treatment.=--The difficulty here, in _treatment_, consists in the
necessity for counteracting the pull of the triceps. The arm first
of all should be dressed in the _extended position_. Sometimes it is
possible, by partly encircling the posterior surface of the arm just
above the fragment with a strong piece of adhesive plaster, to which
is attached some rubber tubing, to make a constant elastic pull upon
the fragment, the tubes being brought down and attached to the sides of
the anterior splint below the elbow. In the absence of swelling this
can often be made quite effective. So long as much fluid is present
no means will be efficient. It may, therefore, be well to wait two or
three days until the fluid has disappeared, aspirating the joint if
necessary. In young and otherwise healthy subjects there is strong
reason for advising _operation_, as only by absolutely approximating
the fragment to the main bone and maintaining it in position can bony
union be secured. In properly selected cases, and when performed
with every precaution, this measure frequently gives ideal results.
A short ligamentous union is represented in Fig. 299. At other times
the fibrous band will stretch out to an inch or more, not completely
disabling the arm but weakening it. The extended position may be
relaxed within a week after operation, but not for at least two weeks
after other treatment. Passive motion should not be begun too early in
the latter cases.
Fracture of the _coracoid process_ is often combined with _backward
dislocation of the forearm_, which is no doubt an incident of the
injury or may occur later by mere muscle pull. The brachialis anticus,
which is inserted into it, will pull the fragment up against the
anterior surface of the humerus. This fracture should be dressed in
the right-angle position, in order to relax the muscle, taking care to
prevent backward displacement, while ligamentous union is ordinarily
all that can be hoped for.
The _ulnar shaft_ may be broken at almost any point, usually as a
result of direct violence. As it is weaker in its lower half the
greater number of fractures occur here. Fracture of the shaft is easily
recognized, crepitus being always obtained, unless muscle tissue has
intervened, this being a condition which will occasionally prevent bony
union. If it can be established by _x_-rays that bony surfaces are
not in contact and cannot be so placed, it is advisable to cut down
upon the site of the fracture, remove the obstacle, and fasten the
fragments together. So long as one bone is broken in the forearm the
other may be relied on to act as a more or less efficient splint. There
is but one position in which any of these fractures can be dressed
with safety, that is _midway between pronation and supination_, _i.
e._, with the thumb pointing toward the patient’s face. Splints used
for this purpose should always be wider than the forearm itself, lest
by pressure the ends be forced toward the other bone. Some hold that
by gentle pressure along the line between the bones, as by a narrow
pad or splint, the muscles may be made to press the injured bone away
from the other; nevertheless only moderate pressure can be tolerated
for this uncertain purpose. It has been generally customary to use two
light wooden splints, one along the palmar, the other along the dorsal
surface of the forearm, padding them properly and securing them in
position by strips of adhesive plaster and suitable bandages. The same
plaster-molded splints mentioned above can, however, be made just as
effective for this purpose, if properly applied.
When either bone is broken near the wrist, and especially when both are
broken, we have to combat the tendency of the pronator quadratus, which
tends to pull the lower fragments together.
The _styloid_ process is occasionally detached, as in violent sprains,
or broken off in connection with other injuries. Inasmuch as it carries
the upper end of the internal lateral ligament its detachment can be
quickly recognized by the abnormal freedom of motion which such an
injury would permit.
[Illustration: FIG. 300
Obliteration of the interosseous space in a fracture of the forearm.]
FRACTURES OF THE RADIUS.
The radius vies in frequency of fracture with the clavicle. The _head_
is seldom broken, its fracture being most likely when the shaft is
driven against the humerus by falls upon the open hand. The _neck_ is
more frequently broken in children than in adults. These fractures have
sometimes to be determined by a process of exclusion or by the use of
the _x_-rays. In muscular forearms they lie so deeply that it is not
always possible to recognize them. Ordinarily, however, if the head
of the bone can be found to remain stationary while the rest of the
bone is being rotated, and if, at the same time, crepitus be felt, the
matter may be regarded as settled. So far as the _shaft_ of the radius
is concerned the remarks made above regarding the ulna mostly hold true
for its fellow-bone. When the neck of the bone is broken the shaft will
be pulled upward by the biceps tendon, while when the shaft is broken
below its insertion the upper fragment is displaced by it. In either
of these cases, then, the forearm should be dressed at a right angle
with the arm in order to relax the muscle. The supinator brevis and
the pronator radii teres should also not be neglected, for the former
will tend to rotate and the latter to more or less displace the upper
portion of a shaft broken high up. With a fracture near the upper end,
in a powerfully muscular arm, diagnosis is not always easy. Fractures
in the lower portion of the shaft are to be treated like those of the
ulna. But those high up should be dressed with the elbow at a right
angle and the forearm supinated. A plaster-of-Paris molded splint here
can be adapted to the needs of every individual case if the surgeon
will give minute care _at the time of its hardening_ to placing the
parts just as he desires them to remain.
FRACTURES OF BOTH BONES OF THE FOREARM.
These are not uncommon, though much less frequent than injuries to
either bone alone. They may occur at the same level or be quite widely
separated. The loss of function is complete in these instances, while
deformity will depend largely upon whether the fractures lie near
together or not. It is of the greatest importance to remember, in these
cases, that the mass of muscles around the upper fragments tends to
crowd them together, while the lower fragments are brought together
especially by the pronator quadratus. Everything then conspires to
convergence of the four fragments, a tendency which it is sometimes
difficult to combat. Every large museum contains specimens showing
a common callus, in which all four bone ends are involved, and
illustrating the permanent loss of rotation that ensues. This is to be
combated, not alone by rest, which tends to limit callus formation, but
by _position with the arm midway between pronation and supination_,
in which the bones are naturally farthest separated, and by _splints_
applied with such gentle pressure as may hold the bones apart. This
pressure should be applied between the dorsal and palmar surfaces,
while the lateral aspects of the forearm should be kept absolutely free
from it (Figs. 300 and 301).
[Illustration: FIG. 301
Fracture of both bones near lower extremity. (Lejars.)]
It is a serious matter to dress any of these injuries with moistened
pasteboard, or other material which does not take its desired shape and
strength promptly, for no matter how carefully the desired position may
be enforced at first the very nature of a material which remains too
long plastic will permit the loss of all that should be maintained. The
writer has seen malpractice suits instituted and men forced out of the
State by inattention to this precaution.
FRACTURE OF THE LOWER END OF THE RADIUS; COLLES’ FRACTURE.
This is perhaps one of the commonest fractures in the body, occurring
at all ages; when seen in growing children it is to be regarded as an
epiphyseal separation rather than as a distinct fracture. It derives
its name from the fact that until Colles, a Dublin surgeon, over one
hundred years ago, described this injury as a fracture it had been
always regarded as a peculiar dislocation at the wrist. It is produced
by falls upon the hand in the hyperextended position, the force
being usually transmitted through the carpus to the radial end. The
name is usually limited to those fractures which occur within one
and a quarter inches of the articular surface (Fig. 303). Here the
structure of the bone is cancellous and impaction may easily occur,
this being a decided feature in many of these accidents, and making
replacement more difficult. The deformity which results from the
fracture is characteristic and more or less uniform. This is called the
“silver-fork appearance,” the lower fragment being so displaced, and
usually more or less tilted, as to raise the tendons and the structures
on the back of the wrist; at the same time it is usually drawn toward
the radial side. The more the fragment is impacted or driven into the
shaft of the bone the less easily is crepitus elicited.
The fracture is more common than is supposed, and there is no doubt but
that many alleged sprains of the wrist illustrate cracks in the bone
without displacement, which, nevertheless, are slow to heal and are
sometimes followed by thickening and impairment of function. (See Plate
XL.)
Along with the radial fracture separation of the _styloid process_ of
the ulna may also occur, or, as Moore has shown, the process itself may
perforate the internal lateral ligament so as to protrude through the
skin; and the surgeon has occasionally to withdraw the styloid from
the ligament which has been impaled upon it. The radio-ulnar ligament
is also frequently injured, and this permits the ulna to become more
prominent than normal. If the styloid has perforated the skin it lends
a compound feature to the case. The interarticular fibrocartilage may
also be displaced.
=Treatment.=--The secret of obtaining a good result and the explanation
for failures lie in the completeness or incompleteness of the
reduction of the fragment. If the latter be _absolutely and accurately
replaced_ it makes but little difference what dressing is applied.
On the other hand any fragment not completely restored will lead to
subsequent deformity and impairment of function. _Successful reduction,
then, is the keynote to success_, and should be accomplished at any
reasonable cost. Sometimes it is not difficult, and then no anesthetic
is required; sometimes it is extremely difficult, and the operator
has to exert all the strength he has in his arms, aided by profound
anesthesia. Moderate cases can usually be dealt with successfully
under nitrous oxide gas. The surgeon grasps the hand as if to shake
hands, _i. e._, with his corresponding hand, the elbow being firmly
held by an assistant. Traction is then made upon the hand to which the
fragment is affixed, while with his other hand the operator makes such
pressure, rotation, or coaxing manipulation with his thumb and fingers
as may assist in restoring the fragment to its place. With whatever
other effort may be made traction should be combined. Forcible swaying
movements, combined with hyperextension, may be necessary to dislodge
an impacted fragment. Any degree of force is preferable to failure in
this respect. Perfect reduction is the key of success; without it, no
dressing is efficient; with it, almost anything will suffice.
[Illustration: FIG. 302
Comminuted but not compound fracture of wrist. (Beatson.)]
Reduction once accomplished it is usually an easy matter to hold the
arm in position. The writer prefers above all other means a molded
plaster-of-Paris splint, which should extend from the line of the
knuckles upon the palmar surface well up toward the elbow. It should
be fitted neatly to the hand and forearm, bandaged comfortably upon
it, while as it solidifies the surgeon should hold the hand slightly
flexed to the ulnar side as well as anteriorly. When the splint is
hardened and bandaged a simple sling will suffice. The hand should be
dressed with the thumb pointing toward the face, while upon the back of
the wrist an ice-bag can be applied. Ecchymosis is sometimes extreme;
I have seen it extend even to the shoulder after an apparently simple
break (Figs. 304 and 305).
[Illustration: PLATE XL
Skiagram of a Fracture of the Lower End of the Radius. (Wharton.)]
I have not described other splints for dressings, at this point, for
two reasons: the dressing given above is ample and sufficient for all
cases, and, aside from it, the number of splints and methods devised is
so large as to be confusing. It is much better to know one method well
than to have a slight working acquaintance with several.
[Illustration: FIG. 303
Colles’ fracture. (Anger.)]
[Illustration: FIG. 304
FIG. 305
Deformity from faulty union following fracture of wrist. Buffalo
Clinic. (Skiagrams by Dr. Plummer.)]
While Colles’ fracture is far more frequent than all other fractures
about the wrist, it is possible to have less-known forms with different
displacements; thus a fracture the reverse of Colles’ has been
described by Barton and by R. W. Smith, being occasionally produced by
falls upon the back of the hand instead of upon the palmar surface.
Figs. 306 and 307, from photographs given me by Dr. Beatson, of
Glasgow, illustrate both the clinical picture and the actual condition
of the bones. Of all these fractures it may be said that accurate
reposition, as in the case of Colles’ fracture, is the key to success.
Once the fragments are reduced the same plaster-of-Paris molded splints
will answer for these as for the others.
[Illustration: FIG. 306
A Barton or Smith fracture at wrist. (Beatson.)]
[Illustration: FIG. 307
Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case
represented in Fig. 306.)]
BENNETT’S FRACTURE.
When considerable force is applied to the distal end of the first
metacarpal, as in striking with the clenched fist, or, as in a fall
upon the outstretched thumb, the first metacarpal is often fractured
transversely at its neck or longitudinally, its interior basal
projection being broken off, both injuries being often associated.
This is a condition lately proved by Russ, of San Francisco, to be
more common than has been generally supposed. It was first described
by Bennett, of Dublin, in 1885, and is known as Bennett’s fracture of
the thumb. Its peculiar features can be best seen in a radiograph.
It produces much pain and swelling of the hand, with tenderness,
especially at the base of the bone involved, _i. e._, at the root of
the thumb. There may be more or less displacement of fragments. The
injured thumb should be treated by traction and with such coaptation
splints as may be extemporized or prepared for the purpose, in the
position of abduction. If accurate coaptation and sufficient traction
be made to overcome both deformity and muscle spasm the result obtained
will be satisfactory. Otherwise more or less loss of function and local
tenderness may long persist.
[Illustration: PLATE XLI
Skiagram of Fracture of the Proximal Phalanx of the Ring Finger.
(Wharton.)]
FRACTURES OF THE WRIST AND HAND.
Fractures of the carpal bones seldom occur, except when the parts have
been crushed. The _scaphoid_ is, however, broken much more often, and
doubtless many cases of so-called severe sprain include this injury.
The use of the _x_-rays has done more to teach the relative frequency
of carpal fractures than was ever previously appreciated. The scaphoid
ossifies by two centres, which do not appear until the eighth year.
When the bone has been thus cracked the usual signs of sprain are
present, which subside and leave a tender wrist and hand whose fingers
can be normally moved, but whose wrist movements are reduced one-half,
while attempts at motion beyond these limits produce great muscle
spasm and pain. Codman and Chase[40] have shown that the sheaths of
the radial extensor tendons are in close relation to the periosteum of
the bone at this point, as well as to that of the radius, so that by
injury here blood may escape into the sheath without appearing at other
parts; the result being a tense, fluctuating, triangular swelling over
the radial half of the wrist, the blood being effused so deeply as not
to discolor, or at least not at first. They regard the presence of such
an engorged bursa as diagnostic of fracture either of the radius or the
scaphoid.
[40] Annals of Surgery, March, 1905.
While carpal fractures call ordinarily for treatment by absolute rest,
Codman and Chase have advised removal of any loose fragment, especially
of the scaphoid, by incision along the back of the wrist just to the
inner side of the long radial extensor. The annular ligament is to be
divided between it and the long extensors of the fingers, and without
opening tendon sheaths; inasmuch as this ligament does not retract when
divided its borders must be held apart. In this way the joint may be
completely exposed over the proximal half of the scaphoid. The line of
fracture being made out, a blunt hook is introduced into the fissure
and the fragment elevated, loosened by a tenotome, and removed, its
removal seeming nowise to interfere with the function of the whole bone
or the usefulness of the wrist.
The _metacarpal bones_ are frequently broken, usually as the result
of violence, the distal portions suffering more than the proximal.
The diagnosis is best made with the fingers closed, when any lack
of symmetry in the row of knuckles may be seen or any protrusion of
a fragment noted. Here the _x_-rays are useful. Such injury should
be treated by placing the hand upon a palmar splint extending well
up the forearm and maintaining rest by suitable pressure, with or
without traction upon the finger of the bone involved. For this purpose
adhesive plaster may be passed up and down the finger and attached to
an elastic band which is fixed to the end of the splint.
The same is true of fractures of the _phalanges_, which are often made
compound by the injury. Here the danger is not so much to the bone
as to the tendon sheaths or thecæ, along which infection may easily
spread. Widespread and prolonged suppuration might disable a hand thus
injured unless properly and promptly dressed. Ordinarily adjoining
fingers can be utilized for splints, and if the outstretched hand be
fastened upon a palmar splint and the injured finger kept in position
by its neighbors a good result can generally be obtained. Occasionally
distinct splints for one or more fingers are required, and occasionally
also the suggestion made above with regard to traction may need to be
enforced.
FRACTURES OF THE PELVIS.
Fracture of the pelvis may be serious not only in and of itself but
because of frequently accompanying injuries to the various pelvic
viscera. Save in the possible separations that may occur during
parturition it is always the result of direct violence. Such injuries
are usually divided into fractures of the _pelvic girdle_ and those of
the more exposed prominences, such as the _iliac crest_, the _ischiac
tuberosity_, the _coccyx_, etc. Lines of fracture may run at any
point, although it is at the synchondrosis that the pelvis is usually
broken loose from the sacrum. As in the skull and the lower jaw double
fractures or even comminutions may occur. The same considerations
concerning the transmission of serious violence may account for some
of the vagaries seen in these cases. The _sacrum_ is usually broken
as the result of great violence. The pelvic girdle is perhaps weakest
opposite the joints and in the neighborhood of the pubis. Here there
may be a separation of the symphysis, but the break usually occurs a
little to one side of the middle line. In rare instances the head of
the femur has been forced through the acetabulum (Fig. 308).
In a general way fractures of the pelvic girdle can be recognized not
merely by local evidences of injury and shock, but by the resulting
more or less complete loss of function; patients will be disabled
in proportion to the violence and extent of the injury. The more
unilateral the symptoms the easier it is to localize the site of the
injury. Mobility can often be detected upon examination, sometimes
crepitus. This is essentially true of fractures of the pubis.
Occasionally combined manipulation, with a finger in the rectum or
vagina, will permit more accurate localization of the injury. When the
crest of the pelvis is fractured, or any of the parts to which the
abdominal muscles are inserted, then the patient will be still further
disabled in movements of the lower part of the body, while by palpation
the fracture is sometimes easily determined.
Not the least serious features of these injuries are those which
pertain to the viscera. These include not only the ordinary results of
abdominal contusions which may produce all sorts of harm, for example,
ruptures of the kidneys, spleen, or liver, but also more localized
lesions, such as ruptures of the rectum, bladder, or urethra, or
even the pelvic connective tissue. If the urinary passages be torn
there is always opportunity for urinary infiltration and infection.
The same is true of the rectum so far as possibility of infection is
concerned. Therefore one of the earliest maneuvers in dealing with such
a case should be the passage of a catheter, to determine if the urine
be bloody or the urethra obstructed. In such a case, in the male at
least, it will usually be wise to make a perineal section and to open
widely and then drain the bladder. In not a few of these instances the
laceration takes place internally, and a pelvic crushing injury, which
is followed by collapse and abdominal rigidity, without satisfactory
explanation as above, should be _promptly explored_ by abdominal
section, the danger of doing it being considerably less than the risk
of leaving it undone.
[Illustration: FIG. 308
Fracture of pelvis. (Mudd.)]
[Illustration: FIG. 309
Great deformity after multiple fracture of femur, with synostosis.
(From the Buffalo Museum.)]
Some of these fractures are conspicuously _compound_, and the treatment
for the external wound will permit of more careful exploration of the
bone injury, as well perhaps as the insertion of wire sutures or other
means of fixation.
Fig. 309 illustrates a serious complication that ensued in one case
after multiple fractures of the pelvis and hip, with synostosis at the
hip, as well as extensive deformity following fracture of the shaft of
the femur.
=Treatment.=--Treatment of pelvic fractures should comprise, first,
absolute rest. This means not merely confinement in bed, with traction
applied to one or both limbs, but probably fixation of the pelvis
and perhaps the thighs, either in a compressing bandage or in a
plaster-of-Paris double spica, the pelvic jacket running as high as may
be necessary upon the trunk of the body. Cases which seem to permit of
operation and suturing are entitled to it, but they will constitute
but a small proportion of the total. While patients are so rigidly
confined provision should be made for free elimination, and possibly
conveniences provided for receiving the evacuations without possibility
of infection. Recovery is in many instances complete; occasionally it
occurs with considerable displacement. If the viscera escape injury
much may be expected in the way of repair of the bones under suitable
treatment.
The _margin of the acetabulum_ is occasionally chipped off, sometimes
by itself, sometimes as a complication of dislocation of the hip.
The posterior margin of the brim is the part which usually suffers.
Diagnosis should be made by the ease with which such a dislocation
recurs after manual reduction. Sufficient traction to keep the limb
from displacing the fragment, and snug bandaging with pressure,
especially around the injured hip and above the trochanter, is
indicated in such cases.
The _coccyx_ and even the lower portion of the _sacrum_ are
occasionally broken loose, either by external violence or during
parturition. Here the fragment is drawn forward by the levator ani,
displacement is marked, and pain and soreness are great. Should there
be doubt as to the nature of the injury, combined manipulation, with a
finger in the rectum, will make diagnosis positive. Fibrous union is
about all that can be expected in either of these cases. The fragment
may be justifiably removed at any time.
FRACTURES OF THE THIGH.
Fractures at the upper end of the thigh are more common than those at
the lower. At the upper end there may be fractures of the _head_, of
the _neck_, those which pass _between the trochanters_, and _epiphyseal
separations_. All of these are rare except those of the neck.
Fractures of the _neck of the femur_ occur most commonly in those who
have passed the fiftieth year of life. They occur, however, during the
middle period and even in children, and, as Whitman has shown, are by
no means so rare in the young as was until recently supposed.
The shape and structure of this portion of the bone, and the peculiar
changes which occur with advancing years, constitute the explanation
for the frequency of this injury in late life. As the jaw begins to
change in shape, and the teeth to drop out, there occur also unseen
changes within the cancellous structure of the head and neck of the
femur by which the strength of the latter is materially reduced. It
is still further weakened by the change in shape which the bone also
undergoes as it loses its obtuse angle and becomes set more at a right
angle with the shaft. The reduced ability to resist strain produced
by these changes is remarkable, and accounts for the ease with which
fractures occur, even from so apparently trivial an accident as
tripping on the floor. With all the violence directly transmitted there
is usually present an element of twist or torsion by which fracture is
still further favored.
As between so-called _intracapsular_ and _extracapsular_ fractures
surgeons have made distinctions to which unnecessary importance
has been attached. Anteriorly the capsule is attached to the
intertrochanteric line, while posteriorly it does not extend nearly
so far outward; it can thus be seen that many fractures are partly
intracapsular and partly extracapsular. These lines vary in different
individuals, especially that of the posterior insertion; it is not
usually possible to make minute distinctions of this kind. The
principal importance which attaches to them is in the direction of
prognosis, for if the fragment be absolutely intracapsular it can
derive its blood supply only through the ligamentum teres, which
is, to say the least, a precarious method of existence and usually
disappointing. In general it may be assumed that a fracture close to
the head is intracapsular, but that when it occurs well out toward
the shaft it may partake of both characters. In this connection the
_x_-rays will afford, usually, more satisfactory information than can
be obtained by even extensive or rude manipulation.
_Impaction_ occurs with considerable frequency in these cases, and,
unless accompanied by too much deformity or displacement, is rather
a fortunate occurrence, since by it is afforded an automatic splint
which it should be the surgeon’s endeavor to not break apart. There
can be no doubt, moreover, but that trifling degrees of impaction with
incomplete fracture occur, especially in the aged, in many injuries
to the hip. It would be the greatest misfortune to the patient in one
of these cases to complete the separation, and when assured of the
existence of such a lesion it is best to treat the case as though it
were a fracture. I am sure that many cases which have gone into court
have been due to incomplete fractures with impaction, where there has
been later absorption of bone, by which the femoral neck has been much
shortened, so that recognizable deformity as well as more or less
disability have resulted. Other changes comprised among those already
described in the chapter on Joints, under the section on Arthritis
Deformans, may also occur. Callus which has been at one time abundant
may also undergo too great absorption.
[Illustration: FIG. 310
Sections of impacted extracapsular fractures of neck of femur, showing
the degree of impaction and of splintering in different cases.
(Erichsen.)]
[Illustration: FIG. 311
Extracapsular fracture of thigh.]
Fig. 311 illustrates extracapsular fracture and comminution. Figs. 312
and 313, also from specimens in the author’s collection, show some of
the changes described above, including impaction, displacement, and
some osteophytic outgrowth.
[Illustration: FIG. 312
FIG. 313
Impacted fractures of necks of femurs.]
_Signs of fracture of the neck of the femur_ of special import are
_history of injury_, _pain_, _loss of function_, _shortening_, _rotary
displacement_, usually eversion, _crepitus_, _relaxation of the fascia
lata_, and _disarrangement of the lines of triangulation_ between the
bony prominences of the pelvis and the trochanter. Diagnosis should
be attempted with as little manipulation as possible lest impaction
be dislodged. The patient should be placed upon a comfortably hard
surface. Anesthesia will sometimes afford important aid. It should be
ascertained, first, that there had been no previous injury which could
produce shortening. If, then, _shortening_ be apparent it is of itself
almost a diagnostic sign. Such a limb is practically helpless, and
unless the neck be so driven in upon itself as to produce impaction the
foot will be usually everted, while the tension of the fascia lata will
be relaxed and there will be fulness in Scarpa’s triangle. Absolute
inability to use the limb implies fracture without impaction. Should
the patient have been able to help himself or work after the injury,
impaction may be safely assumed. The parts are exceedingly tender and
pain is easily produced. Shortening is to be assumed only after placing
the limbs and body in a _perfectly symmetrical position_ (the pelvis
being at right angle with the spine), after which the measurement
most usually made is from the anterior superior spine to the internal
malleolus. _Nélaton’s line_ is the shortest line which can be made to
pass around the hip, in one plane, from the anterior superior spine to
the tuberosity of the ischium. While the line is curved it should lie
in the same plane. Normally this passes just over the great trochanter.
If there be real shortening the trochanter should rise above this
line to an extent corresponding with the shortening made out by other
measurements. Still another method of measurement is to hold a straight
edge opposite to the superior spine and perpendicular to the surface
upon which the patient is lying; the distance between this edge and
the great trochanter should be as much less than the distance found
by similar measurement on the other side as the amount of shortening
measured by the other methods. This is the easiest way to measure the
lines included in Bryant’s iliofemoral triangle. Both are illustrated
in Fig. 314. Impaction can sometimes be determined by comparing
triangles drawn between three points on either side, these points
being, respectively, the great trochanters, the anterior spine, and the
centre of the pubis, which is common to both. The lower line of the
triangle on the injured side should be shorter than on the other, in
proportion as the head and the end of the shaft have been driven toward
each other.
[Illustration: FIG. 314
Nélaton’s line, dark. Bryant’s iliofemoral triangle, dotted.
(Erichsen.)]
_Crepitus_ is a sign to be elicited with care and gentleness.
Up-and-down movements of the thigh upon the side of the pelvis or
gentle rotary movements, combined with circumduction of the knee, will
yield it if it is to be easily detected. Every effort of this kind
disturbs the injured bone and should be minimized as much as possible.
One other sign of considerable value is the fact that if the patient be
turned upon his face a fractured femoral neck will permit the leg to be
_hyperextended_ to a degree not permitted by the normal condition. In
making this test the pelvis should be held firmly; it should be made
but once, the intent being to disturb the parts as little as possible.
=Diagnosis.=--The diagnosis of fracture is often easy, but in some
cases it is accompanied by many difficulties. It would be better to
give the patient the benefit of a doubt and treat him for a fracture
with rest than to subject him to excessive manipulation. Such an injury
is not likely to be mistaken for anything else save a dislocation
of the hip, although occasionally separation of the margin of the
acetabulum might cause confusion.
=Prognosis.=--The prognosis depends upon the age and vitality of
the patient, the location and extent of the fracture, the method of
treatment, and upon causes which seem at first foreign to the subject.
Patients with pulmonary or cardiac trouble, who need frequent change
in position, or perhaps absolute rest, are likely to develop something
hurriedly which will disarrange ordinary calculations. Sometimes
they die suddenly or they may develop pulmonary edema or hypostatic
pneumonia. The circulation may be so poor as to lead to early
development of bed-sores, while ordinary complications in prostatics,
or habitual constipation in the aged, may make care and treatment
exceedingly difficult. It should be emphasized, then, that treatment
of the fracture alone is by no means all that these patients require,
and prognosis means something more than what may merely happen to the
bone. In this last respect, however, the better nourished the fragment
the more likely is bony union to take place _if_ good position can be
maintained. When osseous union has failed patients get fairly useful
limbs with _fibrous or ligamentous union_, even with one or two inches
of shortening, and such patients may hobble about for years, with a
cane or a crutch, with limbs that are semiserviceable.
=Treatment.=--Of these cases it may be said that interests of life
are paramount to those of limb, and the treatment should be directed
to that which the patient can tolerate. Reasonably healthy, muscular
people can bear the application of adhesive strips and traction such
as the thin and delicate cannot tolerate. The ideal method is that by
which sufficient traction is made to overcome all muscle pull which
shall produce shortening, the measure of weight to be used in these
cases being the effect thereby produced. Thus if twenty pounds be
sufficient, well and good; if not, it should be increased to thirty or
forty pounds, providing that the patient can tolerate it. At the same
time a broad binder around the pelvis may afford sufficient support
with a tractable patient, while many will require a _long side splint_,
extending from the axilla to beneath the foot, to which both body
and the injured limb should be fastened, in order to more perfectly
maintain that physiological rest which is so necessary. This last is
the so-called “Physick” splint, which has been variously modified,
while the method of traction has been usually spoken of as Buck’s
extension. It seems well thus to commemorate the names of the American
surgeons who showed the value of these methods. When a long side splint
cannot be borne, sandbags 15 in. or 20 in. in length and 3 in. in
diameter may be used to give support. Any decided tendency to eversion
of the limb should be corrected as well as the shortening. When the
long side splint is used the foot can be held in place with it and thus
the position of the shaft of the femur controlled. At other times this
may be done by flexing the knee and thus preventing upward rotation.
In all methods of traction it is advisable to _keep the heel free from
the bed_, in order that the effect of the method may not be lost by the
obstruction of the mattress.
[Illustration: FIG. 315
Fracture of upper third of femur. Vicious union.]
[Illustration: FIG. 316
Shortening resulting from overlapping.]
[Illustration: FIG. 317
Overlapping fracture of femur.]
Other methods of treatment of these fractures are common as well to
those of the shaft, and will be considered later. These include the
single and double inclined plane and the method by anterior suspension.
In general the _first indication is efficient traction_. This should be
made as efficiently as possible. When the patient cannot tolerate any
of the usual methods, then the double-inclined plane may be used, the
knee being hung over its apex, or anterior suspension may be practised.
In severe cases patients should be simply made comfortable, with such
local treatment as they can bear. It may be even necessary to place
them in the semi-upright position in bed, in order to free the lungs,
or to frequently change their position to avoid the formation of
pressure sores.
[Illustration: FIG. 318
Fracture of lower end of femur, with great displacement of condyles.]
=Fractures of the Shaft of the Femur.=--Fractures of the shaft of the
femur are usually oblique and accompanied by considerable displacement,
because of the powerful thigh muscles which tend to shorten the limb.
These fractures are often _compound_, and occasionally the femoral
fragment causes serious damage to important vessels or nerve trunks.
When the fracture is just below the insertion of the psoas into
the lesser trochanter this muscle tends to not only pull up but to
externally rotate the upper fragment. Inasmuch as there is no way of
controlling this muscle or the fragment, the fractured limb should be
dressed upon an inclined plane, or in anterior suspension, in such a
way as to make the axis of the shaft fall into line with that of the
fragment. When the fracture is in the middle of the thigh, or lower,
there is sufficient length of the upper portion so that pressure can
be made upon it, or that psoas activity can be overcome. Fig. 315
illustrates the tremendous deformity that may result from neglect of
these precautions. Fig. 316 illustrates a certain degree of overlapping
without conspicuous other deformity. Fig. 317 shows the shortening
which is often inevitable.
_Muscle spasm_ should be overcome as an essential part of successful
treatment, the most important feature in making traction being to use
force sufficient to tire out and overcome the irritated muscles.
=Fractures of the Lower End of the Femur.=--Fractures of the lower end
of the femur are usually the result of extreme violence, and may be
classified as were those of the lower end of the humerus. When there
is a _supracondyloid_ fracture the two heads of the gastrocnemius will
help to displace backward the upper end of the lower fragment to an
extent permitting injury to the bloodvessels, while there is always
marked shortening. Here the patella will be made unduly prominent,
and there will be depression above it. _Either condyle_ may be broken
loose alone, or there may be _intercondyloid_ or T-fractures which are
serious because the amount of force required to produce them may have
played serious havoc with the soft tissues. The joint capsule will
probably be filled with blood, the ligaments rent, and perhaps the
blood supply of the limb compromised. In such a case as this the joint
may be opened, the contents turned out, and the fragments readjusted
and wired or fastened in place (Fig. 318). _Epiphyseal separations_,
which may occur up to the twentieth year, are not essentially
different, although lateral displacement is perhaps more common, while
they are often compound.
=Treatment.=--Oblique fractures of the femoral shaft can be more easily
adjusted under the influence of powerful and continuous traction than
the transverse, where lateral displacement and overlapping tend to
occur. A more general application can be made of the method described
above when dealing with fractures at the upper end of the shaft, _i.
e._, when the upper fragment cannot be controlled the balance of the
limb must be adjusted to it in whatever position it may be required
to maintain. By the use of sufficient traction, combined with molded
or other splints, a fair result may usually be obtained. In stout
individuals it is by no means easy to determine just how the fragments
lie, save by the use of the _x_-rays. If traction be so adjusted as
to maintain the limb at equal length with the other the surgeon may
feel that, with certain coaptation splints, he is doing the best he
can. Application of the same rule given above would lead him to place
the limb on a double inclined plane, in case of fracture near the
knee-joint, in order that in this position the sural muscles (the
calf) may be relaxed and backward displacement of the lower fragment
be adjusted. If the apex of this plane be arranged sufficiently high,
so that the patient’s knee is practically hung over it, and that the
weight of the body makes sufficient _countertraction_, then the use of
weight and pulley may not be necessary. Here, however, pressure which
will be efficient may produce numbness, as will any long-continued
pressure in the popliteal space, and after a few days it may be
necessary to assume some other position. Fractures which loosen the
condyles will need lateral pressure, while the position of each condyle
may be controlled by the position of the leg, through the medium of the
corresponding lateral ligament.
[Illustration: FIG. 319
Extension band and foot-piece.]
[Illustration: FIG. 320
Same, folded and ready for use.]
The standard “Buck’s extension” (for which latter word I prefer to
substitute the term “traction”), by weight and pulley, with the limb in
the extended position, is still the resort of the majority of surgeons,
but combined with other support by long side splints or coaptation
splints as may be needed. Fig. 321 illustrates the method of its use,
except that the ends of the adhesive strips should be extended upward
to a point nearly opposite the site of the fracture. The amount of
weight to be used should be graduated to the effect produced. From
ten to forty pounds, or even more, may be needed. After the muscles
are thoroughly tired the amount of weight may be somewhat reduced[41]
(Figs. 319, 320 and 321).
[41] Before applying the strips of adhesive, the best for the purpose
being that made of moleskin spread with material with which zinc
oxide is incorporated, the limb should be carefully washed and shaved
and then completely dried. A little cotton should be placed over each
malleolus, in order to avoid pressure-sores, while the strip of wood
beneath the foot should be sufficiently wide to prevent or minimize
this pressure. The heel should be kept off the mattress.
[Illustration: FIG. 321
Mode of applying adhesive plaster. (When the dressings are completed
the limb should not be allowed to rest on the bed.)]
Continuous and anterior traction was devised by Nathan R. Smith, in
the use of a so-called _anterior splint_, which was later modified
and improved in device by Hodgen. The method of its use is shown in
Fig. 322. Adhesive strips are used in this method as well, permitting
the leg and foot to be attached to the lower bar of the wire frame.
The position of the frame which contains the limb, swung within it
upon turns or strips of bandage, is then controlled by a suspension
apparatus, as shown, which tends to constantly pull the frame and
its attached lower part of the limb _away_ from the patient, the
effect being to make a constant but gentle traction. If the point
of suspension were placed directly above the limb there would be no
traction whatever. The essential feature of the method, then, consists
in arranging it as shown, so that the pull shall be oblique, and that,
according to the obliquity of the suspension cords, the amount of
traction shall be regulated.
[Illustration: FIG. 322
The Hodgen suspension splint.]
In this method of treatment there is no violent attempt made at
reduction or overcoming displacement, but dependence is placed, at
least for two or three days, on the effect of the constant pull and
its overcoming muscular activity. After this such added splints or
expedients may be adopted as the case may require. The knee is usually
flexed at a comfortable angle, the intent being not to lift the foot
too high, so as to avoid being compelled to overcome this added weight,
but to regulate the tension by the obliquity of the suspending cord.
[Illustration: FIG. 323
Fracture of the femur in a child treated by vertical extension.
(Bryant.)]
This method has found favor in the West under the enduring influence
of Hodgen’s teaching. In the East it is not so generally practised.
It has, however, several advantages, as follows: (1) Equably perfect
and comfortable extension; (2) easy adjustment; (3) easy exposure
for inspection; (4) when a fracture is compound it permits of easy
application of dressings; (5) adaptability to nearly all fractures of
the femur. It is peculiarly serviceable for feeble and aged patients
who chafe at restraint. If it be desirable to flex the knee to a
considerable degree this can be done, _e. g._, in fractures near the
lesser trochanter.
In fractures of the thigh, patients are frequently disturbed by
muscle spasms occurring during sleep. This can usually be obviated or
minimized by suitable doses of sulphonal, given early in the evening.
Fractures of the femur _in children_ are not uncommon. In those who
still wear diapers, and perhaps in those a little older, these injuries
may be best treated by vertical suspension, with sufficient weight to
overcome all shortening. Here the adhesive strips and the suspending
cords should be attached to both limbs alike, in order to have
sufficient access to the perineum, and in order to judge of the effect
which we are obtaining. Figs. 323 and 324 illustrate this method.
Plaster-of-Paris dressings for fractures of the thigh appeal especially
to those who are most familiar with the use of the material. Some
patients with fracture of the neck of the femur may be early put in
the erect posture, upon an elevated surface, allowing the injured limb
to hang down while the patient rests upon crutches. In this upright
position, with the down-hanging leg, to which traction can be made by
an assistant, a plaster-of-Paris spica may be applied, extending from
the waist-line down to or below the knee. As a limb is thus dressed
so it will heal, and it is of importance that complete reduction be
effected as a part of the procedure.
[Illustration: FIG. 324
Fracture of the thigh; vertical suspension. The fracture is compound in
the patient on the right. (Stimson).]
FRACTURES OF THE PATELLA.
During the active period of middle life the patella is the bone most
frequently broken by muscular violence. In many cases it is practically
cracked over the condyles, as one would crack a piece of wood over the
knee. If direct force be applied, as by a fall, in connection with the
above, the effect is even more marked. In such cases the fracture is
sometimes comminuted (Fig. 325), or the line of fracture may run more
or less perpendicularly rather than horizontally. Ordinarily, however,
these fractures are transverse, while the upper fragment is pulled
upward, sometimes to a considerable distance, by the powerful extensors
of the leg. When the fracture runs vertically the displacement is very
slight. Occasionally these fractures are compound, a most undesirable
complication, since the knee-joint is thus exposed to infection, from
which it suffers unless first attention be prompt and scientific. There
is usually sufficient hemorrhage to distend the joint cavity, and it
may at first be quite impossible to bring the fragments near enough
to each other to get crepitus, but the loss of the power of extension
and the evident gap between the fragments will serve to make diagnosis
positive, at least in all transverse fractures. A _vertical_ fracture
without much separation is a milder form of injury which may be
regarded in a much more favorable light (Figs. 326, 327 and 328).
In these transverse fractures it is rare that bony union can be secured
by non-operative methods. This is not only because of the difficulty
in maintaining parts in apposition, but because it is notably the
case that fragments of periosteum or other tissue drop in between
bony surfaces and tend to prevent their actual contact, no matter how
firmly they may be pressed toward each other. Osseous union then _may_
occur without operation, but is rare. The best that can be expected
is fibrous union, the intervening fibrous band being short or long,
according to the success met with in treatment and to the amount
of strain later put upon it by too early use of the limb. Even with
two inches of fibrous tissue intervening patients are not completely
disabled. The usefulness of a limb under these conditions, however, is
seriously impaired. Something will depend, also, on the extent to which
the joint capsule and the aponeurosis terminating the vasti muscles may
have suffered.
=Treatment.=--The non-operative treatment consists in placing such
a limb upon a single inclined plane, for the purpose of relaxing
the quadriceps extensor group. In this position the limb should be
maintained for at least from ten to fourteen days. Some expedient
should be added, so soon as swelling has subsided, by which the upper
fragment can be coaxed downward toward its fellow. A neatly molded
splint, formed out of gutta-percha or of plaster of Paris, may be
fitted to the thigh above the fragment, held in position, and then
drawn downward by elastic traction on either side of the leg, the
principle of traction being thus given a special application. Something
of this kind should be done if the fragments are to be approximated to
each other.
[Illustration: FIG. 325
Comminuted fracture.]
[Illustration: FIG. 326
Stellate fracture of the patella. (Erichsen.)]
[Illustration: FIG. 327
Fracture of patella, united by ligamentous tissue. (Erichsen.)]
[Illustration: FIG. 328
Side view of same.]
The more completely mechanical method, partaking of the operative, is
afforded by the use of certain _hooks_, whose points are permitted
to pass through the skin above and below the fragments and to engage
in the bone. By a screw mechanism these points are drawn toward each
other, and thus approximation is effected. This method was first
devised by Malgaigne and is usually known under his name, although his
device has been much improved. This is far from ideal, and yet has
given good results in some cases. The surgeon should constantly guard
against infection through the punctures.
By far the most ideal method, when it can be suitably carried out, is
the _open operation_, a transverse incision being made across the front
of the joint, which is completely opened; this affords an opportunity
to empty out clots and to thoroughly cleanse it, which of itself is a
great advantage, since these clots often produce subsequent adhesions.
The exposed surfaces may now be freed from clot and all soft tissue, or
they may be neatly sawed as near to the fractured surfaces as possible,
the intent being to permit them to come into absolute and complete
contact, and to hold them there by wire or other sutures, for a length
of time sufficient for absolute bony union. When properly performed
this operation gives ideal results; it, of course, exposes to great
danger if improperly done.
Treatment by non-operative method rarely affords a useful member
under an average period of from thirteen to fourteen weeks, while the
operative method permits a reduction of this time to less than half.
It, therefore, has obvious advantages for those (_e. g._, laboring men)
to whom time is of great importance. The operation, however, is not
to be practised as a rude emergency affair, but only when we may be
absolutely certain of everything pertaining to aseptic technique. After
operation it is rarely necessary to use a drain, and such a limb can
usually be dressed in a plaster-of-Paris splint. Compound fractures,
however, will probably need drainage at least for a day or two, and
because of this need may as well be operated at once. In _comminuted
fractures_ the method is desirable, since by a loop or by some other
expedient fragments can be held together as in no other way (Figs. 329
and 330).
[Illustration: FIG. 329
FIG. 330
Wiring patella. (Lejars.)]
Injuries to the patellar region, equivalent to fractures, are
_separations_, either of the _tendon_ from the bone, or of the bone
from the _ligament_ which holds it to the tibia. Such injuries can
be recognized by the fact that the contour of the bone itself is
preserved; in the former case it is not drawn up, although the extensor
muscles have lost their power while in the latter it is drawn up,
leaving a well-marked gap below it.
Remarks concerning the treatment of fractures apply equally here.
Choice can be made between the operative and the non-operative
treatment. In well-selected cases the former seems much the more
desirable, the fibrous end of the tendon or ligament being held to the
bone by strong sutures of silk or wire.
THE LEG; FRACTURES OF THE TIBIA.
The _head of the tibia_ is occasionally broken as the result of extreme
violence, the fragment being usually held reasonably in place by one
or other of the lateral ligaments. Hemorrhage into the joint will be
profuse, with swelling extreme, while disability will be complete. Not
a few of these cases justify operation, directed toward opening the
joint, removing all clot, and fastening the fragment in place with
suitable sutures (Figs. 331 and 332).
_Transverse fracture below the tubercle_ is less rare. The insertion of
the terminal ligament of the quadriceps extensor group will, in all of
these injuries to the upper portion of the tibia, tend to pull up the
upper fragment and make it project beneath, even protrude through the
skin. Fractures of the _lower part_ of the tibia are freer from such
distorting influences. Fig. 333 illustrates the distortion produced
as above, while Fig. 335 shows one of the tendencies in fracture of
the lower end of the tibial shaft, which has to be overcome by correct
emplacement of the foot within the dressing. Fig. 334 illustrates
synostosis as the result of fracture of both bones at about the same
level. Torsion is a factor of no small importance in the production
of most of the fractures of the leg, to such an extent as sometimes to
make a completely spiral fracture, a condition generally held to be
more serious than fracture of the ordinary type. The line of fracture
often extends in such a direction as to leave a sharp spicule of
bone close beneath the skin; here rough handling, or carelessly made
pressure in the dressing, may cause a perforation within a few hours or
days after the injury, by which a simple is converted into a compound
fracture. Such a complication should always be avoided.
[Illustration: FIG. 331
FIG. 332
Wiring tibia. (Lejars.)]
FRACTURES OF THE FIBULA.
The lower end of this bone is much more often fractured than the upper,
although it may be broken at any point. Into its upper termination
is inserted the external lateral ligament, and this insertion may be
torn off from the bone in cases of violent sprain of the knee, damage
occurring which is similar to that which happens in injuries about the
ankle. The upper portion of the bone lies well buried beneath muscles,
and fractures here are not so easily recognized. A good maneuver for
their recognition is to seize the bones at the lower portion of the
leg and press them together; if such pressure gives severe pain
above, or if it be shown that the fibula is more movable than natural,
fracture may be practically diagnosticated, even though crepitus be not
detected. A skiagram would, of course, clear up such a diagnosis.
Fractures of _both bones of the leg_ occur almost as frequently as of
either alone, usually as the result of direct violence, with or without
more or less torsion; as, for instance, when the foot is more or less
entangled, and, at the same time, twisted at the time of injury. These
double fractures are by no means necessarily placed upon the same
level; thus the tibia may be broken low down and the fibula high up,
so high indeed that the latter fracture may escape observation. With
fracture of both bones disability becomes complete, while shortening
is very likely to occur, all the muscles passing from the leg to the
foot conspiring to this effect. These fractures, moreover, are often
_comminuted_ and _compound_, sometimes to an extent necessitating
exsection of fragments or of an inch or more from the shaft of each
bone. In exsection of the tibia an equivalent amount should for obvious
reasons be taken from the fibula. Displacements are extremely likely
to occur, and in every compound fracture the presence of the opening
may be utilized for the emplacement of sutures or suitable means for
enforcing approximation. Indeed, other means failing, resort may be had
to this measure in order to secure an ultimately good result.
[Illustration: FIG. 333
Fracture of upper end of tibia.]
[Illustration: FIG. 334
Transverse fracture, with anterior displacement. (From the Buffalo
Museum.)]
[Illustration: FIG. 335
Line of fracture at junction of lower and middle thirds of tibia.]
While wire sutures may be used as freely as may be indicated it will be
well, at least in the majority of cases, to leave the ends protruding
in such a way that they can later be untwisted and removed. The
presence of wire after a certain length of time rather interferes with
the process of ossification than helps it.
Fractures of the _lower end of the leg_ nearly always involve the
joint, to some extent at least, in respect of being accompanied by
sprain if nothing else. They are accompanied by displacement of
the foot, and are produced by violence, which first involves the
foot. The term “_Pott’s fracture_” is meant to include the injury
originally described by Pott himself. In the typical Pott’s fracture,
as shown in Figs. 336 and 337, there are a chipping off of the
internal malleolus, of the outer portion of the articular end of
the tibia, and fracture of the fibula a little above the joint. In
spite of the classical description which Pott gave fractures of the
fibula alone, those accompanied by tearing of the internal lateral
ligament, or chipping off of the malleolus, are frequently referred
to under the same term. The more complete the injury the greater the
possibility for displacement. Eversion and outward displacement, of
course, are conspicuous. Lesser degrees of injury are accompanied
by less displacement, but all of these injuries will be followed by
extreme swelling of the ankle-joint, which may at first make diagnosis
somewhat difficult, because of the extreme tenderness which prevents
the handling necessary for careful determination. It is not always
easy to so completely replace the bones, when we have the combination
of three fractures as above, as to get an ideal result. Nevertheless
with suitable treatment usually very useful limbs are secured. When the
injury has been made _compound_ the difficulties are increased. Such a
result will not be obtained, however, unless the tendency to backward
and lateral displacement be overcome, when the limb is placed in its
permanent plaster-of-Paris splint, as it should be after a few days.
Great care should be given to this point in the management.
[Illustration: FIG. 336
Pott’s fracture. (Hoffa.)]
[Illustration: FIG. 337
Exaggerated deformity in Pott’s fracture.]
=Treatment of Fractures of the Leg.=--Nearly all these fractures are
likely to be followed by swelling, even to a degree which makes it
impracticable to put them up in permanent dressing until the swelling
has subsided. This means a period of two to several days, during which
the limb should be kept absolutely at rest, and the bones maintained
in apposition by side splints, while the limb is restrained within a
folded pillow or other comfortable cushion. More frequently here than
in any other part of the body there will form blebs or large blisters,
which are most liable to occur in alcoholic subjects. The leg should
be scrubbed and shaved before putting on dressings, in order that the
skin may be reasonably clean before its surface epithelium is raised.
Ecchymosis, infiltration, and sometimes general edema may become
somewhat pronounced, and the splint which would be required to fit
a limb under these circumstances would soon be too large when this
disturbance has subsided. The limb should not, therefore, be placed in
a fixed or permanent dressing until it is in every respect ready.
While these disturbances are subsiding, or perhaps being encouraged
to subside by the use of an ice-bag or of cold wet applications,
extreme care should be taken that proper position and apposition are
maintained. This will at times need considerable ingenuity. A delirious
or maniacal patient would need restraint far beyond that required for
one who is rational and docile. Moreover in all of these fracture cases
which entail confinement to bed there is a tendency to deficiency of
elimination which will require judicious use of laxatives and other
eliminatives.
The writer prefers a well-molded set of side splints, properly padded,
to any other first dressing for fractures of the leg. A limb thus
dressed may be supported on a pillow and even made adaptable for
transportation should it be necessary to remove the patient from one
place to another. The fracture box can be well superseded by this
method.
So soon as swelling has subsided, plaster of Paris should be used for a
fixed dressing. The limb should be enveloped in a layer of cotton, by
which the skin is protected, within which swelling may occur without
much strangulation. Over this and down the front of the leg a strip
of thick pasteboard should be placed, which can be moistened and made
to adapt itself, or a strip of sheet tin, an inch wide, which can
be made to fit the part, and upon which one may cut down later in
removing the splint. This refers especially to the use of the roller
bandage saturated with plaster of Paris. Molded splints can be made,
as recommended for the upper extremity, out of surgeons’ lint, canton
flannel, or old blanketing, while at the lower end of these splints
may be incorporated, with the plaster, a strip of bandage or other
material, by which a loop is formed beneath the foot, which may be
utilized for the purpose of traction.
The foot should _always be placed at a right angle to the leg_.
If there be too much muscle spasm to permit this, or make it too
uncomfortable, the tendo Achillis may be divided. This position should
be maintained during the period of repair, in order that so soon as one
resumes the use of the limb the foot may be planted naturally upon the
ground. In addition to this precaution it must be noted that backward
displacement is completely overcome, and that eversion is perhaps a
trifle overcorrected.
In all fractures of the lower end of the leg the foot and entire leg
should be enclosed in a bandage. In fractures near or above the middle
not only the leg but the lower part of the thigh should be immobilized
if the promptest and most satisfactory results are to be obtained.
The limb being immobilized it soon becomes a question as to how quickly
the patient can leave the bed and begin to move about on crutches.
This will depend to some extent on the patient’s temperament. Timid
women are less desirous of getting out of bed than are active men and
children. Some patients acquire facility with crutches very slowly.
Others are so tenderly built that crutches give pain and even produce
crutch paralysis. It is advisable to get patients at least into the
sitting posture so soon as the immobilization has been secured, while
those inclined may be encouraged to use the uninjured limb and move
about with crutches. A foot and leg too long kept off the ground will
swell when again lowered. The later this dependent position is attained
the greater the liability to edema. Patients should be cautioned about
this.
The so-called _ambulatory method of treatment_ has found favor with
some surgeons. This implies something more than merely permitting
motion with crutches; it means really such dressing as to permit use
of the injured limb in locomotion. The various forms of splints used
for immobilizing the limb in hip-joint disease may be used in this way.
A useful splint is made with body and perineal bands, or an inside
steel bar with ischiatic crutch and a cross-bar below the sole of the
foot, on which the weight of the body may be supported. This is to be
combined with a plaster-of-Paris support.
The ambulatory treatment is occasionally of value, but the advantages
claimed for it have not been generally sustained.
FRACTURES OF THE FOOT.
The astragalus and the calcis suffer more often than the other tarsal
bones, partly because of their size and partly because they are in the
line of transmission of force as usually directed after accident. When
the posterior end of the calcis is broken off there remains a fragment
which is easily palpated, and which would be displaced backward and
upward by the tendo Achillis were it not for the plantar fascial fibers
which are inserted into it. The bone may also be comminuted, in which
case that part of the foot will lose much of its shape and distinctive
peculiarities. The sole will be flattened, but swelling and hemorrhage
will at first be so great that there will be much difficulty in
recognizing the exact nature of the injury.
The _astragalus_ is usually broken by being caught between the calcis
and the lower end of the leg. It is generally broken through the line
of its so-called neck. Not infrequently one or more of the fragments
is forced out of place, usually beneath the anterior tendons. When
such extensive displacement occurs the fragments should be removed if
the fracture is compound. In both of these bones results are generally
satisfactory when displacement is not marked, also after removal of
the entire astragalus. The foot and leg should be immobilized in the
best possible position, and this can be best accomplished within a
plaster-of-Paris dressing.
In regard to the _tarsal bones_, diagnosis can now be made accurately
by the use of the _x_-rays. These bones, according to Eisendrath, may
be fractured in any one of the following ways: (1) Compression, as when
the weight of the body is violently thrown upon the feet; (2) sudden
dorsal flexion, often with fracture of the inner malleolus; (3) forced
supination or pronation, the interosseous ligaments being stronger, the
bones forcibly pulling the latter apart; (4) violent traction upon the
heel through the calf muscles, by which the tuberosity of the calcis
may be torn from the rest of the bone; (5) extensive crushing injuries,
in which several tarsal bones may be involved; (6) gunshot fractures.
Some assistance in diagnosis may be obtained by computing the distance
from the malleoli to the bottom of the heel, which will be shortened
when the bones are compressed; or shortening of the length of the foot,
or by fixed abnormal positions.
The _metatarsal bones_ are broken by direct violence, the first and
fifth being most exposed. As in other fractures of the foot contusion
will be a serious feature, and swelling and laceration will frequently
seriously complicate, while the fractures themselves may be compound.
The same is true, also, of fractures of the _phalanges_, crushing
and comminution being common. The matter of treatment often includes
an estimation of the blood supply and of the vitality of the distal
portion. The operator may sometimes temporize with an antiseptic
dressing until this matter is settled. Simple fractures require only
immobilization in good position.
CHAPTER XXXV.
DISLOCATIONS.
A sprain has already been described as a momentary change of
emplacement or disturbance of the normal relations between joint
surfaces, which, so far as displacement is concerned, is but a
momentary affair and is promptly overcome. The term _dislocation_
implies something more permanent as well as complete in both respects.
It indicates an absolute and direct separation of articular surfaces
of much more than momentary duration and requiring skilled assistance
for its reduction. It pertains to articular surfaces which are enclosed
within a capsule. The term _luxation_ is synonymous with dislocation.
When the condition is evidently partial or incomplete it is often
referred to as _subluxation_. As compared with fracture dislocations
are about one-tenth as frequent.
Dislocations are described as _compound_ when through a co-existing
wound air may enter the cavity of the joint, and as _complicated_ when
accompanied by other lacerations or injuries. When unaccompanied by
these conditions they are described as _simple_.
To dislocations which result from external violence or from sudden
muscular action is given the term _traumatic_. _Pathological_
dislocations are those which are brought about by slow morbid
processes, muscle spasm being the most prominent factor in their
production. A third variety of dislocations, the so-called
_congenital_, do not belong strictly in this class; by common consent
the term is applied to congenital abnormalities where, from errors in
development, normal emplacements and relations are altered.
The distal bone is the one described as that which is dislocated; thus
we speak of dislocations of the forearm upon the arm, of the leg upon
the thigh, etc.
Subluxations or incomplete dislocations are frequently accompanied by
fracture of a bony prominence, _e. g._, the rim of the acetabulum,
the coronoid process of the ulna, etc. The direction in which the
distal member of the joint has been displaced is indicated by one of
the common terms, as forward, inward. A _consecutive_ or _secondary_
dislocation implies a shifting of position from that at first occupied
by the displaced bone end. These injuries may occur at any age,
although usually during the more active period of life, from childhood
to middle age, when mankind are more subject to injuries.
Certain conditions predispose to dislocations. Abnormalities or
previous injury or disease of joint structures figure especially in
this respect. A joint already relaxed by hydrarthrosis will exercise a
relatively small restraining influence and a subluxation, at least, may
easily occur.
The immediate cause is violence, either from without or within,
generally the former. This may be _direct_, as from a blow, or
_transmitted_, as when the shoulder is displaced by a fall upon the
open hand. It occasionally happens that the component bones of a
dislocated joint were in a position of extreme flexion or extension
at the time of injury. The factors of leverage and spiral tension or
wrenching are also important ones. Luxation from _muscular activity_ is
occasionally met with; most frequently when the lower jaw is dislocated
by the act of yawning or violent laughter. The shoulder has been
displaced in a violent effort at throwing or pitching a ball, or in
wild gesticulation.
A few individuals have been in the habit of exhibiting themselves
whose normal ligament and joint arrangements are so lax that they can
voluntarily displace one or more of them and as easily replace them.
These may be spoken of as instances of _voluntary_ dislocation.
A joint once displaced may never fully recover its normal degree of
tension, and will yield more readily to subsequent similar injuries.
In this way there may occur so-called _recurrent_ or _habitual_
dislocations. Expressions of this kind are seen most often in the lower
jaw and in the patella.
Actual injury to tissues is to some extent unavoidable. In arthrodial
joints the capsule is nearly always lacerated, at least upon one side.
In hinge joints both lateral ligaments are likely to be ruptured. It
is probable, however, that about the maxillary joints the ligaments
may stretch without tearing to any extent. Not only are ligaments torn,
but bony prominences are frequently detached, while sometimes there is
extensive tearing away of tissue.
In connection with these injuries to joints proper other complications
may occur, such as fractures of prominences about joints and epiphyseal
separations, or such injuries as compound fracture of the neck of the
humerus with dislocation of its head. Furthermore, bloodvessels are
occasionally lacerated and nerves are frequently injured. This latter
lesion is liable to occur after shoulder dislocations, the head of the
bone injuring the circumflex nerve, paralysis of the deltoid being the
consequence. This is a feature of the injury, and yet the result has
often been unjustly imputed to the physician in attendance. Even a
momentary contusion of the nerve may be followed by lasting effects,
for which the medical attendant should be held blameless. Other
injuries, _e. g._, contusions or lacerations of nerves, may occur about
any of the joints.
Dislocations of the spine subject the cord to a special class of
injuries which will be dealt with later in this work. In very rare
instances the head of the humerus has been forced within the thorax
or the head of the femur within the pelvis, these, injuries being
practically always fatal.
Compound dislocations rarely occur about the jaw or shoulder. They
pertain usually to the joints below. In every case of such character
the question will be promptly raised whether a more or less complete
exsection of the joint will not be preferable to mere reduction with
the ensuing probability of ankylosis. Such injuries will, under all
circumstances, require aseptic measures.
So far as _repair_ is concerned, dislocations by themselves are so
rarely fatal that there have been but few opportunities for a study
of tissue recovery under these circumstances. It is apparent that
repair is complete, for after almost any simple dislocation there is
restoration of function.
The obstacles to reduction are spasm of muscles pertaining to the
injured limb, by which the dislocated bone end is firmly held in its
abnormal position, and, in those joints provided with a capsule,
the fact that the head of the bone is frequently forced out through
a comparatively small opening, through which it is only with the
greatest difficulty reduced. It is a part of the manipulation in most
cases to enlarge this rent in the capsule, after which reduction is
comparatively easy, although impossible until it is accomplished.
Dislocations which have long gone unreduced are called _old_,
_inveterate_, or _ancient_. By common consent a period of six weeks
has been fixed, beyond which the dislocation is spoken of as old or
ancient; up to that time it is usually described as unreduced. In
proportion to the length of this period the difficulties of reduction
are materially enhanced. So soon as a dislocated joint has been put
at rest, _i. e._, fixed by muscle spasm and by the timidity of the
patient, the blood which has been poured out will begin to coagulate
and conditions are soon favorable for organization of clot and
formation of adhesions in abnormal position. In the course of a few
weeks these adhesions become strong, and in the course of months they
are frequently stronger than the bone itself, which has been disused
and has undergone a certain amount of fatty atrophy. Thus it happens
that even with well-directed effort the bone will yield before the
adhesions, and thus, in spite of every precaution, fracture sometimes
complicates the effort to reduce these ancient dislocations.
So generally is this fact now recognized that surgeons do not hesitate
to make open incisions for the purpose of separating adhesions and
reopening what remains of the capsule in the endeavor to replace the
head of a bone. Nor do they hesitate sometimes to cut down upon the
latter and exsect rather than run the risk of more extensive injury.
Efforts at reduction under these circumstances subject the patient not
only to risk of failure, or of fracture of bone ends, but to rupture
of vessels or laceration of nerve trunks. I recall seeing one case of
enormous traumatic aneurysm of the axillary artery which was brought
about by unsuccessful attempt in this direction.
SYMPTOMS AND DIAGNOSIS OF DISLOCATIONS.
The cardinal indications of a dislocation are _deformity with
alteration in contour and position_ of the affected joint. It usually
happens that the dislocated bone ends cannot be felt in normal
position, but are felt somewhere else in the vicinity. About the
shoulder and hip of stout or fat individuals it may not be easy to feel
the head of the bone, but unless the case be complicated by a fracture
it can usually be detected by aid of anesthesia. The deformity may
include a _lengthening or shortening_ of the limb, apparent or real,
as well as _abnormal eversion or inversion_, or other peculiarity of
position.
Whatever alterations in position appear will be accentuated by _spasm
of the muscles_ which pertain to the movement of the affected joint
or even of the entire limb. These are usually so tightly contracted
as to form a complicating feature of such cases and to lead to that
_loss of mobility_ which is diagnostic of every dislocation. Limitation
of motion is not entirely a matter of muscle spasm. It is not under
voluntary control and subsides only under anesthesia. To some extent
motion may be limited by escape of the head of a bone through a small
rent in the enveloping capsule, by which it is afterward tightly
clasped. This is particularly true of the shoulder and hip. Certain
dislocations of the fingers or thumbs are also made more rigid by
fixation of the tendons, which become tightly stretched within the
neighboring tendon sheaths.
A sort of _crepitus_, which may be easily mistaken for that of
fracture, is occasionally detected during the examination of a
dislocated joint. It lacks the peculiar grating character of true bony
crepitus.
In addition to these features there are certain subjective symptoms,
of which _loss of function_ is the most prominent, while _pain_ is a
more or less frequent but variable accompaniment, and dependent on
the amount of tissue injury or pressure upon nerves. Moreover, the
displacement once completely rectified (“reduced”) does not tend to
recur, as is the case with fractures.
PATHOLOGICAL AND CONGENITAL LUXATIONS.
The statements made above refer almost entirely to recent and traumatic
dislocations.
_Pathological dislocations_ are those which are produced gradually and
through the mechanism of disease affecting the joint structures. The
head of the bone is gradually drawn out of the acetabulum, in tonic
spasm of hip-joint disease, by the continuous action of muscles, the
result being the complete displacement of the bone from its original
socket, or what is known, at the hip, as the _migration of the
acetabulum_, where its upper margin, being softened by disease, is
gradually extended and altered, so that the femoral head rests an inch
or more higher upon the side of the pelvis than is normal. Pathological
dislocations, then, may occur both in the course of the infectious
joint diseases as well as in the neuropathic.
_Congenital luxations_ are those which occur from defect in the
shape or arrangement of joint structures, permitting a departure
from the normal standard. While no joint in the body is exempt from
abnormalities of this description, the congenital hip dislocations
are those which have attracted attention by their frequency and the
disability which they produce.
While the general character of these changes is easily made out by
the ordinary methods of examination, coupled with a suitable history,
a well-made skiagram will tell at a glance a story which it may take
some effort to elicit by other means; hence radiography has here been
of great value to the surgeon. Congenital dislocations are devoid of
nearly all the features which characterize traumatic dislocations, and
their consideration will be found in the chapter on Orthopedics.
_Differential diagnosis as between fractures and dislocations_ is
not always easy. Furthermore it is frequently the separation of a
prominence by fracture which permits of dislocation, this being
particularly true of the elbow and the ankle. The extent of a fracture
may seriously complicate the problem of treatment, as, for instance,
when the head of the humerus is not only dislocated below the clavicle
but separated from the shaft by fracture at the surgical neck. A
dislocation made possible only by fracture will not remain reduced as
will one which is simple and uncomplicated, while it will display even
a greater amount of motility and displacement. Other complications may
occur, many of which are common both to dislocations and to fractures
in the vicinity of joints, such as lacerations of bloodvessels or nerve
trunks, pressure upon the latter, compound injuries with infections,
etc.
TREATMENT OF DISLOCATIONS.
The essential requisite of every case is complete reduction or
replacement of the dislocated bone end. The earlier this is attempted
the better the result. Brief as such a statement is, dislocations
frequently offer considerable difficulties, both in reduction and in
maintenance in proper position with the necessary physiological rest of
the injured part. Thus dislocations of the clavicle, which can hardly
occur without considerable injury to the ligaments, may be reduced with
slight effort, but are kept in place with difficulty. The simplicity of
the after-treatment is proportionate to the difficulty experienced in
reduction, so that while “to put the part in place and keep it there”
sounds very simple, it will often perplex the ingenuity of the surgeon.
Reduction having been effected, rest is the essential feature of the
after-treatment, which should be absolute for a few weeks and relative
for many months. Should reaction be extreme, ice-cold applications will
afford relief.
The causes which prevent reduction of dislocation are either those
attributable to ignorance, carelessness, or failure in diagnosis
on one hand, or, on the other, mechanical difficulties, including
“button-holing” of the capsule around the expanded end of a bone or
the interposition of some of the adjoining tissues. Dislocations of
the class referred to above as unreduced or ancient, offer great
difficulties, proportionate to their duration, which are due to the
formation of adhesions that sometimes take place and become very
dense. Judgment, skill, and effort are needed in their management.
A dislocation which has become unreducible is only to be treated by
arthrectomy and the establishment of a false joint. Nevertheless
in a small proportion of cases, especially of the hip and shoulder
dislocations, the adhesions which first form gradually relax, and
in time there is formed a natural substitute for a joint which may
be regarded as a _nearthrosis_, and which will sometimes prove as
serviceable as any result afforded by arthrectomy. The duration of time
after which reduction is impossible or impracticable varies so widely
with different cases that it can scarcely be stated. It rarely is more
than a few months and often but a few weeks. It is greater when it is a
ball-and-socket joint which is affected.
Nearly everything that has been stated in the previous chapter
concerning compound fractures applies here to compound dislocations.
They are subject to the same dangers, both of infection and of injury
to important adjoining structures. There is the same necessity for
aseptic management if the case be seen early, and for antiseptic
treatment, including drainage, if seen late. In many instances there is
so much liability to subsequent ankylosis that the first treatment may
well be made to include an arthrectomy, or the total removal of a small
bone, _e. g._, the astragalus. Fortunately compound features are less
frequent in dislocations than in fractures.
SPECIAL DISLOCATIONS.
DISLOCATIONS OF THE LOWER JAW.
Unless accompanied by fracture there is but one direction in which
the condyle of the inferior maxilla can be dislocated, _i. e._,
_forward_. One side or both may be affected, _i. e._, dislocation may
be unilateral or bilateral, the latter being more frequent. It is rare
during the extremes of age, and most common during middle life. There
is considerable variation in the degree of tension of the capsule of
the maxillary joint. In some it is so loose that dislocation may occur
during the act of yawning or vomiting. Ordinarily it occurs only as
an expression of violence from without. By a blow which shall thrust
the jaw forward, whether the mouth be closed or open, the ramus may
be made to carry the condyle over the articular eminence. The capsule
is not necessarily torn, but is always tightly stretched, while as
a reflex result the temporal muscle is thrown into a condition of
tonic spasm by which the jaw is fixed and firmly held in its abnormal
position. This produces the symptoms, then, of a more or less widely
opened mouth, with rigidity and inability to close it, with protrusion
of the chin and tense contraction of the temporal muscle, which can be
easily recognized. When the dislocation is unilateral the symptoms are
essentially the same, save that the protrusion is toward the side that
is injured.
=Treatment.=--The method of reduction is simple and consists in
depressing the angle of the jaw, while, at the same time, the chin is
supported and carried both upward and backward. If temporal spasm be
not too pronounced the reduction is rather easy and may be effected
while the patient is seated in a chair, the surgeon standing in front
of him and grasping the jaw with the fingers of each hand, while the
thumb is utilized within the mouth to press the angle of the jaw
downward and backward. At the same time the fingers should lift the
chin. The operator should protect his thumbs by wrapping them with
some material in order that they may not be injured by the patient’s
teeth. Should muscle spasm offer much resistance it would be well to
administer nitrous oxide or one of the other anesthetics, at least to
the point of primary anesthesia, with sufficient relaxation of muscle
to make reduction easy. When once this has been effected the lower jaw
should be bound to the upper and kept at rest for at least two weeks.
When this injury has taken place it is likely to recur with much less
effort until it becomes almost a habit.
[Illustration: FIG. 338
FIG. 339
Reduction of dislocation of lower jaw.]
There is a condition of relaxation of the capsule and elongation, with
abnormal loosening of the interarticular fibrocartilage, peculiar to
this joint, by which it has too free play, to such an extent that a
clicking sound in its movements may be frequently heard by others than
the patient. This condition is either congenital or the result of
previous injury, and is one for which little can be done, although this
explanation should be afforded to all who suffer from it.
DISLOCATIONS OF THE LARYNX.
The _cartilages of the larynx_ are sometimes displaced as the result
of direct violence applied to the anterior region of the neck. Almost
any lesion of this character may take place between the independent
cartilages of the larynx or the attachments of the larynx to the hyoid.
The injury may simply give rise to pain and soreness, or may cause so
much interior damage as to be quickly followed by edema of the glottis
and suffocation. If the latter be impending a quick tracheotomy should
be done, after which time may be afforded for such replacement as may
be required, by manipulation, and subsidence of swelling with relief
from occlusion of the respiratory tract.
DISLOCATIONS OF THE STERNUM.
The various portions of the sternum, especially the upper and the
lower, may be displaced as the result either of direct violence by
forcible backward flexion, or by muscular action accompanied by flexion
of the trunk and neck. When the latter, it is usually forward; when
produced by violence, it is usually backward.
These displacements are sometimes so easily reduced by mere pressure as
to make it almost impossible to retain them. At other times anesthesia
with firm pressure, accompanied by flexion of the trunk backward or
forward, may be required; reduction has been possible sometimes only
through incision and by the use of instruments applied as levers, or
by the use of a screw driven into one of the fragments, thus affording
a handle by which to manage it. Serious dislocations are frequently
accompanied by fractures of the ribs or of the sternum. The same
fixation of the thorax is required as in fractures of these parts, and
should be conducted in the simplest manner possible.
DISLOCATIONS OF THE RIBS.
To displace a rib from its sternal connections requires actual fracture
of bone or cartilage. Forward dislocation at its posterior and spinal
connection, especially of the eleventh and twelfth ribs, has been
described. Considerable effort is necessary for its production, and the
case should be treated on its individual merits.
DISLOCATIONS OF THE CLAVICLE.
Either end or both ends of the clavicle may be dislocated. Its sternal
end may be thrown in any direction but downward; its acromial end in
any direction, although usually upward. Dislocations of the sternal end
can only occur in consequence of serious damage to the sternoclavicular
ligaments, because of which, and in the absence of a socket, it is
extremely difficult to maintain the parts when restored to position.
Violent backward traction upon the shoulder permits anterior
displacement when the joint is thus weakened. Backward displacement is
usually the result of indirect violence when the shoulder is forced
forward and inward, while upward displacement is the result of tilting
which occurs when the shoulder is violently depressed. Respiration
is generally more or less disturbed, while in backward luxations
deglutition may be made difficult and painful.
Reduction is not difficult to effect, but extremely difficult to
maintain. Pressure in the proper direction, accompanied by traction
upon the shoulder, suffices for the former. For the latter there should
be a combination of fixation of the shoulder and arm with proper
traction, and at the same time pressure upon the end of the clavicle.
For all of the clavicular dislocations the dressing and position
advised by Dr. Moore, of Rochester, and referred to in the chapter
on Fractures as his double figure-of-eight, serves admirably for
maintaining the proper position of the shoulder, while pressure can be
made by a pad, retained either by adhesive plaster or by some further
addition to the dressing itself. (See p. 494.) Acromial dislocation is
usually in the upward direction, and is produced by violence upon the
shoulder, which has expended itself in rupturing ligaments rather than
in fracturing the acromion process. The indication here is to keep the
shoulder elevated by any dressing which will accomplish the purpose and
the clavicle bound down.
[Illustration: FIG. 340
Position of clavicle in dislocation of sternal end upward.]
Dislocation of _both ends_, _i. e._, complete loosening of the bone,
occurs occasionally, in which case the indications already given are
reinforced, while the difficulties of treatment are considerably
aggravated. Here the shoulder should be kept upward, outward, and
backward, and the clavicle retained by pressure or some other means.
=Treatment.=--Clavicular dislocations yield fair results to intelligent
treatment. Ideal results are difficult to secure without coöperation
on the part of the patient. Functional results, however, are usually
satisfactory.
DISLOCATIONS OF THE SHOULDER-JOINT.
The upper end of the humerus is attached to the margin of the glenoid
cavity by a capsule which has a certain degree of elasticity, and which
resembles a short section of a sleeve or a cuff. It is sufficiently
loose to permit a wide range of motion, and were it not for the
acromial process above it there would be as much motility in the
upward direction as in any other. It is not the capsule which keeps
the articular surfaces together, but the tension of the muscles which
are wrapped around the shoulder-joint, all of which contribute to
this effect. The glenoid cavity is made a more complete socket by
a fibrocartilaginous rim. Thus a certain degree of subluxation or
displacement may be permitted without very serious damage to this rim
and capsule, but a complete dislocation is hardly possible without more
or less laceration. The prominence and exposure of the joint and its
natural freedom of motion help to account for the fact that more than
half of all dislocations occur here, and that this rarely ever occurs
in children or in the aged, in whom the violence which may be expanded
produces either epiphyseal separations or fractures of the surgical
neck. The relation of structure to function also accounts for their
far greater frequency (_i. e._, four to one) in men than in women. The
influence of atmospheric pressure should not be forgotten, as in the
shoulder this affords a force of some fifty pounds, and in the hip of
nearly double that amount, of pressure.
[Illustration: FIG. 341
Subcoracoid.
Subclavicular.
Subspinous.
Subglenoid.
Dislocations of the head of the humerus. (Erichsen.)]
[Illustration: FIG. 342
Relation of circumflex nerve to the head of the humerus, explaining
mechanism of deltoid paralysis. (Marion.)]
For convenience of description, and in the order of their frequency,
shoulder dislocations are referred to as _anterior_, _downward_,
_posterior_, and possibly _upward_, when combined with acromial
fracture. Anterior displacements vary in degree, so that they are
described as _subcoracoid_ or _subclavicular_. Complete displacement in
this direction can only occur through a rent in the anterior portion of
the capsule, while the subclavicular muscle is pushed away or torn. The
nearer the head of the bone rests to the sternum the greater the amount
of laceration of the capsule, while its posterior portion is either
stretched tightly or torn. In aggravated cases the tendon of the biceps
is also torn out of its groove (Figs. 341, 343 and 344).
[Illustration: FIG. 343
Subclavicular dislocation. (Lejars.)]
[Illustration: FIG. 344
Subcoracoid dislocation. (Lejars.)]
In the downward or _subglenoid luxations_ the capsule is lacerated
lower down. These displacements occur when the shoulder has been
dislocated with the arm in the extended and elevated position. Here the
head of the humerus is found in the axilla, resting against the border
of the scapula, and the axillary structures, especially the circumflex
nerve, usually sutler, while the external rotators are either ruptured
or their insertions detached (Fig. 345).
[Illustration: FIG. 345
Subglenoid dislocation. (Lejars.)]
The posterior or _subspinous_ dislocation is the least common of all.
In its production the arm is apparently adducted and the elbow raised.
Here the humeral head is found beneath the posterior surface of the
acromion or beneath the spine of the scapula (Fig. 341).
=Symptoms.=--The indications of shoulder dislocation are _pain_;
_flattening of the shoulder_; _undue prominence of the acromion_;
_depression opposite the glenoid cavity_, with loss of the rounded
contour due to the presence therein of the head of the humerus;
_appearance of a more or less globular mass_ in the position now
abnormally occupied by the head of the humerus; _change in the axis_ of
this latter bone; _inability to bring the elbow to the side_; more or
less complete loss of function, and more or less spasm of the muscles
about the joint. Owing to the fact that the thorax presents a curved
or warped surface, to which a straight line can be tangent only at one
point, it results that the _hand of the injured side cannot be made to
wrap itself over the opposite shoulder while its elbow still touches
the chest or side_ (Dugas’ test).
=Diagnosis.=--As between fracture and dislocation the surgeon may
be greatly helped by deciding that the head of the humerus is still
in its proper position; that the deltoid is not flattened as in
dislocation; that the arm is shortened rather than lengthened; that
motility is increased rather than diminished; that bony crepitus is
usually obtainable, and that replacement, which may be comparatively
easily secured, is maintained only so long as the parts are held in
position by the operator’s hands. An additional sign of value is the
fact that a straight edge cannot ordinarily be made to touch the tip
of the acromion and the external condyle of the humerus at the same
time, because of the protrusion caused by the presence of the head of
the humerus in its socket. When the straight edge can be so applied
it must be either because the head of the bone is out of the socket
or the upper end of the bone broken. A still more crucial test which
should, however, only be applied when others prove unsatisfactory, may
be furnished by passing a sterilized hat-pin through the sterilized
skin over what seems to be the displaced head of the bone and into the
globular mass. Rotation of the humerus will then cause its end or head
to make an excursion which will be quite distinctive.
[Illustration: FIG. 346
Exhibits a subcoracoid dislocation and the position of the patient in
his endeavor to find relief from pain. (Mudd.)]
=Treatment.=--Prompt reduction is the only treatment for shoulder or
other dislocations. This may be first attempted without anesthesia.
Should muscle spasm prevent easy reduction it should be relaxed by an
anesthetic, for which purpose nitrous oxide will often suffice. In
the forward or forward and downward dislocations it will sometimes
be sufficient to simply make firm traction in a direction obliquely
outward and upward, with rotation. When this is insufficient it may
be assumed that there is more or less laceration of the capsule and
entanglement of the head of the bone, as well as that it is caught
around the border of the glenoid cavity, against which it is firmly
held.
The above simple maneuver failing, the luxation is to be reduced by a
more scientific manipulation, in which traction figures largely, the
method now generally in vogue being that suggested by Kocher, by which
rotation and leverage are added to traction, and a minimum of power
made to do a maximum of good. Kocher’s method is especially applicable
to the anterior displacements. It consists of a triple manipulation
whose three stages are portrayed in Figs. 347 to 349. The first
procedure is to flex the forearm to a right angle with the arm, apply
the former firmly to the side, and then, while keeping the elbow at the
side, forcibly rotate the limb outward until the forearm points away
from the body (Fig. 348). This having been done the arm is abducted
and the elbow moved upward until the limb is in the horizontal plane
of the shoulder, the scapula being held firmly during these movements,
as shown in Fig. 348. After the arm has been brought to the level of
the shoulder it is rotated inward and brought downward by a process
of circumduction, the elbow being made to describe some part of the
arc of a circle as it comes down. The displaced head should slip into
place during this movement, and will do so unless the capsular tear is
too small. In that case the movements should be repeated, perhaps with
more force, until the opening is sufficiently enlarged to permit the
button-hole in the capsule to slip over the head of the bone.
[Illustration: FIG. 347
First position in Kocher’s rotation method.]
[Illustration: FIG. 348
Arm is being carried forward and upward toward second position.]
[Illustration: FIG. 349
Completion of third movement in Kocher’s method.]
This method of manipulation, with such modification as circumstances
may require, or such addition as pressure with the hand or fingers of
the assistant, has superseded all the older more crude and forceful
methods, and proves sufficiently applicable for all cases. It is
assumed that the operator has sufficient judgment to modify any method
to fit the exigencies of a given case, else he should not proceed
with it. For instance, in the axillary dislocations upward traction
affords valuable assistance. In the subspinous form the arm is raised
to a level while extension is made upward and forward. In other words,
all these methods depend upon the combination of traction, rotation,
and leverage. The old method of Astley Cooper, with the foot in the
axilla, the shoe having been removed, coupled with traction upon the
arm and swaying movements, combined with rotation, abduction, and
adduction, may be made effective, but is not nearly as elegant as the
simpler manipulation above described. On the other hand, old, unreduced
dislocations, complicated with adhesions, are often exceedingly
difficult.
In rare instances dislocations several months old have been reduced
after adhesions have been broken up by more or less violent
manipulations. When forcible efforts of this kind prove futile fair
restoration of function may be obtained by maintaining regular motion,
at first passive, later active, to prevent reformation of adhesions,
the head of the bone gradually forming a new and false socket for
itself. Finally, the method of excision can be employed should occasion
demand. The experience of a number of surgeons has shown that in old
cases, or those impossible of reduction by justifiable force, an open
division of the joint, with severance of those tissues which prevent
reduction, may be profitably, safely, and satisfactorily practised.
Porter and McBurney, among the American surgeons, have devised a
corkscrew instrument which may be driven into the head of the bone, by
which manipulation after arthrotomy is materially facilitated.
The _simultaneous occurrence of fracture and dislocation_ has been
treated of in the previous chapter. When difficulty presents the best
result will be obtained by open incision, replacement of the head of
the humerus, and fixation of fragments by sutures, wire or otherwise.
If seen late the upper fragment should be removed. The possibilities
of aseptic surgery have led to the abandonment of the old method of
first permitting the fracture to unite and then attempting to reduce
dislocation.
Physiological rest is the essential feature of the after-treatment of
all these cases, a sling and a retentive bandage being sufficient for
the purpose. Function should be restored by an increasing degree of
motion.
One of the most serious complications of shoulder dislocations is
_deltoid paralysis_ from injury to the circumflex nerve. The momentary
pressure of the head of the bone upon the nerve is sufficient to more
or less permanently impair its function. In its medicolegal aspect it
should always be maintained that the surgeon is never to blame for the
accident, and is only to some degree blamable in case he has failed
to diagnose the dislocation so soon as opportunity was afforded and
has thus permitted prolonged pressure to possibly intensify the effect
which has already been produced by the injury.[42]
[42] The shoulder is liable to numerous injuries that produce
disability. Pain in some of these conditions may be almost constant
and spread upward to the neck and be aggravated by even passive
motion. Loss of power varies from moderate paresis to complete
paralysis. When the circumflex nerve is especially involved it is the
deltoid which shows the effects. More severe injuries may involve the
muscles of the arm and the forearm. Muscle atrophy may be greater
than can ordinarily be accounted for by mere disease. In rheumatic
patients a dry synovitis may be added to the other complications.
Most of these features are due to traumatic neuritis. When aggravated
they may result from rupture of nerves or cicatricial formations
around them. The best treatment consists of immobilization for three
or four weeks to favor nerve repair, counterirritation, especially
with the flying cautery, over the roots of the branchial plexus,
with massage, electricity, and even deep injections of strychnine to
stimulate the paralyzed muscles. When paralysis is persistent and
scar tissue seems to press upon nerves, exposure of the plexus and
freeing its branches from all source of pressure will be necessary.
DISLOCATIONS OF THE ELBOW.
The irregularities of the elbow-joint have permitted a complicated
dovetailing of its component parts which would seem to make
dislocations almost impossible without fracture. Nevertheless, and
especially in the tender years of childhood, both bones may be
dislocated in either direction, or either bone of the forearm alone in
any direction save toward the other. Diagnosis will be greatly aided by
observance of the anatomical facts stated in the section on fractures
of the elbow-joint and by an estimate of the relative positions
occupied by these bony landmarks. When, however, intense swelling
prevents this then we should either wait for its subsidence or depend
upon a skiagram.
The most common dislocation is that of _both bones backward_, one of
the possible consequences of a fall upon the extended arm and palm of
the hand. The coronoid process may rest beneath the joint end of the
humerus, making the dislocation incomplete, or back of it, making it
complete. If the coronoid process has been broken off the dislocation
can be made and reduced as often as desired. The fan-shaped lateral
ligaments are always more or less lacerated. The arm will be partially
bent and there will be prominent deformity upon the posterior aspect of
the joint while the axes respectively of the arm and the forearm will
be somewhat disturbed. Usually the lower end of the humerus can be felt
in front of the normal situation of the elbow-joint (Figs. 350, 351 and
352).