=Fractures=
_How to Tell a Broken Bone--A Simple Sling--Splints and Bandage,--A
Broken Rib--Fractures of Arm, Shoulder, Hand, Hips Leg and Other
Parts._
=BROKEN BONE; FRACTURE.=[5]
_First Aid Rule 1.--Be sure bone is broken. If broken, patient can
scarcely (if at all) move the part beyond the break, while attendant
can move it freely in his hands. If broken, grating of rough edges of
bone may be felt by attendant but should not be sought for. If broken,
limb is generally shortened._
_Rule 2.--Do not try to set bone permanently. Send at once for
surgeon._
=COMPOUND FRACTURE.=
_Important. If there is opening to the air from the break, because of
tearing of tissues by end of bone, condition is very dangerous; first
treatment may save life, by preventing infection. Before reducing
fracture, and without stirring the patient much, after scrubbing your
hands very clean, note:_
_First Aid Rule 1.--If hairy, shave large spot about wound._
_Rule 2.--Clean large area about wound with soap and water, very
gently. Then wash most thoroughly again with clean water, previously
boiled and cooled. Flood wound with cool boiled water._
_Rule 3.--Cover wound with absorbent cotton (or pieces of muslin)
which has been boiled. Then attend to broken bone, as hereafter
directed, in the case of each variety of fracture._
_After the bone is set, according to directions, then note:_
_Rule 4.--Renew pieces of previously boiled muslin from time to time,
when at all stained with discharges. Every day wash carefully about
wound, between the splints, with cool carbolic-acid solution (one
teaspoonful to a pint of hot water) before putting on the fresh
cloths._
=BROKEN BONES OR FRACTURES.=[6]--It frequently happens that the first
treatment of fracture devolves upon the inexperienced layman.
Immediate treatment is not essential, in so far as the repair of the
fracture is directly concerned, for a broken bone does not unite for
several weeks, and if a fracture were not seen by the surgeon for a
week after its occurrence, no harm would be done, provided that the
limb were kept quiet in fair position until that time. The object of
immediate care of a broken bone is to prevent pain and avoid damage
which would ensue if the sharp ends of the broken bone were allowed to
injure the soft tissues during movements of the broken limb.
Fractures are partial or complete, the former when the bone is broken
only part way through; simple, when the fracture is a mere break of
the bone, and compound, when the end of one or both fragments push
through the skin, allowing the air with its germs to come in contact
with the wound, thus greatly increasing the danger. To be sure that a
bone is broken we must consider several points. The patient has
usually fallen or has received a severe blow upon the part. This is
not necessarily true, for old people often break the thigh bone at the
hip joint by simply making a false step.
Inability to use the limb and pain first call our attention to a
broken bone. Then when we examine the seat of injury we usually notice
some deformity--the limb or bone is out of line, and there may be an
unusual swelling. But to distinguish this condition from sprain or
bruise, we must find that there is a new joint in the course of the
bone where there ought not to be any; e. g., if the leg were broken
midway between the knee and ankle, we should feel that there was
apparently a new joint at this place, that there was increased
capacity for movement in the middle of the leg, and perhaps the ends
of the fragments of bones could be heard or felt grating together.
These, then, are the absolute tests of a broken bone--unusual mobility
(or capacity for movement) in the course of the bone, and grating of
the broken fragments together. The last will not occur, of course,
unless the fragments happen to lie so that they touch each other and
should not be sought for. In the case of limbs, sudden shortening of
the broken member from overlapping of the fragments is a sure sign.
=SPECIAL FRACTURES.=
=BROKEN RIB.=--_First Aid Rule.--Patient puts hands on head while
attendant puts adhesive-plaster band, one foot wide, around injured
side from spine over breastbone to line of armpit of sound side. Then
put patient to bed._
A rib is usually broken by direct violence. The symptoms are pain on
taking a deep breath, or on coughing, together with a small, very
tender point. The deformity is not usually great, if, indeed, any
exists, so that nothing in the external appearance may call the
attention to fracture. Grating between the fragments may be heard by
the patient or by the examiner, and the patient can often place his
finger on the exact location of the break.
When it is a matter of doubt whether a rib is broken or not the
treatment for broken rib should be followed for relief of pain.
[Illustration: FIG. 8.
METHOD OF BANDAGING BROKEN RIB (SCUDDER).
Note manner of sticking one end of wide adhesive plaster along
backbone; also assistant carrying strip around injured side.]
=Treatment= consists in applying a wide band of surgeon's adhesive
plaster, to be obtained at any drug shop. The band is made by
overlapping strips four or five inches wide, till a width of one foot
is obtained. This is then applied by sticking one end along the back
bone and carrying it forward around the injured side of the chest over
the breastbone as far as a line below the armpit on the uninjured side
of the chest, i. e., three-quarters way about the chest. These four-
or five-inch strips of plaster may be cut the right length first and
laid together, overlapping about two inches, and put on as a whole,
or, what is easier, each strip may be put on separately, beginning at
the spine, five inches below the fracture, and continuing to apply the
strips, overlapping each other about two inches, until the band is
made to extend to about five inches above the point of fracture, all
the strips ending in the line of the armpit of the uninjured side.
(Fig. 8.)
If surgeon's plaster cannot be obtained, a strong unbleached cotton or
flannel bandage, a foot wide, should be placed all around the chest
and fastened as snugly as possible with safety pins, in order to limit
the motion of the chest wall. The patient will often be more
comfortable sitting up, and should take care not to be exposed to cold
or wet for some weeks, as pleurisy or pneumonia may follow. Three
weeks are required for firm union to be established in broken ribs.
=COLLAR-BONE FRACTURE.=
_First Aid Rule.--Put patient flat on back, on level bed, with small
pillow between his shoulders; place forearm of injured side across
chest, and retain it so with bandage about chest and arm._
[Illustration: FIG. 9.
A BROKEN COLLAR BONE (SCUDDER).
Usual attitude of patient with a fracture of this kind; note lowering
and narrowed appearance of left shoulder.]
Fracture of the collar bone is one of the commonest accidents. The
bone is usually broken in the middle third. A swelling often appears
at this point, and there is pain there, especially on lifting the arm
up and away from the body. It will be noticed that the shoulder, on
the side of the injury, seems narrower and also lower than its fellow.
The head is often bent toward the injured side, and the arm of the
same side is grasped below the elbow by the other hand of the patient
and supported as in a sling. (See Fig. 9.) In examining an apparently
broken bone _the utmost gentleness may be used_ or serious damage may
result.
=Treatment.=--The best treatment consists in rest in bed on a hard
mattress; the patient lying flat on the back with a small pillow
between the shoulders and the forearm of the injured side across the
chest. This is a wearisome process, as it takes from two to three
weeks to secure repair of the break. On the other hand, if the forearm
is carried in a sling, so as to raise and support the shoulder, while
the patient walks about, a serviceable result is usually obtained; the
only drawback being that an unsightly swelling remains at the seat of
the break. To make a sling, a piece of strong cotton cloth a yard
square should be cut diagonally from corner to corner, making two
right-angled triangles. Each of these will make a properly shaped
piece for a sling. (See Figs. 10 and 11.)
Fracture of the collar bone happens very often in little children,
and is commonly only a partial break or splitting of the bone, not
extending wholly through the shaft so as to divide it into two
fragments, but causing little more than bending of the bone (the
"green-stick fracture").
[Illustration: FIG. 10.
HOW TO MAKE A SLING (SCUDDER).
In Fig. 10 note three-cornered bandage; No. 2 end is carried over
right shoulder, No. 1 over left, then both fastened behind neck; No. 3
brought over and pinned.]
[Illustration: FIG. 11.
HOW TO MAKE A SLING (SCUDDER).
The above illustration shows sling in position. It is made of cotton
cloth a yard square cut diagonally from corner to corner.]
A fall from a chair or bed is sufficient to cause the accident. A
child generally cries out on movement of the arm of the injured side,
or on being lifted by placing the hands under the armpits of the
patient. A tender swelling is seen at the point of the injury of the
collar bone. A broad cotton band, with straps over the shoulders to
keep it up, should encircle the body and upper arm of the injured
side, and the hand of the same side should be supported by a narrow
sling fastened above behind the neck.
=LOWER-JAW FRACTURE.=
_First Aid Rule.--Put fragments into place with your fingers, securing
good line of his teeth. Support lower jaw by firmly bandaging it
against upper jaw, mouth shut, using four-tailed bandage. (Fig. 12.)_
Fracture of the lower jaw is caused by a direct blow. It involves the
part of the jaw occupied by the lower teeth, and is more apt to occur
in the middle line in front, or a short distance to one side of this
point. The force causing the break usually not only breaks the bone,
but also tears the gum through into the mouth, making a compound
fracture. There is immediate swelling of the gum at the point of
injury, and bleeding. The mouth can be opened with difficulty.
The condition of the teeth is the most important point to observe.
Owing to displacement of the fragments there is a difference in the
level of the teeth or line of the teeth, or both, at the place where
the fracture occurs. Also one or more of the teeth are usually
loosened at this point. In addition, unusual movement of the
fragments may be detected as well as a grating sound on manipulation.
=Treatment.=--The broken fragments should be pressed into place with
the fingers, and retained temporarily with a four-tailed bandage, as
shown in the cut. Feeding is done through a glass tube, using milk,
broths, and thin gruels. A mouth wash should be employed four times
daily, to keep the mouth clean and assist in healing of the gum. A
convenient preparation consists of menthol, one-half grain; thymol,
one-half grain; boric acid, twenty grains; water, eight ounces.
[Illustration: FIG. 12.
BANDAGE FOR A BROKEN JAW (AMERICAN TEXT-BOOK).
Above cut shows a four-tailed bandage; note method of tying; one strip
supports lower jaw; the other holds it in place against upper jaw.]
=SHOULDER-BLADE FRACTURE.=
_First Aid Rule.--There is no displacement. Bandage fingers, forearm,
and arm of affected side, and put this arm in sling. Fasten slung arm
to body with many turns of a bandage, which holds forearm against
chest and arm against side._
Shoulder-blade fracture occasions pain, swelling, and tenderness on
pressure over the point of injury. On manipulating the bone a grating
sound may be heard and unnatural motion detected. The treatment
consists in bandaging the forearm and arm on the injured side from
below upward, beginning at the wrist; slinging the forearm bent at a
right angle across the front of the body, suspended by a narrow sling
from the neck, and then encircling the body and arm of the injured
side from shoulder to elbow with a wide bandage applied under the
sling, which holds the arm snugly against the side. This bandage is
prevented from slipping down by straps attached to it and carried over
each shoulder.
=ARM FRACTURE.=
_First Aid Rule.--Pad two pieces of thin board nine by three inches
with handkerchiefs. Carefully pull fragments of bone apart, grasping
lower fragment near elbow while assistant pulls gently on upper
fragment near shoulder. Put padded boards (splints) one each side of
the fracture, and wind bandage about their whole length, tightly
enough to keep bony fragments firm in position. Put forearm and hand
in sling._
In fracture of the arm between the shoulder and elbow, swelling and
shortening may give rise to deformity. Pain and abnormal motion are
symptoms, while a grating sound may be detected, but manipulation of
the arm for this purpose should be avoided. The surface is apt soon to
become black and blue, owing to rupture of the blood vessels beneath
the skin.
The hand and forearm should be bandaged from below upward to the
elbow. The bone is put in place by grasping the patient's elbow and
pulling directly down in line with the arm, which is held slightly
away from the side of the patient, while an assistant steadies and
pulls up the shoulder. Then a wedge-shaped pad, long enough to reach
from the patient's armpit to his elbow (made of cotton wadding or
blanketing sewed in a cotton case) and about four inches wide and
three inches thick at one end, tapering up to a point at the other, is
placed against the patient's side with the tapering end uppermost in
the armpit and the thick end down. This pad is kept in place by a
strip of surgeon's adhesive plaster, or bandage passing through the
small end of the wedge, and brought up and fastened over the shoulder.
[Illustration: FIG. 13.
FIG. 14.
BANDAGE FOR BROKEN ARM (SCUDDER).
In Fig. 13 note splints secured by adhesive plaster; also pad in
armpit; in Fig. 14 see wide bandage around body; also sling.]
While the arm is pulled down from the shoulder, three strips of
well-padded tin or thin board (such as picture-frame backing) two
inches wide and long enough to reach from shoulder to elbow, are laid
against the front, outside, and back of the arm, and secured by
encircling strips of surgeon's plaster or bandage. The arm is then
brought into the pad lying against the side under the armpit, and is
held there firmly by a wide bandage surrounding the arm and entire
chest, and reaching from the shoulder to elbow. It is prevented from
slipping by strips of cotton cloth, which are placed over the
shoulders and pinned behind and before to the top of the bandage. The
wrist is then supported in a sling, not over two inches wide, with the
forearm carried in a horizontal position across the front of the body.
Firm union of the broken arm takes place usually in from four to six
weeks. (See Figs. 13 and 14.)
=FOREARM FRACTURE.=
_First Aid Rule.--Set bones in proper place by pulling steadily on
wrist while assistant holds back the upper part of the forearm. If
unsuccessful, leave it for surgeon to reduce after "period of
inaction" comes, a few days later, when swelling subsides. If
successful, put padded splints (pieces of cigar box padded with
handkerchiefs) one on each side, front and back, and wind a bandage
about whole thing to hold it immovably._
Two bones enter into the structure of the forearm. One or both of
these may be broken. The fracture may be simple or compound,[7] when
the soft parts are damaged and the break of the bone communicates with
the air, the ends of the bone even projecting through the skin.
In fracture of both bones there is marked deformity, caused by
displacement of the broken fragments, and unusual motion may be
discovered; a grating sound may also be detected but, as stated
before, manipulation of the arm should be avoided.
[Illustration: FIG. 15.
SETTING A BROKEN FOREARM (SCUDDER).
See manner of holding arm and applying adhesive plaster strips; one
splint is shown, another is placed back of hand and forearm.]
When only one bone is broken the signs are not so marked, but there is
usually a very tender point at the seat of the fracture, and an
irregularity of the surface of the bone may be felt at this point. If
false motion and a grating sound can also be elicited, the condition
is clear. The broken bones are put into their proper place by the
operator who pulls steadily on the wrist, while an assistant grasps
the upper part of the forearm and pulls the other way. The ends of the
fragments are at the same time pressed into place by the other hand of
the operator, so that the proper straight line of the limb is
restored.
[Illustration: FIG. 16.
FRACTURE OF BOTH BONES IN FOREARM (SCUDDER).
This cut shows the position and length of the two padded splints; also
method of applying adhesive plaster.]
After the forearm is set, it should be held steadily in the following
position while the splints are applied. The elbow is bent so that the
forearm is held at right angles with the arm horizontally across the
front of the chest with the hand extended, open palm toward the body
and thumb uppermost. The splints, two in number, are made of wood
about one-quarter inch thick, and one-quarter inch wider than the
forearm. They should be long enough to reach from about two inches
below the elbow to the root of the fingers. They are covered smoothly
with cotton wadding, cotton wool, or other soft material, and then
with a bandage. The splints are applied to the forearm in the
positions described, one to the back of the hand and forearm, and the
other to the palm of the hand and front of the forearm.
Usually there are spaces in the palm of the hand and front of the
wrist requiring to be filled with extra padding in addition to that on
the splint. The splints are bound together and to the forearm by three
strips of surgeon's adhesive plaster or bandage, about two inches
wide. One strip is wound about the upper ends of the splints, one is
wrapped about them above the wrist, and the third surrounds the back
of the hand and palm, binding the splints together below the thumb.
The splints should be held firmly in place, but great care should be
exercised to use no more force in applying the adhesive plaster or
bandage than is necessary to accomplish this end, as it is easy to
stop the circulation by pressure in this part. There should be some
spring felt when the splints are pressed together after their
application. A bandage is to be applied over the splints and strips of
plaster, beginning at the wrist and covering the forearm to the elbow,
using the same care not to put the bandage on too firmly. The forearm
is then to be held in the same position by a wide sling, as shown
above. (See Figs. 15, 16, 17.)
[Illustration: FIG. 17.
DRESSING FOR BROKEN FOREARM (SCUDDER).
Proper position of arm in sling; note that hand is unsupported with
palm turned inward and thumb uppermost.]
Four weeks are required to secure firm union after this fracture. When
the fracture is compound the same treatment should be employed as
described under Compound Fracture of Leg, p. 116.
=FRACTURE OF THE WRIST; COLLES'S FRACTURE.=--This is a break of the
lower end of the bone on the thumb side of the wrist, and much the
larger bone in this part of the forearm. The accident happens when a
person falls and strikes on the palm of the hand; it is more common in
elderly people. A peculiar deformity results. A hump or swelling
appears on the back of the wrist, and a deep crease is seen just above
the hand in front. The whole hand is also displaced at the wrist
toward the thumb side.
[Illustration: FIG. 18.
A BROKEN WRIST (SCUDDER).
Characteristic appearance of a "Colles's fracture"; note backward
displacement of hand at wrist; also fork-shaped deformity.]
It is not usual to be able to detect abnormal motion in the case of
this fracture, or to hear any grating sound on manipulating the part,
as the ends of the fragments are generally so jammed together that
it is necessary to secure a surgeon as soon as possible to pull them
apart under ether, in order to remedy the existing "silver-fork"
deformity. (See Figs. 18, 19, 20, 21, 22.)
=Treatment.=--Until medical aid can be obtained the same sort of
splints should be applied, and in the same way as for the treatment of
fractured forearm. If the deformity is not relieved a stiff and
painful joint usually persists. It is sometimes impossible for the
most skillful surgeon entirely to correct the existing deformity, and
in elderly people some stiffness and pain in the wrist and fingers are
often unavoidable results.
[Illustration: FIG. 19.
FIG. 20.
FIG. 21.
FIG. 22.
FRACTURE OF THE WRIST (SCUDDER).
Above illustrations show deformities resulting from a broken wrist;
Figs. 19 and 20 the crease at base of thumb; Fig. 21 hump on back of
wrist; Fig. 22 twisted appearance of hand.]
=FRACTURE OF BONE OF HAND, OR FINGER.=
_First Aid Rule.--Set fragments of bone in place by pulling with one
hand on finger, while pressing fragments into position with other
hand. Put on each side of bone a splint made of cigar box, padded with
folded handkerchiefs, and retain in place with bandage wound about
snugly. Put forearm and hand in sling._
This accident more commonly happens to the bones corresponding to the
middle and ring finger, and occurs between the knuckle and the wrist,
appearing as a swelling on the back of the hand. On looking at the
closed fist it will be seen that the knuckle corresponding to the
broken bone in the back of the hand has ceased to be prominent, and
has sunken down below the level of its fellows. The end of the
fragment nearer the wrist can generally be felt sticking up in the
back of the hand.
[Illustration: FIG. 23.
A BROKEN FINGER (SCUDDER).
Note splint extending from wrist to tip of finger; also manner of
applying adhesive plaster strips and pad in palm.]
If the finger corresponding to the broken bone in the back of the hand
be pulled on forcibly, and the fragments be held between the thumb and
forefinger of the other hand of the operator, pain and abnormal
motion may be detected, and the ends of the broken bone pressed into
place. A thin wooden splint, as a piece of cigar box, about an inch
wide at base and tapering to the width of the finger should be applied
to the palm of the hand extending from the wrist to a little beyond
the finger tip, secured by strips of adhesive plaster, as in the cut,
and covered by a bandage. The splint should be well padded, and an
additional pad should be placed in the palm of the hand over the point
of fracture. Three weeks are required for firm union, and the hand
should not be used for a month.
It is usually easy to recognize a broken bone in a finger, unless the
break is near a joint, when it may be mistaken for a dislocation.
Pain, abnormal motion, and grating between the fragments are observed.
If there is deformity, it may be corrected by pulling on the injured
finger with one hand, while with the other the fragments are pressed
into line. A narrow, padded wooden or tin splint is applied, as in the
cut (p. 102), reaching from the middle of the palm to the finger tip.
Any existing displacement of the broken bone can be relieved by using
pressure with little pads of cotton held in place by narrow strips of
adhesive plaster where it is needed to keep the bone in line. The
splint may be removed in two weeks and a strip of adhesive plaster
wound about the finger to support it for a week or two more.
In fracture of the thumb, the splint is applied along the back instead
of on the palm side.
=HIP FRACTURE.=
_First Aid Rule.--Put patient flat on back in bed, with limb wedged
between pillows till surgeon arrives._
[Illustration: FIG. 24.
TREATING A BROKEN HIP (SCUDDER).
Note the manner of straightening leg and getting broken bone into
line; also assistant carefully steadying the thigh.]
A fracture of the hip is really a break of that portion of the thigh
bone which enters into the socket of the pelvic bone and forms the hip
joint. It occurs most commonly in aged people as a result of so slight
an accident as tripping on a rug, or in falling on the floor from the
standing position, making a misstep, or while attempting to avoid a
fall. When the accident has occurred the patient is unable to rise or
walk, and suffers pain in the hip joint. When he has been helped to
bed it will be seen that the foot of the injured side is turned out,
and the leg is perhaps apparently shorter than its fellow. There is
pain on movement of the limb, and the patient cannot raise his heel,
on the injured side, from the bed. Shortening is an important sign.
With the patient lying flat on the back and both legs together in a
straight line with the body, measurements from each hip-bone are made
with a tape to the bony prominence on the inside of each ankle, in
turn. One end of the tape is held at the navel and the other is swung
from one ankle to the other, comparing the length of the two limbs.
Shortening of less than half an inch is of no importance as a sign of
fracture. The fragments of broken bone are often jammed together
(impacted) so that it is impossible to get any sound of grating
between them, and it is very unwise to manipulate the leg or hip
joint, except in the gentlest manner, in an attempt to get this
grating. If the ends of the fragments become disengaged from each
other it often happens that union of the break never occurs.
[Illustration: FIG. 25.
TREATMENT FOR FRACTURED HIP (SCUDDER).
Note method of holding splints in place with muslin strips; one above
ankle, one below and one above knee, one in middle and one around
upper part of thigh.]
The treatment simply consists in keeping the patient quiet on a hard
mattress, with a small pillow under the knee of the injured side and
the limb steadied on either side by pillows or cushions until a
surgeon can be obtained. (See Thigh-bone Fracture.)
=THIGH-BONE FRACTURE.=
_First Aid Rule.--Prepare long piece of thin board which will reach
from armpit to ankle, and another piece long enough to reach from
crotch to knee, and pad each with folded towels or blanket._
_While one assistant holds body back, and another assistant pulls on
ankle of injured side, see that the fragments are separated and
brought into good line, and then apply the splints, assistants still
pulling steadily, and fasten the splints in place with bandage, or by
tying several cloths across at three places above the knee and two
places below the knee._
_Finally, pass a wide band of cloth about the body, from armpit to
hips, inclosing the upper part of the well-padded splint, and fasten
it snugly. The hollow between splint and waist must be filled with
padding before this wide cloth is applied._
In fracture of the thigh bone (between the hip and knee), there is
often great swelling about the break. The limb is helpless and
useless. There is intense pain and abnormal position in the injured
part, besides deformity produced by the swelling. The foot of the
injured limb is turned over to one side or the other, owing to a
rolling over of the portion of the limb below the break. With both
lower limbs in line with the body, and the patient lying on the back,
measurements are made from each hip-bone to the prominence on the
inside of either ankle joint. Shortening of the injured leg will be
found, varying from one to over two inches, according to the
overlapping and displacement of the fragments.
=Treatment.=--To set this fracture temporarily, a board about five
inches wide and long enough to reach from the armpit to the foot
should be padded well with towels, sheets, shawls, coats, blanket, or
whatever is at hand, and the padding can best be kept in place by
surgeon's adhesive plaster, bicycle tape, or strips of cloth.[8]
Another splint should be provided as wide as the thigh and long enough
to reach along the back of the leg from the middle of the calf to the
buttock, and also padded in the same way. A third splint should be
prepared in the same manner to go inside the leg, reaching from the
crotch to the inside of the foot. Still a fourth splint made of a thin
board as wide as the thigh, extending from the upper part of the thigh
to just above the knee, is padded for application to the front of the
thigh.
When these are made ready and at hand, the leg should be pulled on
steadily but carefully straight away from the body to relax the
muscles, an assistant holding the upper part of the thigh and pulling
in the opposite direction. Then, when the leg has been straightened
out and the thigh bone seems in fair line, the splints should be
applied; the first to the outside of the thigh and body, the second
under the calf, knee, and thigh; the third to the inside of the whole
limb, and the fourth to the front of the thigh.
Wide pads should be placed over the ribs under the outside splint to
fill the space above the hips and under the armpit. Then all four
splints are drawn together and held in place by rubber-plaster straps
or strips of strong muslin applied as follows: one above the ankle;
one below the knee; one above the knee; one in the middle of the
thigh, and one around the upper part of the thigh. A wide band of
strong muslin or sheeting should then be bound around the whole body
between the armpits and hips, inclosing the upper part of the outside
splint. The patient can then be borne comfortably upon a stretcher
made of boards and a mattress or some improvised cushion. (See Figs.
24 and 25.)
When the patient can be put immediately to bed after the injury, and
does not have to be transported, it is only necessary to apply the
outer, back, and front splints, omitting the inner splint. It is
necessary for the proper and permanent setting of a fractured thigh
that a surgeon give an anaesthetic and apply the splints while the
muscles are completely relaxed. It is also essential that the muscles
be kept from contracting thereafter by the application of a fifteen-
or twenty-pound weight to the leg, after the splints are applied, but
it is possible to outline here only the proper first-aid treatment.
=KNEEPAN FRACTURE.=
_First Aid Rule.--Pain is immediate and intense. Separated fragments
may be felt at first. Swelling prompt and enormous. Even if not sure,
follow these directions for safety._
_Prepare splint: thin board, four inches wide, and long enough to
reach from upper part of thigh to just above ankle. Pad with folded
piece of blanket or soft towels. Place it behind leg and thigh;
carefully fill space behind knee with pad; fasten splint to limb with
three strips of broad adhesive plaster, one around upper end of
splint, one around lower end, one just below knee._
_Lay large flat, dry sponge over knee thus held, and bandage this in
place. Keep sponge and bandage wet with ice water. If no sponge is
available, half fill rubber hot-water bottle with cracked ice, and lay
this over knee joint. Put patient to bed._
Fracture of kneepan is caused either by direct violence or muscular
strain. It more frequently occurs in young adults. Immediate pain is
felt in the knee and walking becomes impossible; in fact, often the
patient cannot rise from the ground after the accident. Swelling at
first is slight, but increases enormously within a few hours.
Immediately after the injury it may be possible to feel the separate
broken fragments of the kneepan and to recognize that they are
separated by a considerable space if the break is horizontally across
the bone.
[Illustration: FIG. 26.
A BROKEN KNEEPAN (SCUDDER).
A padded splint, supporting knee, is shown reaching from ankle to
thigh. Note number and location of adhesive plaster strips.]
Nothing can be done to set the fracture until the swelling about the
joint has been reduced, so that the first treatment consists in
securing immediate rest for the kneejoint, and immobility of the
fragments. A splint made of board, about a quarter of an inch thick
and about four inches wide for an adult, reaching from the upper part
of the thigh above to a little above the ankle below, is applied to
the back of the limb and well padded, especially to fill the space
behind the knee. The splint is attached to the limb by straps of
adhesive plaster two inches and a half wide; one around the lower end
of the splint, one around the upper part, and the third placed just
below the knee. To prevent and arrest the swelling and pain, pressure
is then made on the knee by bandaging.
One of the best methods (Scudder's) is to bind a large, flat, dry
sponge over the knee and then keep it wet with cold water; or to apply
an ice bag directly to the swollen knee; a splint in either case being
the first requisite. The patient should of course be put to bed as
soon as possible after the accident, and should lie on the back with
the injured leg elevated on a pillow with a cradle to keep the clothes
from pressing on the injured limb. (See cut, p. 110.)
=FRACTURE OF LEG BONES, BETWEEN KNEE AND ANKLE.=
_First Aid Rule.--Handle very carefully; great danger of making
opening to surface. Special painful point, angle or new joint in bone,
disability, and grating felt will decide existence of break. Let
assistant pull on foot, to separate fragments, while you examine part
of supposed break. If only one bone is broken, there may be no
displacement._
_Put patient on back. While two assistants pull, one on ankle and one
on thigh at knee, thus separating fragments, slide pillow lengthwise
under knee, and, bringing its edges up about leg, pin them snugly
above leg._
_Prepare three pieces of thin wood, four inches wide and long enough
to reach from sole of foot to a point four inches above knee. While
assistants pull on limb again, as before, put one splint each side
and third behind limb, and with bandage or strips of sticking plaster
fasten these splints to the leg inclosed in its pillow as tight as
possible._
In fracture of the leg between the knee and ankle we have pain,
angular deformity or an apparent false joint in the leg, swelling and
tenderness over the seat of fracture, together with inability to use
the injured leg. Two bones form the framework of the leg; the inner,
or shinbone, the sharp edge of which can be felt in front throughout
most of its course, being much the larger and stronger bone. When both
bones are broken, the displacement of the fragments, abnormal motion
and consequent deformity, are commonly apparent, and a grating sound
may be heard, but should not be sought for.
[Illustration: FIG. 27.
FRACTURE OF BOTH LEG BONES (SCUDDER).
This cut shows the peculiar deformity in breaks of this kind; see
position of kneepan; also prominence of broken bone above ankle.]
An open wound often communicates with the break, making the fracture
compound, a much more serious condition. To avoid making the fracture
a compound one, during examination of the leg, owing to the sharp
ends of the bony fragments, the utmost gentleness should be used.
Under no circumstances attempt to move the fragments from side to
side, or backward and forward, in an effort to detect the grating
sound often caused by the ends of broken bones. The greatest danger
lies in the desire to do too much. We again refer the reader to First
Aid Rule 1.
[Illustration: FIG. 28.
BANDAGE FOR BROKEN LEG (SCUDDER).
Note the pillow brought up around leg and edges pinned together; also
length and method of fastening splint with straps.]
When one bone is broken there may be only a point of tenderness and
swelling about the vicinity of the break and no displacement or
grating sound. When in doubt as to the existence of a fracture always
treat the limb as if a fracture were present. "Black and blue"
discoloration of the skin much more extensive than that following
sprain will become evident over the whole leg within twenty-four
hours.
=Treatment.=--When a surgeon cannot be obtained, the following
temporary pillowdressing, recommended by Scudder in his book on
fractures, is one of the best. With the patient on his back, the leg
having been straightened and any deformity removed as far as possible
by grasping the foot and pulling directly away from the body while an
assistant steadies the thigh, a large, soft pillow, inclosed in a
pillowcase, is placed under the leg. The sides of the pillow are
brought well up about the leg and the edges of the pillowcase are
pinned together along the front of the leg.
Then three strips of wood about four inches wide, three-sixteenths to
a quarter of an inch thick, and long enough to reach from the sole of
the foot to about four inches above the knee, are placed outside of
the pillow along the inner and outer aspects of the leg and beneath
it. The splints are held in place, with the pillow as padding beneath,
by four straps of webbing (or if these cannot be obtained, by strips
of stout cloth, adhesive plaster, or even rope); but four pads made of
folded towels should be put under the straps where they cross the
front of the leg where little but the pillowcase overlaps. These
straps are applied thus: one above the knee, one above the ankle, and
the other two between these two points, holding all firmly together.
This dressing may be left undisturbed for a week or even ten days if
necessary. (See Figs. 27 and 28.)
The leg should be kept elevated after the splints are applied, and
steadied by pillows placed either side of it. From one to two months
are required to secure union in a broken leg in adults, and from three
to five months elapse before the limb is completely serviceable. In
children the time requisite for a cure is usually much shorter.
=ANKLE-JOINT FRACTURE.=
_First Aid Rule.--One or both bones of leg may be broken just above
ankle. Foot is generally pushed or bent outward. Prepare two pieces of
thin wood, four inches wide and long enough to go from sole of foot to
just below knee:--the splints. Pad them with folded towels or pieces
of blanket._
_While assistants pull bones apart gently, one pulling on knee, other
pulling on foot and turning it straight, apply the splints, one each
side of the leg._
A fracture of the ankle joint is really a fracture of the lower
extremities of the bones of the leg. There are present pain and great
swelling, particularly on the inner side of the ankle at first, and
the whole foot is pushed and bent outward. The bony prominence on the
inner side of the ankle is unduly marked. The foot besides being bent
outward is also displaced backward on the leg. This fracture might be
taken for a dislocation or sprain of the ankle. Dislocation of the
ankle without fracture is very rare, and when the foot is returned to
its proper position it will stay there, while in fracture the foot
drops back to its former displaced state. In sprained ankle there are
pain and swelling, but not the deformity caused by the displacement of
the foot.
This fracture may be treated temporarily by returning the foot to its
usual position and putting on side splints and a back splint, as
described for the treatment of fracture of the leg.
=COMPOUND OR OPEN FRACTURE OF THE LEG.=--This condition may be
produced either by the violence which caused the fracture also leading
to destruction of the skin and soft parts beneath, or by the end of a
bony fragment piercing the muscles and skin from within. In either
event the result is much more serious than that of an ordinary simple
fracture, for germs can gain entrance through the wound in the skin
and cause inflammation with partial destruction or death of the part.
=Treatment.=--Immediate treatment is here of the utmost value. It is
applicable to open or compound fracture in any part of the body. The
area for a considerable distance about the wound, if covered with
hair, should be shaved. It should then be washed with warm water and
soap by means of a clean piece of cotton cloth or absorbent cotton.
Then some absorbent cotton or cotton cloth should be boiled in water
in a clean vessel for a few minutes, and, after the operator has
thoroughly washed his hands, the boiled water (when sufficiently cool)
should be applied to the wounded area and surrounding parts with the
boiled cotton, removing in the most painstaking way all visible and
invisible dirt. By allowing some of the water to flow over the wound
from the height of a few feet this result is favored. Finally some of
the boiled cotton, which has not been previously touched, is spread
over the wound wet, and covered with clean, dry cotton and bandaged.
Splints are then applied as for simple fracture in the same locality
(p. 113). If a fragment of bone projects through the wound it may be
replaced after the cleansing just described, by grasping the lower
part of the limb and pulling in a straight line of the limb away from
the body, while an assistant holds firmly the upper part of the limb
and pulls in the opposite direction. During the whole process neither
the hands of the operator nor the boiled cotton should come in contact
with anything except the vessel containing the boiled water and the
patient.
FOOTNOTES:
[5] The engravings illustrating the chapters on "Fractures" and
"Dislocations" are from Buck's "Reference Handbook of Medical
Science," published by William Wood & Co., New York; also, Scudder's
"Treatment of Fractures" and "American Text-Book of Surgery,"
published by W. B. Saunder's Company, Philadelphia.
[6] It should be distinctly understood that the information about
fractures is not supplied to enable anyone to avoid calling a surgeon,
but is to be followed only until expert assistance can be obtained
and, like other advice in this book, is intended to furnish first-aid
information or directions to those who are in places where physicians
cannot be secured.
[7] For treatment of compound fracture, see Compound Fracture of Leg
(p. 116).
[8] This method follows closely that recommended by Scudder, in his
book "The Treatment of Fractures."