Part 25

21. After the application of the apparatus, if the patient be obliged to keep his bed, the fore-arm is to be extended on a pillow, taking care to keep it always half-bent, and guarded by hoops from the weight of the bed-clothes. But if the fracture be not a compound one, and if the fall has done no injury to the system in general, it is unnecessary to confine the patient to a position wearisome, and oftentimes insupportable to many persons. Then the limb is to be suspended in a sling, which is always sufficient to support it, without having recourse to the kind of hollow case recommended by Bell, which is seldom at hand, and the use of which must be extremely inconvenient.

22. The subsequent treatment to be adopted in such fractures is simple and easy: to wet the apparatus daily, for a few days, with vegeto-mineral water, to obviate, by proper means, the accidents that may occur; to renew the application of the roller at the end of eight days, or perhaps later, according to the degree of its relaxation; to repeat this application two or three times during the course of the treatment; to allow, at first, but light diet, which may be afterwards more solid, and given in larger quantity, and to admit finally of a return to the patient’s usual mode of living: such was, in cases of fracture, the practice of Desault, which was always attended with happy effects.

23. Sometimes a considerable swelling occurs, after the application of the bandage, on the back and face of the hand; small blisters appear between the fingers; the patient experiences sharp pains along the fore-arm; and other small blisters rise on its surface. It is then necessary to remove the apparatus, to open the blisters by pricking the cuticle, and dress the part with cerate spread on linen rags; replace the apparatus, making it less tight than before, taking care to renew it every day, till the excoriation be entirely gone. This accident, of no great consequence in itself, has frequently occurred to Desault, although the rollers were applied at first with but a moderate degree of tightness.

24. The consolidation being completed generally in twenty-four or twenty-five days, leaves, at this time, a little stiffness in the joints, in consequence of their having remained so long without motion: the movements of pronation and supination are performed but imperfectly. Their return is facilitated and hastened by frequent exercise of the limb, as well at its junction with the os humeri, as in its own proper joints; and, in general, by the fifteenth or twentieth day from the removal of the apparatus, things are in the same state in which they stood before the fracture.

FRACTURE OF THE RADIUS.

§ VII.

OF THE CAUSES AND THE DISPLACEMENT.

25. The radius, which is the moveable and almost the only support or abutment of the hand, receives, in falls on that part, a much greater share of the shock than the ulna, which is joined to the hand by only a small surface. Hence, without doubt, arises the greater frequency of the fractures of the radius; fractures which, when produced by falls on the hand, are evidently the result of a counter-stroke. Oftentimes also this bone is broken by the immediate action of external bodies, because it is defended below with but a thin covering of muscles.

In whatever way the fracture may be produced, it occurs in the middle or at the extremities of the bone; very rare near its articulation with the os humeri, it is more common in its middle; but more frequent still at its lower end. The difference arises probably from this circumstance, that, in falls on the wrist or hand, the shock is weakened and lost in proportion as it is propagated upwards.

26. In such fractures, displacement is almost constantly observable in the thickness or cross direction of the bone and fore-arm, and is produced by the action of the pronator muscles, which, by forcing the fragments of the radius towards the ulna, tend to diminish the interval between the bones. The ulna remaining unbroken, always prevents any displacement in a longitudinal direction. The first kind of displacement is the more perceptible, in proportion as the fracture is nearer to the middle part of the radius, where the bones are at the greatest distance from each other. This displacement is seldom outwards, because the interosseous ligament prevents that: yet experience furnishes some exceptions to this rule.

CASE I. Desault was called, in the month of July, 1781, to visit a mason, who, sleeping at the foot of a wall, with his fore-arm stretched out, received on the anterior part of it, a round stone, of the size of a bowl, which, falling from a scaffold, fractured the radius in its middle, and produced a large contusion, accompanied by an enormous swelling, to which the usual discutient remedies were applied. On the fifth day the swelling had in part disappeared; but then there was discovered a very evident protuberance of the inferior fragment, which, by pointing outwards, separated itself from the superior one, which remained nearly in its place. The interval between the bones was evidently increased below.

The fracture was reduced by pressing the lower fragment inwards, and, instead of employing graduated compresses the whole length of the limb, they reached only to its middle, along the part corresponding to the superior fragment. The roller was drawn a little tighter below than above, in order to keep the inferior part of the radius near to the ulna.

By being treated afterwards in the usual mode, the fracture was cured. But, in consequence of being over-stretched by the separation of the bones, the ligaments of the wrist became the seat of a tedious lymphatic swelling, which left behind it some degree of stiffness.

27. Examples of this kind occur too rarely to affect the general law relative to the direction of the displacement of a fractured radius, a displacement which, if not properly treated, makes the fragments unite in such a manner as to form an angle pointing inwardly towards the ulna, as is evinced by a perceptible depression under the cuticle. In such a case, from this contraction or narrowing of the interval between the bones, arise the inconveniencies already mentioned (9).

§ VIII.

OF THE SIGNS.

28. The diagnosis of fractures of the radius is in general easy, when they occur at the lower end, or in the middle (25). In these two cases, a depression more or less perceptible, on the external side of the fore-arm; an inability to perform pronation or supination, by the action of the muscles alone; and a severe pain, necessarily resulting from moving the bone in this two-fold direction. Such are the particular signs or appearances which first disclose the existence and the place of the fracture. The reality of the accident is afterwards more fully confirmed by the signs common to all fractures, namely, the flexibility of the bone, the crepitation perceived by moving it in different directions, &c.

29. Desault cautioned his pupils not to confound this last sign or symptom with a kind of noise, sometimes heard in the sheaths of the tendons of the extensor longus, extensor brevis, and abductor longus; a noise resulting from a filtration of synovial fluid into the sheaths, or produced by some other cause. But, besides this crepitus in the sheaths being a very rare occurrence, it is always easy to distinguish it from a crepitation of the bone, by this circumstance, that the first is heard on merely pressing the parts, but the latter only by making the bony surfaces rub against each other. Besides, by an experienced ear there is no danger of any mistake being committed.

30. If the fracture exist at the upper end, the thick muscular covering which there surrounds the radius, renders the diagnosis more difficult. Petit has, however, thrown some light on the subject, by judiciously advising to place one hand on the upper extremity of the radius, and with the other to make the fore-arm rotate on this bone. The solution of continuity or fracture will be rendered evident, if, in the midst of these motions, the head remain stationary. But if, on the other hand, it rotate, it has sustained no injury. These two circumstances can be easily explained; but, it is not so easy for the practitioner to avail himself of them in every case. This precept may also be applied in cases where a considerable swelling, occupying the whole fore-arm, conceals from the touch of the surgeon the fragments of the bone, even when broken in the middle.

§ IX.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

31. The reduction of a fracture of the radius is effected in nearly the manner already described for that of the two bones of the fore-arm (10–13), except that, here, the extension must be less, because there exists no displacement in a longitudinal direction (26).

To remove that which exists in a cross direction, an assistant whose business it is to make extension, places the hand in a state of adduction, for the purpose of removing the inferior fragment outwards. This precept cannot be applied to much advantage, if the division exist towards the upper end, on account of the interosseous ligament.

At the same time the surgeon endeavours to bring the ends of the bone into perfect contact, by pushing them in a direction opposite to that of their displacement; and when he has attained this end, he begins the application of a bandage or apparatus the same as that already described (19 and 20), with this difference, that as the ulna is here sound, and performs, in relation to the fractured radius, the office of a natural splint, it is unnecessary to place an artificial one between the internal condyl of the humerus, and the styloid apophysis of the ulna.

32. The consolidation or cure is here always more speedy than in the preceding cases, where nature, with the same amount of means and resources, has twice the quantum of labour to perform, and where she supplies her deficiency of power, by the greater length of the time which she employs. In general the bone is united by the twentieth or twenty-fourth day.

33. When the fracture exists at the superior part of the radius, it is essential, after the removal of the apparatus, to make the limb very frequently perform all its natural motions. In such a case, indeed, the parts sometimes swell, become stiff, and an anchylosis of the fore-arm may be the consequence, as Ambrose Pare observes, in his book on fractures, where he says he has seen many accidents of this kind. Galen has remarked the same thing before him. The following case reported by Jeo. Dol**, confirms the truth of it.

CASE II. Jane Rene was received into the Hotel-Dieu, in consequence of a fracture of the upper extremity of the radius, produced by a fall on that part, for which she was subjected to the treatment already described (31). The apparatus being removed at the expiration of twenty-five days, the consolidation was perceived to be complete. The motions of pronation and supination were impracticable; those of flexion and extension very much impeded. The patient was now ordered to have the fore-arm moved daily, in these several directions, for the space of an hour, and this space was even increased morning and evening, notwithstanding the pains which, at first, accompanied the exercise. On the eighth day pronation and supination could already be performed in a small degree; they became more and more free, in proportion as the exercise of the limb was longer continued; finally, on the twenty-second day from the removal of the apparatus, the patient was conducted, according to custom, to the amphitheatre, where all the pupils witnessed the perfect freedom of the motions.

CASE III. A few days after this, a man, who had left the Hotel-Dieu about eight months before, while under treatment for a similar fracture, returned, to be the subject of a public consultation in consequence of a different disease.