Part 56

Fracture of the shaft of the humerus is either oblique or transverse, according to the direction of the force applied. There is considerable displacement. The limb is always shortened to a certain extent, and the natural contour destroyed; the arm is useless, and bent towards the trunk, and the muscles are in a state of spasmodic contraction. The nature of the injury is at once and readily recognised. There is unusual and unnatural mobility of the arm, and distinct crepitation at the fractured point. There is great pain from the pressure of the lower extremity of the bone upon the nervous trunks. The large vessels are seldom torn—though the branches of the humeral artery, and the vessel itself, have in a few cases been ruptured—but there is often considerable bloody swelling in this as in all fractures. Occasionally, when the violence has been great, either the upper or the lower fractured end is thrust through the skin.

When the inferior part of the shaft is broken, there is less displacement than when the fracture is towards the middle of the bone. Fracture above the condyles sometimes extends through them; and the one may be detached from the other either with or without fracture of the shaft. When such an accident is suspected, the position of the condyles in regard to the ends of the bones of the forearm should be accurately observed. Flexion and extension of the forearm can be readily performed, though with pain; not so, when the bones are luxated. Crepitation is detected along the line of fracture, during motion of the limb, and when the condyles are laid hold of and moved upon each other, or on the shaft.

In fracture of the middle of the shaft, coaptation is easily accomplished; slight extension is made by one hand grasping the elbow, whilst, by the other, the bones are brought together, and the straightness and outline of the limb restored. The proper position is readily maintained by two splints of bookbinders’ pasteboard, or of leather prepared for the purpose; one applied from over the acromion process to beyond the point of the elbow, the other from the axilla, and also passing over the elbow on the inside; thus the neighbouring joints are fixed, and the muscles rendered inactive. The conjoined breadth of the splints should be sufficient to embrace the limb almost entirely; some space being left, so that when the swelling subsides, they may neither meet, and consequently lie loose, nor overlap each other. They are softened by steeping in hot water, so that they may embrace every part of the limb to which they are applied; and the extremities should be rounded off, to prevent galling of the parts. They are padded with soft flannel, lint, or cotton wadding, or, what is better, with finely carded tow, and retained by a circular roller applied from the points of the fingers up to the shoulder. The binding should proceed from below upwards, to avoid swelling from obstructed circulation, and do away with the necessity of removing the apparatus arising from this cause. It is well to place a wooden splint on the outside, retained by an additional bandage, so as to steady the parts till the pasteboard or leather has dried, and formed a firm mould or case for the limb; then the wood is no longer necessary, and should be removed. The forearm is bent at right angles, and the humerus fixed to the trunk. In simple fracture, there is in general no necessity for interfering with the apparatus until the bandage slackens, in consequence of the swelling subsiding; then, usually at the end of eight days, it is to be reapplied. One splint is carefully raised, whilst the other is kept fixed and the parts steadied, and the limb is ascertained to be straight and of a proper length; if not, then, or even later, the position of the bones may be rectified without causing much uneasiness. The patient need not be confined to bed on account of a simple fracture; he may walk about with the arm supported in a sling.

In compound fracture similar splints are applied, after due attention has been paid to the wound and to the position of the bones. The patient is placed on his back in bed; and the splints are retained by slips of bandage, double, one end being passed through the loop and secured to the other by a running noose. This method of deligation affords facility for the removal of the splints, in order to examine into the state of the limb and dress the wound. It also permits the apparatus being slackened in the first instance during the swelling, and of being afterwards tightened, without lifting the limb or disturbing its position.

Fracture at the distal extremity of the humerus is managed most conveniently with the limb in the straight position. The fragments are placed accurately together, and one splint placed on the fore part, another posteriorly. The forearm is kept in a state of supination. At the end of about twenty days the apparatus should be removed, and the position of the articulation changed if possible. The forearm is to be bent slightly, and a splint applied,—made to fit accurately, and with a joint corresponding to the bend of the arm. This should be occasionally removed, provided consolidation of the fractured bones has advanced so far as to admit of it, and slight passive motion of the elbow-joint employed. Obstinate rigidity of the parts is thus guarded against.

Fracture of the condyles has been already alluded to. It may be farther observed, that the exact nature of the accident is often difficult to detect; in all cases accurate and careful manipulation is required. Displacement of one or other of the bones of the forearm almost uniformly attends this fracture, sometimes rendering diagnosis obscure.

Fracture of the olecranon process of the ulna is occasioned by falls on the point of the elbow; or the bone may be snapped asunder by powerful and sudden action of the triceps extensor cubiti, when the arm is much and quickly bent. The injury is readily recognised; there is inability to extend the forearm by its own muscular powers, a considerable space is felt between the separated portions of the bone, and the upper fragment is moveable as well as detached; these marks of the injury are rendered more conspicuous by bending the joint. Crepitation is produced by moving the limb when extended, and the separated parts thereby approximated. Bloody swelling soon takes place, large and extensive when bruising of the soft parts has been great—and this is usually the case, in consequence of the injury being almost always the result of direct violence. In some cases the process is comminuted.

Compound fracture is rare, and likely to be productive of serious consequences. I have treated and witnessed several cases. In one the process was cut off by the patient falling out of bed on an earthenware vessel, which broke under the limb. The joint is necessarily opened. Violent inflammation soon commences, and can very seldom be kept within moderate bounds. Discharge of increased and vitiated synovial secretion takes place, followed by profuse and unhealthy suppuration. The cartilages ulcerate, and then the bones. The cellular tissue around becomes infiltrated, the parts swell and are discoloured, and collections of matter form probably at more points than one; perhaps there is a succession of abscesses. The condyles, and often a portion of the shaft of the bone, are denuded by the suppuration, and superficial necrosis results. Ultimately the patient grows hectic. Amputation had to be resorted to in three of the cases which have come under my observation, at the end of some weeks or months from the receipt of the accident.

Union of the simple fracture will take place by bone, if the portions be retained accurately and permanently in contact; but there is a risk of the joint remaining stiff, and of re-separation being produced by even slight violence. Union by ligament is as rapid as that by osseous matter; and if the ligament is short, the arm is quite as useful. Approximation of the broken surfaces is favoured by extension of the elbow-joint, the triceps muscle being thus relaxed. The limb must not, however, be but perfectly straight. The position is preserved by a splint placed on the fore part of the limb, extending from the middle of the arm to the lower part of the forearm, and retained by a roller applied, not over-tight, from the fingers upwards. The application of apparatus to the separated portion, with the view of forcing it into contact with the shaft of the ulna, is useless. The figure of 8 bandage, and such like, are hurtful. Permanent relaxation of the triceps, with prevention of motion, is sufficient. This is continued for three or four weeks; by that time the fracture will in all probability have united, and then gentle and gradual passive motion of the joint is to be commenced.

In compound fracture the prognosis is always unfavourable. Means must be taken to avert incited action—the limb must be properly placed without delay, the edges of the wound accurately approximated, and antiphlogistic measures pursued. Purulent collections must be opened early. Rest of the joint is to be insured, and support afforded, by bandaging and by the application of a splint. The patient will be fortunate if he escape mutilation by the amputating knife; but when the wound is trifling, and the parts not much lacerated or bruised, and the treatment carefully conducted, a cure may be effected by the same process as the simple fracture.

Fractures of the bones of the forearm, of one or both, are common; generally simple. The Radius may be broken at various points—at the upper part—near its head—at the middle—most frequently near the distal extremity. At the two first points the fracture will probably have been produced by direct violence; but near the carpus, it is usually the result of force applied to its extremity, as by falls in which the weight of the body is thrown on the palm of the hand. The ulna is usually broken by force directly applied, as when the arm is brought in contact with hard bodies in falls. By direct violence also, both bones may give way about the middle, and at corresponding points: or, when force is applied in the direction of the bones, the ulna may be found broken near the wrist, and the radius near the elbow.

When one bone is broken, there is little displacement. The power of motion is lost to a considerable degree, and there is some deformity, but little or no shortening. The existence of fracture is ascertained by tracing the bones with the fingers, and by gently rotating the limb; the broken portions moving on each other produce distinct crepitation. When the radius is broken near its middle, the forearm is kept pronated, and the broken extremities are drawn towards the ulna; by bringing the limb towards the supine position, the ends come together, and the one bone is removed from the other. Fracture of the radius near or through its distal extremity produces displacement of the wrist, with great deformity; and this is increased by bloody effusion into the sheaths of the tendons, and into the superficial cellular tissue. In fracture of both bones, there is much deformity and shortening of the limb; the power of moving the hand is lost; the muscles are bruised and torn, and great swelling soon results.

There is little difficulty in remedying the slight displacement which takes place when but one bone is broken, and in retaining the parts in a favourable position. In children, occasionally, one of the bones of the forearm is broken, the other being bent very considerably, so as to cause great deformity. When both have given way, slight extension is required, and the forearm is placed in the middle state between pronation and supination. Two pasteboard splints, softened in hot water, and padded with tow, are applied, one on each aspect, from a little above the elbow to over the fingers; the outer should extend to the tips of the fingers, the inner need not pass the palm; they are retained by a roller. In fracture of both bones, a wooden splint should be retained on the outside of the limb for a few hours; but this precaution is scarcely required when but one has suffered. Similar treatment, along with attention to the wound, is required in compound fracture.

The metacarpal bones and phalanges of the fingers are subject to fractures, both simple and compound. The metacarpal bone supporting the little finger most frequently suffers from force applied to the knuckle, as in pugilistic encounters. The other metacarpal bones are occasionally broken from crushing of the hand, as by a heavy body falling on it, or by its becoming entangled amongst machinery. The injury is readily ascertained by moving the fingers, and pressing in the course of the bone. On laying hold of the distal end of the bone suspected to have given way, placing the fingers over the shaft, and attempting slight motion, distinct crepitation is perceived. For the cure, motion of the parts must be prevented for a sufficient time, and inflammation warded off when threatened; there is a little or no displacement, and consequently retentive apparatus can be almost wholly dispensed with.

Simple fractures of the phalanges are recognised and treated by even the most unlearned in the surgical profession. The deformity is so striking as to render mistakes as to the nature of the accident impossible; reduction is accomplished without difficulty; and the bones are kept in their proper places by a small splint, either of wood or pasteboard, placed on each side of the finger, and retained by a narrow roller fixed by glue or starch.

Compound fractures of the phalanges are almost uniformly followed by most violent inflammatory action in all the tissues, terminating in disease of the joints, and in death of the tendinous and fibrous tissues. The suppuration is profuse and unhealthy, and the infiltration of the soft parts extensive. The diseased action not unfrequently pervades the palm of the hand. In the great majority of cases, necessity for amputation arrives sooner or later.

Fracture of the bones composing the pelvis occasionally takes place, but can be produced only by the application of great force, as by a loaded vehicle passing over the body, or by a fall from a great height. The accident is usually attended with serious injury of the viscera contained in the pelvic cavity, or in that of the abdomen; they may be either ruptured, or lacerated by sharp projecting spiculæ, or merely bruised. The nature and extent of the injury is not easily ascertained. There is great pain on motion of the body or of the limbs, and usually extensive extravasation of blood in the soft parts; these circumstances, along with the symptoms that may arise from internal organs which have been injured, and a knowledge of the way in which the injury was inflicted, lead to a strong suspicion of fracture of the pelvis.

A portion of the crest of the ilium may be broken off, without serious mischief ensuing, and may unite favourably. More extensive fractures, deeper in the pelvis, as in the neighbourhood of the acetabulum, are attended with excruciating pain on the least motion; in these the existence of fracture may be suspected from the first, but the extent of the injury is not fully known till after death. Fractures near the symphysis, and of the rami, either of the os pubis or ischium, are usually attended with injury to the bladder or to the urethra. Wound of the bladder is almost necessarily fatal; extravasation of urine, with all its fearful consequences, taking place in the loose cellular tissue connecting the upper part of the viscus to the parietes of the pelvis, and in the cellular tissue behind the peritoneum. The urethra may be lacerated by the sharp edge of fractured bone, or it may be ruptured by direct violence applied to itself. The latter case sometimes accompanies partial diastasis of the symphysis, produced by the person falling astride on a beam. Either injury separately is sufficiently dangerous, and a patient with both is in a very precarious situation. Great extravasation of blood takes place in the perineum, scrotum, penis, and tops of the thighs, infiltration of urine quickly follows, retention supervenes, abscesses form, and the patient perishes under a train of symptoms already detailed when treating of the urinary organs.

The treatment is seldom satisfactory. Absolute rest must be procured, and with this view the limbs are to be secured, and a broad band passed round the pelvis. The state of the viscera must be attended to; collections of matter must be evacuated; and all other untoward symptoms must be actively met, and their consequences either adverted or got over as far as possible.

Fracture of the Sacrum is uncommon, as also detachment or fracture of the Coccyx. The former accident happens in consequence of a fall from a great height. There is little or no displacement whether the fracture is transverse or longitudinal; sometimes there is splintering of the bone. Acute pain is occasioned by motion of the limbs and of the trunk, and by pressure over the injured part. Abscess is apt to follow, both under the integument, and in the concavity of the bone, and the chief duty of the surgeon is to prevent this if possible.

Fractures of the Thigh.—On account of the thick muscular covering, much attention is required to enable the surgeon to form an accurate diagnosis regarding the effects of an injury of the upper part of the femur. The necessity for ascertaining what the injury really is, need not be insisted on. Consequences dreadful to the patient have too often followed blunders in diagnosis. As in the accidents of the shoulder-joint, some idea as to the exact injury may be formed by ascertaining how the force was applied; but this, alone, may sometimes mislead. Careful manipulation is to be chiefly trusted to.

Fracture within the capsule is met with most frequently in those of advanced age, when the form of the neck of the bone has been altered,—when it has become shorter, and attached less obliquely to the shaft, as is sometimes the case; the bones, too, are then more brittle than in earlier life. The accident often happens from slight force, applied either to the farther end of the bone or to the trochanter, as by a fall in going up or down stairs. Though the height often be not great, yet the patient’s energies are weakened, he can make no effort to break the fall, and the weight of the body is thrown on either the fore or the back part of the trochanter. Though the fracture, in such an accident, generally extends beyond the capsule, and the processes are broken to a greater or less extent, yet occasionally the head of the bone is separated by transverse break of the neck without farther injury. This fracture occurs sometimes in those of middle life; and even in children, separation of the head of the bone may on good grounds be supposed occasionally to take place.

The marks of fracture within the capsular ligament are inability to move the limb, pain about the joint on attempts being made to move it, and shortening to a slight extent, as ascertained by comparison with the sound limb; the patient being laid straight on his back, with the crests of the ilia in a line, either the knees or the ankles are looked to, and the comparative length of the limbs thereby observed. In some cases, neither shortening nor deformity is apparent for some time after the accident; there is merely want of power, and crepitation produced by rotation; but retraction of the thigh would after a time inevitably occur, and has done so when the nature of the injury was not at first ascertained, nor proper treatment adopted. Most frequently there is eversion of the toes, and to a considerable extent; sometimes there is inversion, and this is owing to the limb either having been placed in that position in falling, or having acquired it after the injury has been inflicted. The rotators outward are the more powerful; the limb naturally inclines outwards, and when in the recumbent posture, the weight of the foot favours eversion. But in fracture the muscles do not act as in a sound limb; and when the limb is once placed, the patient will not by his own efforts alter the position. Thus it is that inversion not unfrequently happens in this form of fracture, although the opposite state is that which, from a consideration of the muscles involved, is à priori to be expected. In inversion the limb presents somewhat of the appearance arising from the most common luxation; but it possesses greater mobility, and has not the want of prominence occasioned by displacement of the articulating extremity of the bone. The facility of lengthening the member, and the crepitation felt on a proper and more attentive manipulation, will remove all doubt.

On examining the injured hip, motion to some extent can be effected, though with excruciating suffering to the patient. On stretching the limb to its original length, and then rotating slightly, crepitation can be felt by the hand, or heard by the ear, placed over the trochanter major.

Fracture is much more frequently met with outside of the capsular ligament, generally passing obliquely through the trochanters, and communicating with fissures in various directions. Splinters are often detached, and sometimes the small trochanter is broken off. Here, also, there is inability to move the joint, violent pain on attempting it, swelling and deformity of the member; there is shortening to a greater extent than in the fracture within the capsule; there is free motion in all directions; rotation, abduction, adduction, flexion, and often extension, can be effected to an unnatural and unusual extent—the degree of motion is no longer limited by the ligamentous attachments of the head and neck of the bone. Here, also, the limb is most frequently everted, but occasionally inverted; and that even when, from the direction and extent of the fracture, neither the rotators outwards nor the rotators inwards have been deprived of the power of acting.

In some cases of fracture, partly within and partly without the capsule, all the usual marks of this injury are present, but it is impossible to move the limb without employing considerable force. This arises from the broken portions being jammed together, the neck of the bone being, as it were, driven into and wedged in the cancellated texture of the trochanter major, or of the upper part of the shaft.

The trochanter major is sometimes, though rarely, detached, without separation of the neck of the bone from its shaft. In this injury there is apparent lengthening of the limb, and flattening of the hip; the patient is able to use the member, though not freely. Before swelling has taken place, crepitation can be perceived on laying hold of the trochanter whilst the limb is in motion; and the trochanter itself is found to be in a slight degree moveable.

Fracture of the upper part of the shaft is attended with immediate and great shortening; the limb is much misshapen, and lies on its outer side, with the knee partially bent. The upper fragment of the bone projects; the resistance to the action of the psoas and iliacus is in a great measure done away with, consequently these muscles raise the upper, whilst the lower end falls back and is drawn upwards behind the other. In mismanaged cases, I have found on dissection the lower end of the bone lying in the sacro-ischiatic notch, and a process advancing very different from reparation—necrosis. The marks of this accident are so conspicuous, that the surgeon is satisfied of what has happened without enquiring for crepitation. Rapid and great swelling takes place, if reduction and coaptation are not soon resorted to; the bloodvessels are torn more and more by the ends of the bone, and effusion of blood into the intermuscular cellular tissue is easy. Very soon more extensive and dangerous swelling takes place, the result of inflammatory action, accompanied with startings of the muscles and greater retraction of the limb.