Part 57

Fractures of the middle and lower thirds of the bone are not attended with such great risk, and are more manageable in every way. There is less disfiguration—the ends of the bone are not drawn by the action of the muscles so far apart. The fracture is either oblique or transverse, according to the direction of the force applied; and the bruising and the degree of swelling are also dependent on the same circumstance. From transverse fracture fissure sometimes extends, separating one or other condyle.

The reparation of injury in the upper part of the femur is opposed by a variety of circumstances. Fractures of the neck of the bone are almost uniformly met with in those whose powers of life have been nearly exhausted. The whole injury is confined within the synovial capsule, and the fibrous tissues which support that are unyielding, and but slightly vascular; consequently, in fracture of the neck of the femur, there occurs none of the swelling and increased vascularity of the surrounding tissues, which follow fracture of other bones, or other parts of this bone: no temporary callus can be formed; from this cause, support of the disunited parts is deficient. The head and neck of the bone are not so well supplied with bloodvessels as the other parts; those arteries which pass along the ligamentum teres are the chief support. And perhaps the influx of blood is not increased, in consequence of injury, to such a degree as in other parts; in these, when the surrounding parts are bruised or otherwise injured by fracture in their immediate vicinity, their vascular action is soon excited, the vessels ramifying on the periosteum are enlarged, and blood is poured into the bone at all points. Instead of these salutary changes, the secretion of synovia is increased, and a fluid, perhaps vitiated, surrounds the bone, and is interposed betwixt its ends. There is also difficulty in performing accurate adaptation of the broken ends, and in securing retention so long as is necessary for union; the limb has a tendency to retraction; in readjusting the apparatus, when become loose, the broken surfaces are rubbed on each other, and thus any union which may have been in progress is interfered with. In consequence of all this, union seldom takes place by bone; it has occurred, and will occur, in favourable cases, when the fibrous investment of the neck of the bone does not happen to be torn, and under good treatment. Two sketches which, through the kindness of Sir Astley Cooper, I am enabled to introduce here, show the union complete: the patient from whom this was taken had received other severe injuries, and very little attention had been paid to that of the hip. But it is an undeniable fact, that the circumstances which of a necessity follow fracture at this point are inimical to its effective reparation. The broken ends are sometimes united by fibrous tissue. Most frequently no union takes place, and the broken surfaces gradually become smooth, polished like a bit of china, and adapted to each other; a false joint is formed, but at the same time the capsular ligament, and tissues exterior to it, are thickened and strengthened, and so the unnatural motion is limited. The rough and irregular portions of the bone are absorbed, and the neck of the femur, from interstitial absorption, almost disappears; its diminished head lies in and is attached to the cotyloid cavity, and is rubbed upon by the opposed surface of the shaft. Shortening of the limb is an inevitable result: at first the power of motion is slight, and the support afforded to the body weak; in course of time the member becomes strong and useful.

Many bones are preserved and exhibited, in which fracture of the neck of the thigh-bone, with bony union, is supposed to have taken place; but there are strong grounds for suspecting that many such have not sustained actual fracture. The neck of the bone may be shortened, and set on awkwardly, and there may be masses of new osseous deposit round the neck and the trochanters. Perhaps the history of the case is known.—An old person sustains an injury of the hip by falling, or by a blow on the trochanter; great lameness ensues, and, after a confinement of many weeks, the patient begins to use the member, which, however, remains considerably shortened. But all this may have taken place, and on examination after death, the parts may have presented the appearances above alluded to, without any fracture. The change in the bone is the consequence of diseased action induced by the injury. The bloodvessels of the bone and its coverings are excited, and new osseous matter is formed at various points; at the same time, interstitial absorption of the cancellated texture of the neck gradually advances, and the bone is consequently altered in length and form. These appearances alone, therefore, do not warrant the confident belief of fracture having occurred, even though the history should seem to favour the assumption. And it ought to be recollected, that mere bruising of the parts about the hip is not unfrequently attended with inability to move the limb, with eversion of the foot, so as to relax the muscles which have suffered, and sometimes with slight apparent lengthening. This change in the form of the head and neck of the thigh-bone is not found only in old subjects. Some drawings from patients under forty and fifty years are given at pages 87 and 88, exhibiting in a remarkable manner this deformity.

In many patients advanced in life, who have sustained fracture of the neck of the femur, there is little, if any, chance of union. In these cases, the application of apparatus with the view of adapting and retaining the parts, is productive of great annoyance, and is apt to produce either ulceration or sloughing of the integuments at various parts; and confinement to one constrained position for a considerable time has a mischievous effect on the general health. Instead, the limb is placed in the easiest posture, either extended and slightly retained, or bent over a double inclined plane formed by pillows, with the knee of the affected side fixed to the opposite; a broad band is passed round the trochanters and pelvis, so as to restrain motion without causing inconvenience; and when pain about the thigh is troublesome, fomentation may be used. After some weeks, when the uneasy feelings have subsided, the position is changed, the patient is set up, and encouraged to move about, supporting the weight of the body upon crutches.

In more favourable subjects, whether the fracture is suspected to be without or within the joint, either entirely or partially, the broken surfaces are to be brought in contact, and retained immoveably in apposition for a time sufficient to admit of union. The limb is put up in apparatus not requiring removal, and but little readjustment. This can be effected only in the extended position. Many splints, with foot-boards, straps, and screws, are intended for this purpose, some to be attached to the injured limb, others to the sound one; but the apparatus which is most simple, and easily procured at all times and in all circumstances, is at once the best and the most efficient. This is a straight wooden board, not too thick to feel cumbrous, and not too thin to be pliable or easily broken; in breadth corresponding to the dimensions of the limb, in length sufficient to extend, from two, three, or four inches beyond the heel, to near the axilla, deeply notched at two places at its lower end, and perforated by two holes at the upper. The splint, well padded, is applied to the extended limb, the ankles being protected by proper adjustment of the pads. The apparatus is retained by bandaging. A common roller is applied round the limb, from the toes to near the knee, so as to prevent infiltration, which would otherwise follow pressure above by the rest of the apparatus. The splint is then attached to the limb by involving both in a roller from the foot to above the knee; and in doing this, the bandage, after having been turned round the ankle, should be passed through the notches, so as to be firmly attached to the end of the splint, thereby preventing the foot from shifting. A broad bandage is applied round the pelvis over the groin, and down the thigh, investing all that part of the limb left uncovered by the previous bandaging. A broad band, like a riding belt, is fastened round the pelvis, so as to bind the splint to the trunk, and thereby keep the broken surfaces of the bone in contact. A large handkerchief, or shawl, is brought under the perineum, and its ends secured through the openings at the top of the board. It is evident that, the splint being thus securely fixed and made as part of the limb, tightening of the perineal band will extend the member, and preserve it of its proper length. By care and attention in applying the apparatus, and in adjusting the cushions about the ankle and perineum, there is little or no risk of the skin giving way. The bandages will require to be reapplied once or twice during the cure, and the perineal band should be tightened frequently. The apparatus is retained for six or eight weeks, the time necessary for union varying according to circumstances. After its removal, great care must be taken at first in moving the limb and in putting weight upon it: it should be accustomed to its former functions very gradually.

The same apparatus in the most effectual for all fractures of the thigh; but those near the distal extremity, and in the lower third of the bone, may be managed tolerably well on the double inclined plane—M’Intyre’s splint, the thigh-piece of which is double, the one portion sliding on the other, and made to shorten and lengthen by means of a screw, without removal from the patient. To this the limb is secured by bandaging from the toes upwards; the upper bandage, which should be broad, being continued close to the perineum, and then passed several times round the loins. By elongating the thigh-piece by means of the screw, extension is kept up. Great complaint is commonly made by the patient of pain and stiffness in the knee for a long time after the treatment of broken thigh in the bent position.

There is no possibility of treating fracture of the thigh, with any satisfaction or credit, on the outside of the limb with the knee bent; however attentively the splints are placed, shortening, eversion of the foot, and deformity of the whole limb, are sure to follow. No greater absurdity and cruelty are conceivable than leaving the fracture unadjusted for weeks, making attempts to subdue consequent over-action, and then endeavouring to reduce and retain the bones at a period when otherwise they should have been firmly united. “Experience teacheth” not “fools,” and cannot amend those whom prejudice has blinded.

Compound fracture of the thigh, if circumstances do not forbid attempts to save the limb, is to be reduced and retained in the same way as the simple, the wound being attended to, and means taken to subdue inflammatory action. Abscesses must be opened timeously, the limb must be equably supported, and the powers of the system preserved.

The application of force may, in young persons, detach the epiphysis of the lower end of the femur, and displace it to a greater or less extent; and if the accident be not detected, the epiphysis will become consolidated with the shaft in this unnatural position, impairing the usefulness of the member, and probably laying the foundation for disease in or around the articulation. Reduction is easy, and the retentive treatment is the same as that recommended generally for fracture of the thigh near the knee-joint. I have met with one well-marked case of this form of diastasis. A girl sustained an injury of the knee when fourteen years of age, in consequence of the limb having been entangled amongst the spokes of a carriage-wheel in motion; the knee continued painful and swollen, and she had a halt in walking. After the lapse of about three years, extensive suppuration occurred in the lower part of the thigh and round the knee-joint, and amputation very soon became indispensable for the preservation of life. The synovial apparatus was much diseased, and the epiphysis of the lower end of the femur was found displaced forwards and upwards, so that only the posterior part rested on the tibia; in fact, it was turned, as here shown, almost half round on the shaft: firm union by bone had taken place.

Fracture of the Patella is generally simple. It is occasioned either by great force applied to the bone directly, or by the action of the strong extensor muscles—the knee being suddenly bent, and the bone snapped across over the end of the femur. The degree of immediate swelling, and of incited action, will vary according to the mode of infliction. When the injury is caused by a blow upon the part, the bone may be broken either transversely or vertically, or both; either the upper or the lower portion may be vertically split, usually the upper; sometimes there is considerable comminution. Muscular action produces transverse fracture only.

The nature and extent of the injury is readily ascertained. The patient is unable to extend the limb, and cannot support weight on it; in the bent position, a space is felt in the situation of the patella, the lower portion is found nearly in its place, but the other is drawn upwards on the fore part of the thigh; by extension of the limb and flexure of the thigh the portions are approximated, and crepitus is perceived when they are brought in contact. These symptoms are perceptible through any quantity of bloody effusion. By attentive manipulation, comminution and vertical splitting may also be detected. The circumstances attending the accident will, in most instances, lead to a tolerably accurate expectation of the state of parts.

The ligament of the patella does not often give way from muscular action; it is much stronger than the bone, and the latter consequently snaps. It may be, and has been, divided, along with the superimposed integument, by a fall on a sharp substance. This accident is followed by lameness, the ligamentous tissue does not soon unite, and the limb is long in regaining its usefulness; sometimes the union is imperfect, and the member remains weak.

Division of the integuments over a fractured patella is a very serious accident. The joint is opened, and such a state both of the limb and of the constitution must in general sooner or later occur as to cause necessity for amputation. Cases have, however, occurred, in which compound fracture of the patella has been cured.

The bone unites, under favourable circumstances, in the same way as any other. In longitudinal fracture there is almost always bony union. In transverse, the obstacles to correct apposition are great; the upper portion is acted on by the muscles on the fore part of the thigh, to a greater or less degree, in almost any position; there is increase and vitiation of the synovial secretion, and when the bones are approximated, this fluid is interposed. The union is therefore almost uniformly ligamentous, and, fortunately, this is as strong and as rapidly effected as that by bone. When the treatment is not of the most approved kind, a long portion of ligament is produced, and the limb remains weak. But union by a short ligament is undoubtedly the most desirable result, the member is as useful as when bone is the uniting medium, and ligament is less subject to disruption; bony union is, for a long time, apt to give way on the application of even slight force.

The fragments are to be approximated, and brought nearly into contact, by placing the limb, with the knee extended, and the thigh slightly bent on the pelvis. The limb is retained in this position by the application of a straight splint behind, hollowed at the extremities, extending from a little below the tuberosity of the ischium to below the middle of the leg, and retained by a roller, not at all tight; the foot and lower part of the limb must be previously bandaged to prevent infiltration. All apparatus with straps, buckles, and apertures to receive the portions of the bone, are worse than useless. The splint requires to be worn for some time after the patient gets into the erect position, which ought not to be before six weeks after the accident.

Fracture may occur at any part of the leg. One or both bones may give way, either transversely or obliquely, according to the application of the force. The transverse fracture is produced by a direct blow, by a heavy body striking or falling on the limb, or by the lower part of the limb being fixed whilst the body is in rapid motion; the oblique is caused by force applied in the direction of the bones—as when a person falls or leaps from a height, and alights on one foot, the limb being extended and the body erect. In the latter description of accident, it is frequently supposed, erroneously, that but one bone has given way; fracture of the tibia perhaps is perceived some few inches from the distal end, whilst the fibula at that part is entire; but, by attentive manipulation, it will often be found that the fibula has sustained fracture, within a short space of its upper extremity; the force was applied to the ends of the bones, and they gave way, each at the weakest part.

The tibia is broken at its upper part near the tuberosity, with or without similar injury of the fibula. There is considerable displacement, particularly in the bent position of the knee; there is no restraint to the action of the extensor muscles inserted immediately above the point of fracture, and these, though not acting with unusual power, cause protrusion of the upper end of the tibia, the condyles of the femur serving as a fulcrum over which the muscles are stretched. This injury is usually the result of direct violence.

Fracture of one bone, at a point lower in the limb, is not attended with much displacement or deformity. Indeed, attentive manipulation is often required to detect the site of the injury; and a sense of crepitation is perceived, only when the lower and upper portions of the bone are pressed on alternately or during rotation of the foot. When both bones are broken, the displacement and swelling are great. The foot is sometimes turned inwards, but usually it falls outwards; and if there has been much laceration of the soft parts, with or without division of the integuments, the lower portion of the limb hangs quite loose.

By the application of great force, as by a rope being twisted round and run tight on the limb, both bones and soft parts may be reduced almost to a pulp, without much or any division of the integument. Such an accident is followed by rapid and great swelling, violent incited action, gangrene, and severe constitutional disturbance. The progress of the mortification is not in all cases uniform; in some, the swelling and discoloration extend to the groin and trunk in two or three days, attended with furious delirium; in others, the disorganisation of the limb is very slow, some days elapsing before it reaches the knee, and in these the constitutional symptoms are less severe.

In some cases there is extensive wound of the integuments, without serious injury of the bone, muscles, or vessels. The skin either has been divided by the external force acting upon the resisting bone, or the sharp fractured end of the bone has been thrust through. Sometimes the bone is protruded to a considerable extent, and entangled amongst the more superficial soft parts.

Fractures of the lower portions of the bones are generally the consequence of twisting and partial displacement of the ankle. The fibula is most frequently broken by twisting of the foot outwards, and the fracture is almost uniformly between two and three inches above the articulation. The broken ends are displaced inwards upon the tibia. The injury is detected by moving the foot, and tracing the line of bone; after swelling has taken place, examination, though almost equally easy, is productive of much more pain, and it is of importance to ascertain the nature of the injury at once, and immediately after the accident. The outer malleolus sometimes gives way from the same cause; or it may be snapped off by a direct blow. The lower portion of the tibia is sometimes longitudinally split by bending inwards of the foot, the patient having fallen from a considerable height; occasionally the inner malleolus is broken transversely. Inquiry as to how the accident happened, particularly as to the direction of the twist, the displacement of the foot, and the degree and extent of crepitation, will determine the nature of the injury.

The astragalus, os calcis, the other bones of the tarsus, and those of the metatarsus, are sometimes broken by the application of great force, but they are not much displaced. Sometimes the foot is violently concussed in consequence of a fall from a height, and though no fracture may have occurred, the patient is equally lame and pained; severe inflammation is sure to supervene rapidly, and may terminate untowardly.

Fracture of the upper part of the tibia is to be treated in the straight position, for it has been already observed, that when the knee is bent the upper portion necessarily projects. A hollowed splint of wood, extending from the middle of the thigh to near the heel, is applied behind, whilst one of pasteboard may be placed on each side: all are secured by bandaging, the foot and lower part of the limb being rolled previously to prevent infiltration; by this simple apparatus, motion of the knee-joint, and of the ends of the bones on each other, is completely prevented; the heel is raised, if necessary, for complete adaptation.

Fractures of the middle and lower portions of the bones are treated most advantageously, whether simple or compound, in the bent position, the angle being made more or less obtuse, according to the degree of flexion most conducive to easy reduction and retention. Extension is made on the limb, and the parts brought into as natural and handsome a shape as possible; in doing so, the appearance of the sound member should be kept in view. There is seldom any difficulty in accomplishing reduction; the extending and counter-extending power need be but slight; the upper part of the limb is steadied by an assistant, whilst the lower is stretched and moulded by the hands of the surgeon. In compound fractures at this part, the portions of bone completely detached from the hard and soft parts are to be extracted. And if reduction cannot be effected in consequence of a sharp and long end of the bone projecting through a narrow wound, either the portion must be abridged by the saw or cutting pliers, or the wound must be enlarged. Sometimes the one mode is preferable—sometimes the other—occasionally both are required. When the protruding portion composes but a small portion of the shaft, though perhaps of considerable length, it should be taken away; when, on the contrary, it is more thick than long, it is better to enlarge the wound; but on this subject no general rules can be laid down. The splint is the same as that recommended when treating of fractured thigh, composed of a thigh and leg-piece, with a moveable foot-board—the double inclined plane, improved by the late Mr. M’Intyre of Newcastle and others. A very simple and efficient apparatus has been used in our hospital for some years back. It answers every purpose fully better than the others, and can be had of all the instrument makers for a third of the expense of those previously in use. The foot-board is fixed so as to make the leg-piece of the proper length, and the splint is secured at a convenient angle. It is padded by means of a cushion filled with oat chaff. The foot is rolled separately; the limb is then raised carefully, and laid down on the splint placed quickly beneath by an assistant; it is retained in a proper position by the hands of the assistant, whilst a roller is carried from the toes round the foot-board, and along the limb to the knee. A broad roller is then made to surround the thigh and splint, and having been turned several times round the loins, is secured to the upper part of the cushion. The limb is thus rendered independent of the motions of the trunk; it is made as of a piece with the splint. It should be raised considerably above the level of the trunk, whilst the patient is in bed, in order, by favouring the return of blood, to prevent swelling and inflammatory action. The wound, if any, is to be approximated. If discharge follow, part of the bandage may be undone from day to day, for the purpose either of employing fomentation or of applying suitable dressing, and still the limb is kept perfectly steady. Abscesses must be opened early—spiculæ removed—constitutional symptoms warded off, and, if they do occur, combated,—at one time inflammatory action must be kept down—at another and more advanced stage, the strength must be supported by all means. In simple fracture it is seldom necessary to undo the bandage, till the apparatus is loosened by subsidence of the swelling—and if the fracture be early reduced, and kept steady, that will be but slight. Then the bandages are undone and reapplied, and the position of the limb attended to. It is seldom necessary to interfere with the leg during readjustment, but should there be any deviation, even considerable, from the proper position, it is easily remedied at the end of the first, second, third, or even of the fourth week; but the sooner the better. The patient may be removed from bed, and may sit up during the greater part of the day, with the heel on a level with the pelvis, within the first week. His health, appetite, and spirits, are thus kept up, sore back is avoided, the tedium of confinement diminished, and the cure greatly accelerated. At the end of five, six, seven, or eight weeks, according to the age, and as the consolidation advances, the patient may be allowed to move about on crutches, some few days after removal of the apparatus, the foot and leg being still bandaged, and supported by light splints, or the bandages may be starched and applied moist, with portions of coarse brown paper interposed. A firm case is thus formed for the protection of the limb and retention of the bones. No weight should be put on the limb for several weeks after, otherwise a leg cured well and straightly may become bent, twisted, and deformed.

Fractures of the lower extremities of the bones, and of the malleoli, are reduced by placing the foot straight, and retaining it so by the application of a wooden splint; the parts are protected by a wedge-shaped pad, and the whole is retained by a common roller. The splint is made to project two inches or two inches and a half beyond the ankle, and to reach near to the knee-joint. It has two perforations in the upper end; to these a bandage is attached by its split end, and it is then carried down along the inside of the splint, and rolled round the foot and ankle; thus the apparatus is prevented from shifting upwards. The other extremity of the bandage, during its convolutions round the foot, is made to pass through notches in the farther end of the splint; the foot is thus turned to the side opposite to that in which it was placed by the accident, and ought to be retained so till consolidation has taken place. The splint is of course always placed on the side of the limb opposite to the fracture.

Disunited Fracture.—In some cases union takes place very slowly. On removing the splints, with the expectation of finding the bones firmly united, the ends can be moved very freely on each other without crepitation or much pain. This, as already stated, may be referrible to various causes,—necessary or accidental evacuations, natural or not—diversion of the nutritious fluids to some particular organ, as in pregnancy—the period of life—a diseased state of the bone of the periosteum or medullary web. By keeping the parts immoveable and firmly compressed for some time longer, consolidation may be brought about. But in spite of every care, the ends of the bones in some cases remain unconnected by any save a soft medium. This happens, however, very rarely under proper management. I have had but one case of it in my own practice, when the patient was from the first under my own inspection and care; and in that the occurrence of false joint was attributable solely to the absurd conduct of the patient. He was tripped up on the street by some individuals following their avocation as pickpockets, fell, and broke his forearm. The fracture was immediately reduced and splints applied—one of pasteboard on each side, with a wooden one exteriorly till the pasteboard hardened. He soon cut away the ends of the splints—within thirty-six hours after they had been put on—so as to allow motion of the fingers and hand, sufficient for indulgence in card-playing. The splints were still farther shortened, and wholly removed much too soon; shortly afterwards he fell from horseback. No union took place by bone. Unless in the case of previous disease of the bone, disunion is generally attributable to some carelessness or recklessness, either of the surgeon or of the patient.

If any osseous deposit has taken place, it is absorbed; the ends of the bone are diminished in size by interstitial absorption; ligamentous or fibro-cartilaginous tissue is formed round the wasted extremities; and the surrounding cellular tissue being thickened and condensed, a sort of synovial pouch is formed, in which the ends, by this time smooth and rounded off, move freely. The limb is shortened in some degree, and its actions are very much diminished in force, there being no sufficient support for the muscles. The bones of the leg and of the forearm are occasionally the seat of false joint, sometimes the femur, but most frequently the humerus.

By the tight application of a firm and broad belt of leather, the part is steadied, and the limb rendered more serviceable. Various measures have been proposed and practised with the view of promoting a salutary increase of action in the parts, by which osseous deposit in sufficient quantity to form a firm uniting medium might be procured. The ends of the bones have been exposed by incision, and removed either by the saw or by cutting pliers; they have then been placed together, retained by proper apparatus, and the case treated as one of compound fracture. The ends have been cut down upon, rubbed over with escharotics, as caustic potass, and afterwards treated as in the former method. Setons have been passed between the ends of the bones, and been retained till sufficient action has occurred; they have been then withdrawn, and the limb steadied by splints and bandaging.