CHAPTER XV DIAGNOSIS OF FRACTURES AND DISLO- (Part 2)

the head of the radius XV] EXAMINATION OP ELBOW 189 is felt in front of the capitellum (capitulum), there IS dislocation of both hones forwards ; in this case the distance between each epicondyle and the styloid process is increased. 4. Although the olecranon maintains its normal relations with the condyles, the head of the radius may be foimd dislocated fonvards, backwards, or out- ivards. In the forward displacement of the bone flexion of tie elbow is brought to a sudden stop by contact of the radius with the front of the humerus bo long as the uhia is articulating with the trochlea' flexion and extension of the joint can be obtained: In yoimg chi dren, forward dislocation of the radius caused by pumng on the forearm is common, and is known as fulled elhoiu. 5. If the olecranon is unduly prominent at the back of the jomt, but the distance between its tip and the outer epicondyle is unaltered, and the sS moid notch Oncisura ulnaris) cannot b^ felt there is ''^''^V^Vhsis of the U^nierusZll r ? d bTdr. '^'"r^" i''^' '^^^^^^^^ be cor- rected by drawing forwards the forearm, and will IS possible. The mner epicondyle may or may not be detached with the rest of the epiphysis-if it^is Lt he distance between it and the olecranon s t- creased, as m backward dislocation of the ulna This injury occurs only in children and youths 6. I he olecranon or either of the evicondvlf, nf a humerus may be fomid movable and gS 1/ to fracture. The detached fragment in eTther may be a mere scale of bone, o'r tH whole p,^i:!f Z " "^'"^^^ ^ P--^ °f the sLToi 190 SURGICAL DIAGNOSIS [chap. and condyles unaltered, showing that there is no dis- location, but the line of the humerus is deformed iust above the joint, and on attempting to draw forwards the forearm crepitus is felt, and the deformity becomes lessened. This shows a jrac- ture of the lower end of the humerus, with displace- ment backwards. If the crepitus is very marked and easily obtained, and especially if one epicondyle can be moved independently of the other, there is a T-shaved fracture into the joint. , . t 8 When on rotating the forearm the head ot the radius does not move, and crepitus is felt just below it, there is a fracture of the neck of the radius. 9 If on rotating the forearm crepitus is felt iust below the outer epicondyle, and is also elicited by pressure on the head of the radius, and especially if any part of this bony process is felt to be movable, it will be evidence of fracture of the head of the radius. . . • „ 10 If the presence of crepitus on moving the elbow shows that there is a fracture, but a 1 the bony points of the joint are in their normal relation and cannot be moved independently and further if there is a deviation in the hne of the limb at the elbow-joint, or a lateral movement there with crepitus, a fracture of the articular frocess of the Wem may be diagnosed. This m]ury is very rare. Fractui-c of forearm—Either of the bones may be broken singly, but fracture of the two bones together is more common ; ' greeiistick fracture is more frequent in this situation than m any o. her. The signs of fracture are the common ones of pa_in, swelling, deformity-nsually very marked-mob b^y and crepitus. The posterior edge of ^lie ulna is sub cutaneous in its whole length, and may th-efore be easily examined; the contmmty of the radius may XV] EXAMINATION OF WRIST 191 be shown by observing whether the head of the bone tollows the movement of the wrist in pronation and supuiation. 1. If the bones are bent, but there is neither mobihty m the length of bones nor crepitus, the injury is a greenstick fracture. This iniurv only occurs in children. 2 An angular deformity of the forearm, with mobility in Its length and crepitus, wiU indicate fracture of the radius and ulna. 3 Or either bone may be found broken singly In this case there will be little if any deformity, but there will be a very painful and tender spot in just there ''''' ^'^^ ^"""^ """P^"' Fractures and dislocations of the wrist ne°ot ^^'^'^ being subcuta- neous any displacement of the joints or fracture with displacement of the fragments^ is easily detec ed by the eye and by the hand. But the X-rays have taught us that many s^ra^rts of the wrist ^ .fvS'"" particularly the relative positions of the styloid processes of radius and ulna, the line of the uJna is unduly prominent and has a dip below it also he outline of the lower end of the Radius and the plane of the hand and forearm Slight i^ !. f unless care is taken to observe these points- it always causes raising of the radial styloid prJce radial shortening) and displacement of The^ hand to the radial side (radial abduction) malwL Ti ulnar styloid stand out. The boneg 'f th^i? and thumb are^U practically suruUneot oXl 192 SURGICAL DIAGNOSIS [chap. dorsum ; tlie surgeon should, therefore, run his fingers along the dorsum of the metacarpal and pha- langeal bones, and note any deformity, and any loss of prominence of either of the knuckles, and then, grasping the extremities of each bone, one in either hand, should see if there is any mobihty with crepitus. He should notice also if there is any lessening of the mobility at any of the joints. The injuries that may be met with are the following : 1. If the styloid process of the radius is on a level with or above that of the ulna, there is a frac- ture of the loiver end of the radius. The lower frag- ment is almost invariably displaced backwards and to the radial side, causing more or less of a promi- nence on the back of the wrist above the styloid process of the radius, and a corresponding hollow on the palmar aspect, and the styloid process of the ulna appears too prominent, with a marked groove or depression below it. This is the commonest accident in this region, and is kno\vn as Colles's fracture (Plate i.). The fracture is usually impacted, and mobility and crepitus are not obtained. The amount of deformity depends upon the extent of the impaction : it may be very slight or strongly marked. If this deformity is met with in a yoiuig person imder 18 or 20 years of age, and it is re- duced with a soft grating sensation on extension of the hand, it is a separation of the loiver epiphysis of the radius. 2. If there is a prominence just above the dorsum of the wrist, and the whole hand is carried back, but is in a straight Une with the forearm (not abducted), the injury is a fracture of the loiver end of the radius and ulna. In this fracture there is generally mobility and cro])itus, and the break in 1'iC(.i''i« of >i- l.-Colles-s fracture: Anteroposterior. Plate I. XV] DISLOCATIONS OP WRIST 193 and the sty oid processes is, of course, shortened. ci. it, while the styloid processes keep their normal relation to each other, the distance between either styloid process and the base of the met! carpus is considerably shortened, the injury is a ff'^^^^on of the carpus. The convex uppi L der of the carpus will be felt as a promin^t swelW is^'e^tt."' '''' ^^^"^ injury^ j. If the lower end of the radius is very nm,^; dislocations are both of them nuit ^'^^^'^ altered. Pronatil , i "e'^^arpus, are un- 7"-«m 0/^/.. a sprain^ir^f ' fi"' ° ^ he lower end of the radius, (6) fTaiture nf other styloid process, or (c racture nf 1 °' ^he. carpus, most common ^ the ^^^^^^^^ uuvHmlare). These iniurio.s can oTl , ^''''^ ■•-I differentiated by X ™ \ J^^^^ ■.uosis has an inntS ^lpt^~/■T ■7 -St a.K.-t'.ti,:^1i;;:^,^« 194 SURGICAL DIAGNOSIS until delay in recovery raises a suspicion of some in- im-y more serious than a sprain. (Plate ii., Fig. 1.) fc- 6. A carpal bone, either the semilunar (os luna- tum) or less commonly the os magnum (os capitatum), may be dislocated forwards on to the carpus ; more rarely backwards. This injury is accompanied, as a rule, by a fracture of the scaphoid bone (os naviculare). 7 Dislocation of a metacarpal bone or fhalanx is recognized by the deformity at the joint and the lessened mobility of the part. 8 Fracture of metacarpus or phalanx is recognized by deformity, mobility, and crepitus in the length of the bone. Shght deformity with tenderness, but without movement or crepitus, indicates a green- stick fracture of a metacarpal bone or phalanx. 9 Pain deformity, crepitus at the outer side ot the base of the thenar eminence, denote a fracture of the base of the first metacarpal. When the fracture involves the articular surface, it is kaown as Bennett's fracture or stave of the thumb. (Plate ii., "^'^10.'^ Mallet finger is a condition in which the patient is miable to extend the termmal phalanx, which hangs in the flexed position, and is due to rupture of the insertion of the extensor tendon mto the base of the phalanx. CHAPTEK XVI DIAGNOSIS OF FRACTURES AND DISLO CATIONS OF THE LOWER LIM^ the obvious deforLty they occasTon' TT'^'t^ to whether a Sn^t ^ conclusion as bones, tie •ZlS^Z'S Z-'Sti'""'"'' °f skiagram is so exart n« „ ootaiued from a good to-day almost entirely unon id I ' ^^^^ "■i«.vcT they a,eTv°ae''rj appreciate that much of wlmt f 1 1 'Student will ^ppi.e., o„,y to thteljlris rfo;",'j;:!°'»p'« their heljj cannot be obtaine.l ° "''™' Juii ™7«au'':,iri', Pll7, and look o„:S ;%„L'™ '""'^^ deformrty, any alteratiou^in the lL „ ° "^""J' oJ the l,„,l, 0, „( , " ™« ^"e or position -aUweUin,, pr„,„,„i„, yreSi^^/Xi™: 196 • SURGICAL DIAGNOSIS [chap. alteration in its length, the existence of which will indicate not only the fact of a lesion of the skeleton of the part, but its situation and m many cases its nature. Next, the limb shou d be examined with the hand, and the outline of the bones and their relative positions compared with those ot the sound limb. Movement in the length of the bone and crepitus are to be tried for and the free- dom of movement at the joints is to be tested ; the seat of pain and tenderness is to be exammed with special care. . A comparison of the foUowmg measurements n the two limbs is of great importance m the diagnosis of injuries of the lower limb : 1 The length of the limb from the anterior superior iliac spinous process to the tip of either malleolus. It is neces- sary to have the patient lying with the pelvis straight, that is, with a line between the two anterior ihac spines crossing the median vertical plane at right angles. The surgeon must also be very careful to take the measurement from exactly the ^^nie pomt of the spine of the ilium on the two sides. Mistakes may easily be made m fat persons, and the best af - guard is to pass the finger on to this pomt of bone from below. This measurement gives the length of the entire limb ; alterations m it afiord no gmde as to the site of a lesion, which may be m the hip thiih kiiee or leg. Inequality of the measurement ontheto sides may be^ue to a -ce.t mpry ^ congenital asymmetry, or to previous m]ui} , opeia tion or diseL. The last three will gonexaUy be SSLted by . scar, by wasting, or by ysis, a^^ the patient will be aware of the fact; 1^ ^ Jie ina> be quite unaware of congenital mequaliiy of he limbs. Congenital asymmetry affects equally the hTgh and the leg, but asymmetry due to injury affects XVI] MEASUREMENTS OP LOWER LIMB 197 only the injured part. With the double object of excluding congenital asymmetry and of localizing the mjury the thigh and the leg should next be measured seiDarately. flJ:iZ^' ^'T "Kf"" ascertained by taking the distance from the anterior superior spine of the uim to the upper border of the patella; or from he pubic spine to the adductor tubercle of th^ pXlTa aJ'/r f"^" '''' border of th care t^it t ^°^^^P«^- Patella is taken, care must be used to ensure that the knee-jomt i m the same position m the two limbs, and the borfe should be pushed up to its full extent. Thi mea ne- ment is shortened by the conditions which mod he vertical position of the trochanter, and, in addt th^ pa Ih rr"'i' ^^^'^'^^^^^^^ ^^P-^rds or tne patella and, when the top of the natelk iq taken as the lower noint h^r f,.n c patella la This measurement is shortened rlr ^''^/^fi-^cd. of the tibia and fibula aml n f "'/^'^^l^^ ^^-'-^ct^i-e end of the bones wl h^e^tln °^ ^"^^^^^ A Ti . ^ ^ «isp acemeiit 4. The distance bilween tbe from „r ih. k „ . Dbula and the tuberele ot the tibia Itl , ?" show whether the head of the fih l "' right p„.ti„. „„ the oufer tSty oTTSi" .tniteirthfit.: rre$- tie^o' '^^ t..opaUe.t,a.e -tlltnt;t^^^^^^ 198 SURGICAL DIAGNOSIS [chap. diagnosis. Gliildren are very liable to transverse fracture of the shaft of the femur, as well as to separation of epiphyses ; greenstick fracture is much rarer in the lower limb than in the upper. Elderly women are liable to fracture of the neck of the femur from shght indirect violence. Dislocation of the hip is caused by violent abduction of the joint, and occurs more often in men than in women. Diastasis results from indirect violence, often combined with rotation ; oblique and spiral fractures are the result of indirect violence with twisting. Efforts to save from fallmg are liable to cause transverse fracture of the patella. Pott's fracture results from eversion of the foot, as in slipping from the kerb on to the inner edge of the sole. Dislocations of the knee and the various displacements and fractures about the ankle are caused by severe violence, such as falls from a height. Injury of a semilunar cartilage is caused by twisting the knee when it is partly flexed and the foot is fixed. Examination ot the hip.— Notice first the position of the limb, whether everted or inverted, flexed or extended. Fracture of the upper end and shaft of the femur always causes eversion, the com- mon dislocation causes marked mversion ; in fracture the thigh is extended, in dislocation it is more often flexed. Next, place the hands flat upon the outer side of the hips and feel for the trochanters, noticing whether these prominences are symmetrical, especi- ally whether on the injured side the trochanter is raised nearer to the iliac crest or not, whether it is more, or less, prominent than on the somid side, farther forward or farther back, and whether its outline is altered and the bone tender. The relation of the great trochanter to the pelvis is of the utmost im- portance in the diagnosis of dislocations of the hip XVI] ■ EXAMINATION OP HIP 199 and fractures of the neck of the femur; it should be determined accurately by one of the following methods : Nelaton's line.— Draw a line from the anterior supe- rior ibac spme over the outer side of the hip to the prommence of the ischial tuberosity. The top of the great trochanter should just touch this line in every position of the joint. By this line we can determine whether the trochanter is above or below Its normal position. The length of the Une in front of the trochanter gives roughly the horizontal position of the bone. Bryant's line. -With the patient lying flat on tiis back, draw a hne vertically down to the bed trom the anterior superior iliac spine, then draw a second line from the top of the great trochanter to jom the first hne at right angles; the length of this second hne marks the vertical distance of the top of the great trochanter below the front of the Iliac crest. This measurement • gives us the same information as Nelaton's line, gut it is obtained w hon ?nl 'i^^^^^^^^t °f the patient, and therefore without infiictmg any pam or damage. If a third hne is drawn from the front of the ibac cres to the trochanter, it forms a triangle and the length of this third line gives roughly the hori zontal position of the trochanter Morris's bitrochanteric test.-By means of a gradu ated rod along which move two pointers, the dis^ tance of the outer border of the trochanter from the mid-lme 0 the body can be accurately measTired d-minired.'''^^^*^^^^ this^distance^t of ll'\Zoftr'''' 'V'^^ --stance or tiie M oj the femur, and if the groin is vpw J.ollow, allowing the fingers to sink in^o.va,! ti^ 200 SURGICAL DIAGNOSIS [chap. acetabulum, feel for the globular head in the buttock. It IS useful to remember that in an unbroken femur the inner surface of its inner condyle always looks m the same direction as its head, and this fact enables us to tell in which direction the bone has slipped m cases of dislocation of the hip. Next, test the movement at the hip ; it is best to get an assistant gently to flex the joint, and to rotate it in and out while the surgeon keeps his hand flat over the trochanter. Rigidity of the joint will be ai^preciated, and crepitus may be felt. It is sometimes noticed that the trochanter roUs round m a smaller circle on the injured side ; if the fracture be impacted the head of