CHAPTER XIIL. (Part 1)

CHAPTER XIIL. FRACTURES. Definitions—A fracture is a solution of the continuity of bone due to traumatism. A simple fracture has « single line of solution and there ix no lesion of the soft parts. A multiple fracture has more than one line of solution of continuity in the same bone or several bones. A comminuted fracture has so many lines of solution running into each other that the bone is in fragments or splinters. A complete fracture involves the whole thickness of the bone. It may be transverse, longitudinal, oblique, dentate or comminuted. In an incomplete fracture, the line of solution dots not involve the whole thickness or extent of the bone. It may be a fissure, “a greed stick,” a depression of a separation of an apophysis. A subcutameows fracture has no communication with the surface. An open or compound fracture has a communication with the surface, has an accompanying solution of continu'ty of the skin and the sab- jacent soft parts. A spontaneous fracture is produced by an insignificant traumatism and is usually pathological, due to disease of the hone. An ununited fracture is one in which bony union has not occurred at the usual time. Gunshot fractures are those produced by projectiles (see Gunshot Wounds). The symptoms, the diagnosis, the prognosis and treatment vary with the region involved, and with respect to these fuctors fractures may be divided as follows: Practures of the skull, Fractures of the face, Fractures of the spine, DIAGNOSIS OF FRACTURE AT THE BASE. 169 Fractures of the thorax. Fractures of the extremities, FRACTURES OF THE SKULL. Fractures of the skull are important practically only from the point ‘of view of their complications, which number three; infection, hemor- rhage, and injury to the brain. In 4 given case, one or all of these complications are possibilities, although for the development of each, certain combinations afcircum- stances are peculiarly favorable, With respect to these variations, fractures of the skull are of two classes: fracture of the base and fracture of the vault. Each has its special symptomatology and prognosis, though the one may merge into the other and the clinical picture be more or less blurred. Either may be fissured, fragmented, or compound, with or without depression. In either the immediate gravity depends upon the nature and exten! of the injury to the brain, and fractures of the base are the more Serious, merely because the more important areas of the brain are there. With regard to the remoter consequences also, fractures of the base are Jess favorable; hemorrhage and its resultant complications are more to be feared; and infection is a more certain eventuality owing to the communications opened up between the cranial cavity on the one side and the car, the nose, or the pharyngeal region on the other. ‘The symptoms in either kind of fracture are such as arise from con- cussion, compression, or laceration of the brain and are general or focal, that is to say, emanating from certain cerebral areas. PRACTURES OF THE DASE. Fractures of the base of the skull arc more frequently indirect, the force being transmitted through the spinal column from some part ‘of the vault or the ramus of the jaw; occasionally direct by a thrust through the mouth, a blow on the root of the nose, or upon the mastoid process. Any of alll of the fosse may be involved. Fracture through the mid- dle fossa is most frequent, and the most serious is fracture through the SS 170 ‘PRACTURES. 4 ~ posterior fossa, ‘These fractures are usually linear because the force &s indirect and because there [s only one determinable table instead ‘of two, as in the vault. ‘These fractures are nearly always compound, which adds to the gravity of the prognosis. The external meatus, the nasal cavities and the nasopharynx ure all prolific sources of meningeal infection, The diagnosis is usually by inference, often impossible, There are certain symptoms always suggestive of fracture at the base, but not to be relied upon exclusively. Exchymosis jn the tissues about the orbit, or hemorrhage into the sclerotic, appearing first some little time after the injury, and gradually progressive—fracture through the anterior fossa suggests itself. Per- sistent bleeding from the mose following bead injury must be given due consideration. Bleeding from the external meatus, copious and per- sistent, suggests fracture through the middle fossa. Late ecchymosis over the mastoid or into the tissues of the back of the neck suggests fracture through the posterior fossa. The discoloration follows the posterior auricular artery, However, these hemorrhages must not he mistaken for local rupture of mucous membrane or other soft parts and their absence does mot necessarily mean absence of fracture. ‘The bleeding, if intrascranial, may come from rupture of the middle meningeal, or the internal carotid, or the sinuses. Instead of the bleed- ing, or accompanying it, there may be escape of cerebro-spinal wid, Its presence is pathognomonic of fracture of the skull, and it mast be distinguished from ordinary serum and the fluid of the middle ear by these chanscteristics: the flow begins at once and continues for several hours; the quantity is considerable, sometimes « tablespoontul in fifteen to twenty minutes; the dow is temporarily increased by the increase of intra-cranial pressure, sneezing, coughing, and vomiting; alkaline in reaction; contains only a trace of albumin and is rich in sodium chloride. Useful In definite diagnasts are the paralyses of the cranial nerves; Recall their origin, course, and functions. ‘The facial, optic, and tri facial nerves are especially likely to be involved. For example, the optic nerve will be involved if there is a fisture of the optic canal, Vision my be lost totally and immediately; even though total at first, - FRACTURES OF THE VAULT. "yr the blindness may gradually pass away. Tt will be impossible for some time to say whether the recovery will be permanent, Added to these ‘nerve symptoms, but not particularly helpful in the diagnosis of fracture, may be those of concussion, compression, or laceration. All these conditions may exist with or without fracture, ‘The treatment has two ends in view, the prevention of further irri- tation of the brain and the prevention of infection, Keep the patient absolutely quiet in bed with the head elevated, ap- ply ice-bags, and keep the bowels open. Whenever fracture of the base is even merely suspected, carefully wipe out the external meatus and pack lightly with sterile gauze. Do not syringe the meatus or at least only very gently, lest infection be forced through the fissure. Remove the gauze as often as it becomes soaked with blood, which may be at frequent intervals for several days. Spray the nose and throat with peroxide of hydrogen or « similar mild antiseptic. These regions cannot be sterilized, but bacterial activity may be minimized. Do not pack the nares except for persistent nasal hemorrhage, a3 the packing irritates the mucosa and unduly stimulates secretion, and this is undesirable. Again, such packing may excite a sneeze which by its explosive effect may carry infection through the fissure to the ‘meninges. If packing is deemed necessary, pack with sterile gauze saturated with sterile vaseline, In the great majority of cases, active dntervention is quite out of the question either for the relief of infection or for hemorrhage. But this is true merely because the technic is not definitely worked out. The principle of drainage for infection and removal of compressing clots applies with as much force here as in fractures of the vault (sce craniectomy). YRACTURES OF THE VAULT. Fractures of the vault of the skull may be fissured, comminuted ‘oF compound, any one of which may be complicated by concussion, compression, confusion, or intra-cranial hemorrhage. The symptoms hhelong to the brain complications rather than to the fracture itself. ‘Simple, fissured fracture without depression is practically impossible - = — | 172 FRACTURES. of diagnosis. The diagnosis is casier if depression is present and yet certain injuries to the scalp simulate fracture with depression. A blow crushes the soft tissues and around the crushed area marked swelling ensues. ‘The sensation to the examining finger fs that of a depression of the bone. Do not be misted. Comminuted fracture of the skull even without depression is gener~ ally diagnosed, and yet a hematoma may mask the fragmentation, Be on your guard in thet matter. ‘The inner table is always more injured than the outer (Figs. 109, 110). ‘The prognosis is good and the treatment simple in fissured Put the patient to bed, keep the bowels open, limit the diet, and await developments, Un- interrupted recovery usually follows, yet the exceptions to this rule are not infrequent aed Wm nein kane Cite” One Must be on bis guard for intra-cranial hemorrhage. Or later, there may develop symptoms which are explainable only om the hypothesis of contusion of the brain. If at any time symptoms arise indicating the occurrence of hemor- rhage, say from a ruptured middle meningeal, immediate intervention is indicated. Some surgeons go so far as to recommend trephining for every fracture of the skull and exploratory operation In every suspected case, but that seems at the present time too radical, especially for the general practitioner beft to his own resource, If the fracture is comminuted or even only fissured, with depression, the chances are so great that there is an injury to the brain that even with no symptoms present, immediate operation is indicated. (See Urgent Craniectomy.) . COMPOUND FRACTURES OF THE VAULT. 173 COMPOUND FRACTURES OF TIE VAULT. Much more serious from every point of view are the compound fractures of whatever origin, The constant element of danger is in- fection. Add to this concussion, contusion, or laceration of the brain, and the outlook is grave indeed. The treatment is not so simple, but its purpose is quite definite, viz.: to prevent infection. ‘This is accomplished not by keeping the streptococel out of the wound—they are already in; not by destroying them with strong antiseptics, as these are too injurious to the brain tissues, but rather by removing the con= ditions favorable to bacterial growth, ‘To this end operation is im- perative. As in gunshot frac- tures, enlarge the wound, re- move extraneous matter, elevate depressed fragments, check the "' sresiercomaryticn and sepreson. hemorrhage and remove clots, Seat trim away devitalized tissues and provide drainage (see Cramiectomy). Careful attention to these details results in the starvation of the germs present, with the result that repair proceeds. Skill in diagnosis, prognosis, and treatment in fracture of the skull depends upon a clear understanding of the mode of causation and the symptoms of contusion, compression, and concussion of the brain, Although presenting quite a diverse clinical picture, separately con- ‘sidered, these three conditions are nevertheless of the same origin fundamentally. They are each merely a complex of symptoms express- ng, on the one hand, varying degrees of either functional depression or stimufation of the cortex of the brain or, on the other, of the deeper centers of the cerebrum and medulla. The cortex is the seat of cxmscfousness and at the same time the most sensitive part of the brain; 4 PRACTORES. therefore it Is the first to be affected by conditions disturbing the circus lation of the brain. ‘The deeper centers, those governing respiration and circulation, are not so readily affected, The result is that loss of consciousness is the first phenomenon following a gencral disturbance of traumatic origin, This trauma may not be sufficient to reach the cardiac and respiratory centers at first or at all; or it may only stimulate them; or finally it may paralyze them as well as the cortex. Tt must likewise be constantly remembered that stimulation of these basal centers means retardation of pulse and respiration; depression of the same centers means ac~ celeration of pulse and respiration, and acceleration is an indication of approaching failure. It is only by reference to these first principles that one may explain and reconcile the variations in the derangements of these functions of consciousness, circulation, and respiration in different cases, CONCUSSION. This is in all probability due to a molecular disturbance of the brain substance, and is accompanied by neither microscopic por macroscopic change. The disturbance may be (a) moderate, (b) severe, or (c) profound. (a) The disturbance is moderate. Under these circumstances, the trauma depresses the cortex, but does not reach the deeper centers of the brain and medulla, so there is therefore only a Seeting lass of consciousness without any change whatever in the palse and respiration, {b) The disturbance is severe. ‘The force depresses the cortex, but only serves to stimulate the deeper centers, and, as before, there is less of consciousness, but there is this tim slowing of pulse and breathing Very soon the normal rate returns and a little later consciousness is restored. (c) The disturbance is profound, ‘The cortex is paralysed and pro- foundly depressed as are also the deeper cesters. The result is loss of tonsciousness and this time rapid and weak pulse and shallow breath~ ing which may terminate very shortly in death, I doubthel cases, ii, CONCUSSION, 175 then, the heart is the chief clement in prognosis. The pulse imme- diately grows either worse or better. ‘Therefore the symptoms of concussion are distinctly fugacious. ‘This is its chief criterion. If the symptoms once improve and later recede, one may be sure the primary concussion is complicated by compression or contusion. Added to these phenomena of concussion, though not particularly helpful in diagnosis or prognosis, are certain other occasional symp- toms, referable to the reflexes, In the severe cases this will usually be the picture: At the moment of injury, unconsciousness occurs, immediate and complete. The patient is more than unconscious, he is anesthetized. ‘The face is pale and sunken and the whole body cool, The pulte is small, rapid, and irregular. The temperature is subnormal. The breathing is shallow and sometimes sighing. The urine and feces may be retained or pass involuntarily. Repeated vomiting is quite common, especially as consciousness hegins to return. Following the return of conscious- ness, a stage of excitement occurs, The symptoms of this stage are those of meningeal irritation, and in uncomplicated cases rapidly subside, ‘The treaiment is quite definite. Disturb the patient as little as possible in getting him into bed. Lower the head at first and try to maintain the body heat with woolen blankets and hot-water bottles. Carefully stimulate the heart. ‘To this end,’ apply a mustard draft ‘over the heart and inject ether hypodermically or a 10 per cent. solu tion of camphorated oil. Repeat these injections frequently, being guided by the pulse. Von Bergmann recommends inhalations of ether for the very weak and failing pulse. Do not forget ariificial respiration. In those severe cases where the respiration is dangerously low, it will sometimes tide the patient over the In the subsequent stage of congestion, keep the head elevated and fce-caps if the dressings will permit. Keep the bowels open. Wi the excitement and restlessness are pronounced, morphine hypoder+ mically is indicated (Von Bergmann). = oe 176 FRACTURES. COMPRESSION. Any condition, traumatic, inflammatory, or neoplastic, which dimin« ishes brain room, may induce symptoms of compression of the brain. The symptoms and their course will vary according to the manner in which the pressure is produced. What is said here applies particularly to the pressure symptoms origi- nating in depressed fracture or traumatic hemorrhage, though much would apply equally well to the pressure of brain abscess or brain tumors, or meningeal exudates and similar conditions, Pressure symptoms have fundamentally the same origin as concus- sion symptoms, that is to say, they are an expression of depression or of stimalation of the cortex and the automatic centers. In both there may be initial stimulation and terminal paralysis, However, this depression or stimulation is produced differently in the two conditions, concussion and compression, In the first case, the disturbance of function is brought about by mechanical injury and in the second by interference with the blood supply. Sudden diminution in the cireulation modifies the functional activity of the brain centers. ‘The cortex, the most sensitive, is first affected, followed by loss of consciousness. The automatic centers are next affected, at first stimulated, though each reacts differently; thus the respiratory center is the first to be stimulated and by the presence of carbon diaxide which was itx primal stimulus. The vaso-motor centers are next invaded, and finally the vagal and convulsive centers. Tn those cases where the circulation becomes gradually slower, the order in which these centers and areas are successively affected is as follows: the cortex, the corona radiata, the gray matter of the spinal cord, the pons, and finally the medulla. Now the symptoms origh nating in these various areas a8 a result of pressure are of two kinds: (a) General or indirect, (b) Foeal or direct. Each may manifest itself in two stages: (1) Stage of stimulation. (2) Stage of depression or paralysis. BLEEDING PROM THE MIDDLE MENINGEAL. 7 It is the knowledge of these facts which enables us to harmonize and reconcile the diverse statements of various observers regarding the ‘character and cause of the symptoms of compression. It is in the hemorrhage arising from the middle meningeal artery that the emer- gency surgeon is chiefly interested. Traumatic compression suffi- ciently serious to require immediate operation in nine cases out of ten originates in: s BLEEDING FROM THE MIDDLE MENINGEAL ARTERY. ‘This may follow injury to the head with or without fracture. ‘The fracture may or may not be diagnosed. In a typical case the concussion symptoms which supervened im- mediately upon the injury disappear after a half-hour. ‘The patient Tegains consciousness, and the pulse and respiration approximate the normal. In the meantime, however, the blood from the torn meningeal is slowly oozing into the space between the dura and the skull, and the “free interval’ is interrupted by headache, irritability, perhaps delir- jum (stimulation of the