all difficult as a whole, for no eye can see the injury wrought to the softer tissucs. In many cases the position will indicate at once that there iss fracture, but one must endeavor to learn: much more—the possible associated injuries to joints, muscles, blood vessels, and nerves. <Callout type="important" title="Important">To be able to do this necessitates a fairly accurate knowledge of anatomy to begin with, aided by systematic examinations, and on this foundation skill grows with experience.</Callout>
lll; DIAGNOSIS OF FRACTURES. 189 ‘The diagnosis of fracture in the bones of the extremities is based ‘on several factors: (a) history of the case, (b) deformity, (c) abnormal mobility, (d) pain and loss of function, (e) crepitus, (f) X-ray examination. {s) [1 is essential to know how the accident occurred. Frequently in the absence of definite symptoms, the diagnosis must rest upon that. For example, in a case of a hip-joint injury in an elderly person pre- senting loss of function and some pain but no other symptoms, a diag- nosis of impacted fracture should be made if it is learned the patient fell striking the hip. (b) Deformity includes changes in the relations or dimensions of the bones and the appearance of the limb. The two limbs must al ways he compared. Tt must be determined that there hax been no previous injury to cause the deformity, When both ends of a bone are accessible to touch, it may be readily measured and compared with its opposite. In the case of the humerus, it is necessary to measure from the acromion; in the case of the femur, from the ilium. The position which the fragments assume may be due to the direction of the force or the action of the muscles. (c) Preternatural mobility implies moyernent in unnatural situations ‘oF in unnatural degree or direction. As one of the cardial signs of fracture, it has hitherto been assigned too much importance. Its presence indicates fracture, but its absence indicates nothing. We all know that in impacted fracture, there is no abnormal mobility, Tn fractures of the bones of the tarsus and carpus, inepiphyscal fracture, in any fracture where the fragments are small or deeply placed, it may be impossible to discover movement without a manipulation which may be distinctly injurious. Tn the case of fractures near joints, it may be impossible to determine whether the movement is in the joint or near it. The fact is that in most cases where abnormal mobility is present, the fracture may be readily diagnosed without reference to this sign, (4) Grepitus is the almost constant accompaniment of abnormal mobility and is the grating produced by the friction of the two fragments It is pathognomonic, but must not be sought for too vigorously, It is absent in impacted fracture, and to break up an impacted fracture, 190 FRACTURES. testing for crepitus, may be a calamity, Crepitus may sometimes be + heard with the phonendoscope and not with the ear. (¢) Pain and loss of function go together since the pain is usually the cause of the loss of function. Both are present in nearly all frac tures, but often occur in as great degree with contusions, ‘The amount of pain varies with the location, but is nearly always aguravated by movements or pressure. ‘Taken in connection with the hiitory of the case, it is a valuable diagnostic aid. The presence af pain may call for anesthesia before the diagnosis can be completed, Stimson has recently emphasized the significance of pain in the diag- nosis of fracture, and indicated the manner in which it may be inter- preted, Crepitus and abnormal mobility are, to his mind, of lexs im portance than pain asa Wagnostic aid (J. A.M. A,, March 27, r909). The search for pain in all doubtful cases should be systematic. Begin first with local pressure over the suspected area with the tip of the finger or with the rubber end of a lead-pencil. ‘There are definite lines of tenderness to be discovered in many of the fractures about joints. For example; in Colles’ fracture this line can be plainly tract across the radius just above the wrist; im fracture of the external conidyle of the humerus, along the external coadylar ridge just above the elbow; end in fracture of the surgical neck of the humerus, along the front or outer side of the bone, Next test the character of pain elicited by cautious movement of the limb. Increased muscular tension thus produced awakens Increased pain at the site of the fracture, and the patient may be able to indicate the exact location af the lesion, ‘The effort on the part of the patient to produce certain movements is helpful Finally, indirect pressure may be employed; thus, in’ transverse fracture of the tibia, pressure upward on the foot exaggerates the pain markedly, and in the same manner, pressure upward at the elbow, may assist in locating the fracture in the shaft of the humerus. Sumson notes the important exception, that in the case of fracture of the neck of the femur forcible pressure upward often fails to cause pain, In the case of fracture of one of the bones of the forearm or leg, squeczing the two bomes together will generally help the patient to locate his trouble.
PRINCIPLES OF TREATMENT OF FRACTURES. 191 (8) The X-ray cannot be ordinarily available in general practice, although of the greatest assistance in cases of doubt. Without its use many fractures in the region of joints will be diagnosed as something ¢lse, Bloodgood particularly emphasizes its value (Progressive Medicine, Dee., 1906), believing that the doctor who neglects the aid of the Rontgen picture, when he is able to obtain it, will have much to regret. There is no danger that its employment will bluat the di nostic sense, unless, as is often done in hospitals, it is used to the ex- clusion of other aids, The X-ray has at least modified our notions 26 to what constitutes a perfect result in the treatment of a fracture. Wherever the X-ray picture is used to back up a claim of malpractice by reason of inaccurate apposition of fractured bone, we must insist that restoration of form and function constitutes a perfect result surgically, whatever discrepancies the Rintgen picture may reveal.
THE TREATMENT implies a reposition and an immobilization that the bones may unite in their normal relations. It has that objective, but has also snother which is not necessarily a concomitant of the first. ‘The bones must unite without deformity but there also must be res- doration of the limb’s functions. Union in good position, then, is only one of the means to a larger end. It is better to say that the treat- ment includes reduction, immobilization, and mobilization Tn making reduction, violence must be avoided. Gentle but per- sistent effort is always better than rude haste in overcoming the re- sistance of muscles and ligaments, which is usually the chief obstacle to reposition. The line of traction must be adapted to the muscular action. Traction must usually be accompanied by countertraction and local manipulation of the broken ends. Tn making traction it should be made directly, if possible, on 1 the Done involved, without the intervention of a joint. For example, in reducing the humerus the traction should be applied above the elbow joint. Often an anesthesia is necessary to relax the muscles, and if Bnesthesin was necessary to complete the diagnosis, everything should have been prepared previously for the treatment so that only a single anesthesia is necessary for diagnosis, reduction ng In the cases of suspected fracture in the vicinity of a joint, it is not always best to hurry the reduction; often it is better to wait a day ui res or so and try to reduce the swelling, for the swelling : difficulties which are always great in the differential diagnosis the joint; and, if flexion is required, as in the case of certain about the elbow, the pressure may shut off the circulation. ‘So far as the shaft of the long bones are concerned, however, formula should be immediate reduction and fixation, That the Y tion has been complete is attested by the appearances of the limb, by absence of any irregularities to the touch, and by the coincidence measurements with those of the sound limb, These comparative Measurements should be a matter of routine practice. Warbasse says (J. A.M. A., March 13, 1999), “the sooner a fracture — is reduced and held immovable, the less will be the swelling and the more satisfactory the result. ‘This is doubtless true in most cases, yet it is too to remember) that in spite of reduction of the bones, lncerated muscles and ruptured vessels may continue for some time, in some cases, to pour their exudate into the tissues to augment the swelling. his idea, however, pertains more to the mode of dressing and does not refute the doctrine of immediate reduction.
Immobilization & a phase of treatment raising many questions in dispute. In what manner shall it be applied and for how long? Or, as Championniere insists, may it not in many cases be dispensed with entirely? For he believes that absolute fixation of the fragments is not the condition most favorable to the processes of repair, A certain amount of movement is necessary to the vitality of the bone, and therefore movements and massage represent the cbief clements of — his treatment. That it is the best treatment for fractures about joints no one will deny, even though unwilling to dispense with fixation In other fractures of the ong bones, be As to the manner In which fixation fs to be attained, let it te said briefly that the simplest effective dressing is the best. Its elaborateness | ro | | USE OF SrEinTs, £93 will depend upon the tendency for the displacement to recur, and this tendency must be measured by the degree of obliquity of the fracture and the action of the muscles. Sometimes the tendency to recurrence is an indication of imperfect coaptation. In one case, then, only a fight retaining splint is necessary and in another it must indeed be firm and strong. At the present time there can be no question but that plaster of Paris is the dressing of choice. At any rate, it will render the best service to the general practitioner who must rely on his own resourees in fash- foning splints. Ready-made splints are an abomination. There are other plastic materials that are often useful, and in lieu of all these materials the splint may be cut into forms to suit the cave from boards, ete., and applied well padded. (See page 45.) Walsham formulates the principles which must regulate the use of splints in any case. 1. The splints must be well padded. 2. Pressure must not be made over the points of bones. §- Strapping or bandages must not be put on too tightly 4 Circular constriction of the limb must be avoided. §. The splints, if possible, should reach beyond the joint above and below the fracture. 6. The patient should be seen within twenty-four hours after the splint is applied for the bandage may become too tight. 7 The splints should not be ni If the patient is comfortable and the limb in good condition 8. Spasm of the muscles is to be overcome hy steady extension 9. The part below the fracture should be bandaged, or at least raised, to prevent swelling and edema ‘The first immobilization will continue till there is no tendency to spontancous recurrence of the displacement, which will vary in differ ent cases. After this time a dressing must be us changed, and daily massage must be instituted. Complete and con tinuous fixation through a long period most especially whene i Rossi bus shown (Wiener Medical Presse, Jan., 902) that the amount of new cartilage formation is proportional 10 the amount of 8 dlessly disturbed—that is to say, 1 which is sily listinetly bad practice and + a joint is involv 194 ‘movement permitted and is found in the greatest amount in treated by massage, and & explained by the greater formation blood vessels and the consequent more active circulation and | tion of effusion, First aid to those disabled with fractured limbs is in civil more frequently given by others than the doctor, It is desirable, } ever, whenever possible, that he should direct the transportation and the preliminary treatment. ‘The utmost care must be practised in lifting and handling the broken — limb, lest the injuries be augmented and a simple fracture converted into # compound. If fracture is merely suspected, it must be assumed to be present. ‘The limb must never be lifted by the foot or hand but must be lifted 5.9 whole, resting upon the palms of the hand. ‘Two attendants are always better than one in handling a broken leg. If the deformity is quite obvious even to the unpractised, an effort should be made toward reduction before applying temporary splints, this with a view to preventing further injury to the soft parts. ‘The limb is seized by an attendant at each end and gentle and steady traction made in the direction of its axis. If this does not succeed, the attendants must not persist in the effort. It must be Jeft for the surgeon. If the fracture is compound, with severe hemorrhage, the clothing must be removed, Otherwise this is not necessary, In removing the trousers or a coat, for example, the sound limb & uncovered first and then, very gently, the injured one. It is better to cut the clothing or rip along a seam. A splint is next improvised {rom whatever may be first at hand, a thin beard, laths, an umbrella, or the branch of a tree. ‘The splint padded, of the limb wrapped with whatever presents itself, a Manket or anything to prevent undue pressure, and then is fastened on the limb by a cord, or belt, or suspenders, etc., and finally the injured leg is bound to the sound leg, the injured arm to the side of the chest of carried in a sling. ‘The limb thus temporarily immobilized, the patient & ready to be moved, yo lita OF THE SHAFT OF THE HUMERUS. 195 patient with the greatest safety in the case of a broken leg, ¢, one attendant standing on the sound side, places his arms ody of the patient, who in the meantime locks his arms nt’s ncck, A second attendant, standing on the es one hand under the body, one under the sound limb, attendant, facing the others, supports the broken limb, of command, all lift. This carefulness must not be tis available, or one canbe improvised, it is placed parallel pationt, its fect at his head, so that without any inconvenience tient may be laid upon it.
ny FRACTURES OF THE HUMERUS. Certain points of anatomy apply to nearly all fractures of the arm, and are useful in diagnosis and reduction. Recall the relations of the humeral head to the acromial and coracoid processes; the great | tuberosity; the internal and external condyles; the attachments of muscles, particularly the deltoid, biceps, and triceps; the relations of the musculo-spiral nerve. Remember that in the normal ons & line dropped from the tip of the actomion to the external condyle will touch the greater tuberosity. ‘The symptoms and treat- ¥ary somewhat with the part of the humerus involved. _ Practure of the Shaft of the Humerus.—Above the attachment of the ‘ | there is not likely to be much deformity; below, the deformity | depend upon the degree of obliquity. Usually the displacement ‘Dol great. Pressure upward at the elbow will elicit pain. —Seat the patient; the assistant standing on a chair the shoulder with a towel passed under the axilla. Now flex the at a right angle, holding it with onc hand and the arm just the elbow with the other, Make traction on the arm in the ‘of the axis, gently rotating to disengage the fragments. It @ good indication, if there is much grating, that none of the soft are . eduction is complete when the acromion, tuberosity, and external fare in the same Jine and the injured arm the game length as the rs, 124 —Trating the hemere or shortening ‘external condyle Meesirang from the Sewn thee HENNEQUIN’S DRESSING. 197 If slight rotation is particularly painful, think of ‘the musculo-spiral. If such a diagnosis is made, it will operite. A general anesthesia may be necessary to It wil! not alter the principle of procedure. The mmends the appli- equin. It is equally some of the other 0 the humerus, and is em- this manner (Fig. 123): is seated; bandage member from the wrist it three inches above the east ‘the axilla with ab- cotton; flex the forearm at a. and maintain in that ; }in a sling. Pass a band under the axilla and fasten it to something (a hook in the wall), so ‘that the shoulder is slightly lifted. } the counter-extension. jer band erasses the forearm ee of Daf of humerin the bend of the elbow wethualel wcuneuestonston ani counter. sation till plagter is it is attuched a weight, say Sorted.” Chejare) 3 that is the extension. Give the Spparatus a little time and it will effect a reduction as the -mascles tire. Employ this interval to prepare the fixation dressing. ; ‘ut sixteen strips of crinoline, each about one yard Jong, and ‘though to cover
<Callout type="tip" title="Tip">Always ensure that the splint is well-padded to prevent pressure sores.</Callout> <Callout type="warning" title="Warning">Avoid using ready-made splints as they can be too rigid and cause additional injury.</Callout>
Key Takeaways
- Accurate history taking is crucial for diagnosing fractures.
- Pain and loss of function are key indicators, but must be interpreted carefully.
- Immediate immobilization is essential to reduce swelling and improve outcomes.
Practical Tips
- Always prioritize a thorough examination over quick assumptions when assessing injuries.
- Use local anesthesia if necessary before attempting to diagnose or treat fractures.
- Ensure that splints are well-padded to prevent pressure sores, but avoid overly rigid commercial splints.
Warnings & Risks
- Avoid applying excessive force during reduction as it can cause additional damage.
- Be cautious when handling compound fractures to prevent further injury.
- Do not assume a fracture is simple if the deformity is obvious; seek professional help.
Modern Application
While many of the techniques described in this chapter are still relevant for emergency response, modern medical practices have improved imaging and diagnostic tools. However, understanding basic anatomy and the principles of immobilization remain crucial skills for any survival situation where immediate medical care may not be available.
Frequently Asked Questions
Q: How can one determine if a fracture is impacted?
An impacted fracture occurs when the broken bone ends are driven into each other. According to the text, it should be suspected in elderly patients who have lost function and experienced pain after falling onto their hips.
Q: What are the key signs of a fracture that can be used for diagnosis?
The text highlights several key signs including deformity, abnormal mobility, pain and loss of function. However, it emphasizes that these signs must be interpreted carefully as some fractures may not show all symptoms.
Q: Why is immediate immobilization important in treating fractures?
Immediate immobilization helps to reduce swelling and improve the outcome of treatment. The text states that 'the sooner a fracture — is reduced and held immovable, the less will be the swelling and the more satisfactory the result.'
Q: What are some common mistakes to avoid when treating fractures?
The text warns against applying too much force during reduction as it can cause additional damage. It also advises against assuming a fracture is simple if the deformity is obvious and suggests seeking professional help in such cases.
Q: How should one handle a suspected compound fracture?
For compound fractures, the text recommends removing clothing carefully to avoid further injury. The limb must be handled gently, and immediate medical attention should be sought if possible.