CHAPTER XIIL. (Part 6)

(Annals of Surgery, January, 1908). Unless the condition of the patient forbids, he proceeds gently to break up the impaction under anesthesia. The limb is reduced by extension and gradual abduction to an angle of forty-five degrees, in the mean- time supporting the upper end of the femur and rotating the leginward, In this position, the limb is well covered with cotton batting, all the bony boints especially well protected and a flannel bandage smoothly applied, A plaster spica is now applied extending from the lower ribs {o, and including, the foot. The plaster fits the pelvis snugly and is molded close to the trochanter and posterior aspect of the joint. It is also molded to the patella and condyles, and to the foot to prevent rotation. ‘This dressing permits the patient to rise up in bed without much discomfort. Walker concludes from his experience that fracture of the neck of the femur occurs under fifty years more fre~ quently than formerly believed; any injury of the hip followed by dis- ability should suggest fracture and calls for expert examination, aided by the X-ray wherever possible; that reduction of deformity and immobilization by plaster bandage in all suitable cases should be practised; that early gymnastic exercise is advisable; and that the weight should not be borne for three or four months. Whitman states that reduction under anesthesia by rotation and traction of the fragments, followed by fixation in abduction with a long spica plaster bandage, produces the best results. ‘The advantage of abduction {is that it makes the capsule tense and thus aligns the displaced fragments; that it directs the surface of the ‘outer fragment toward that of the inner; that it relaxes the muscles that produce distortion by their traction; that it opposes the trochanter to the side of the pelvis and thus checks upward displacement. Repair in these fractures is slow and can hardly be completed within a year; thus prolonged after-treatment is necessary to restoration of function (J. A. M. A., Feb. 20, 1909). (a) Fracture of the Shaft af the Femur—tn this fracture the lower 228 TRACTURES. fragment is nearly always displaced forward and upward. If the fracture hus been produced by direct force, it may be transverse, but this is the exception. ‘The diagnosis is simple: shortening, eversion, toss of function. Manipulation is unnecessary and decidedly to be avoided, not only that the patient may be spared the pain, but also that the trauma may not be aggravated, the periosteum torn, the muscles bruised, the vessels injured. Reduction —This must not be begun till all the dressings are quite ready. Lay the patient on the floor or on a hard mattress without pillows. One assistant grasps the thigh with both hands ncar the pelyis; the other assistant, the foot and lower third of the leg. As they make traction and countertraction the surgeon manipulates the fragments. The traction must be prolonged as these strong muscles relax only gradually. When the fracture is quite oblique and the pointed extremities are caught in the soft parts, a little patience will be required to free the fragments, ‘To effect this, slight rotation and oscillation must be added to extension and abduction. How will one know that reduction is complete? (1) These points must exactly correspond when. the two limbs are placed side by side: the upper border of the two patelle, the lower border of the two internal malleoli, the two soles, {2) The limbs must be the same length by measurement from the anterior superior iliac spine to the inner malleolus. (3) The line dropped from the iliac spine to the malleolus must touch the inner border of the patella. Dressing.—Many forms of splints are described; many of them complex; all effective in some degree, Whatever the form employed, the limb must be frequently measured and the patient’s general con- dition kept under close watch, Scudder highly recommends a moxliiied Buck's extension (Treatment of Fractures, page 300, «t seq.). Many are more successful with the plaster cast. Lejars recommends, as the simplest in emergency practice, the dressing of Tillaux. From a roll of adhesive plaster are cut eight or nine strips one and one-half inches wide, and long enough to extend TILLAUX’S DRESSING FOR FRACTURE OF THE FEMUR. 229 from the level of fracture down the side of the limb, over the sole of the foot after the manner of a stirrup, and up the opposite side of the leg to the level of the fracture. Begin by applying one of the strips in the direction indicated. Next slip a strip transversely under the thigh, another under the calf, anda third under the ankle, and make one circular turn of each. Next apply a second longitudinal strip slightly overlapping the first; fol- low with another turn of cach circular strip, and so on. In this manner the strips are given a firm attachment. Every point of contact of the adhesive must be perfectly smooth. Every longitudinal strip must extend the same distance as its fellows below the sole in order that the extension weight shall make uniform traction on all the components of the stirrup. A cord is fastened to the stirrup, passed through a pulley at the foot of the bed and a weight of five to ten pounds attached, If a pulley is not obtainable, a hole can be cut in the foot of the bed if it is wooden; or the cord may work over a broom handle attached to an fron bedstead. The weight must be Increased in the case of the muscular or in the case of a very oblique fracture. A case will illustrate the difficulties which may attend reduction in these cases of fracture of middle of the shaft. A young man caught and crushed under a falling load of telegraph poles was brought to the City Hospital in full shock. It scarcely seemed possible for him to survive. It seemed certain that he must have had grave internal injuries though there was no direct_evidence to that effect, The shock gradually subsided and no further evidence of visceral complication arising, attention was directed to his fractured femur, which was broken about the middle, Efforts at reduction were painless but wholly ineffectual in securing a coaptation. Continuous extension was ap- plied but after two days an X-ray examination showed the fragments still separated and overlapping. Later an open operation found the broken ends interlocked with muscular tissue. With some effort they were freed, coapted and wired. Some suppuration delayed repair, but he finally recovered with a good limb. (3) Supracendylar fractures derive their importance from the fre= 230 FRACTURES. quency with which the fragments involve the knee joint or the struc- tures in the popliteal space, and from the difficulty of maintaining coaptation. Both these characteristics depend upon the obliquity PIG, 158 —Sepamation of epipchysi epipliyas of the J Lowey west of Secaser: betow be shew the io (ts torsaad relation. of the fracture which usually extends from bebind downward and forward. “The complications must be treated on general principles, ‘The fixation may be any of the means just described for fractures of the shaft. Tn this case as in any very oblique fracture, flexion of knee and hip seem specially indicated. FRACTURE OF THE PATELLA. 231 Hennequin's apparatus, which Lejars describes, secures an cffi- cient extension, combined with flexion of the hip and knee and permits the patient to sit up. Downey, of Gainesville, Ga,, has thought out a device which involves the eame principles as the Hennequin apparatus but is simpler in application. As Downey remarks (Jour. Am, Med. Assn., Aug. 25, 1906) the dressing aims to secure at once the position of the Esmarch, Smith, Hodgen, or Cabot apparatus; the extension of the Buck wpparatus; the fixation of plaster of Paris, This is accomplished by means of a double angular plaster-of-Paris splint. ‘The mode of application (briefly) is this: Secure countertraction by a padded sheet passed between the legs and brought well up against the perineum; traction, by grasping the leg above the ankle with one hand, under the knee with the other, A plaster cast is applied from the toes to just above the knee, which is well flexed. Now secure coaptation. Next apply the second section of the cast, beginning at the upper border of the first and carrying the roller in the ordinary manner up to the ensiform, all the while maintaining the traction with hip well flexed. Strengthen the outer side of the cast at the hip-joint by upand down folds of the roller or by metal splints. Split the splint if con- striction is feared. FRACTURE OF THE PATELLA, Fractures of the patella are comparable with those of the olecranon, They may be transverse, such are usually fractures resulting from indirect force; or they may be vertical, or oblique, or multiple (Figs 159, 060, 161). ‘There are two obstacles to osseous reunion: the action of the quadriceps extensor and the intervention of the patellar fascias, pre- venting exact couptation. In spite of these unfavorable circumstances, there is generally some form of fibrous reunion unless the fragments are very widely separated (Fig. 162). ‘The treatment of the present time is by one of two methods—mas- sage or suture, If the fracture is transverse, with very little separa- tion, and the conditions are not favorable for an aseptic operation, 232 FRACTURES. massage may be expected to give a good functional result, If the separation is considerable, massage will still give a better result than any splints, In any case suturing is the ideal form, although the ideal cannot always be attained. Again, every compound fracture should be im- mediately sutured. J. H. Ford, whose experience with these frac- tures has been large, describes his method. of procedure in ordinary fracture (Ind. Medical Jour., July, 1907) In the non-operative cases he begins by elevating the limb for several days to relax the quadriceps, If there is effusion he bandages lightly FRACTURE OF Titi PATELLA. 233 with a flannel roller, or if the hemarthrosis is marked, a firm con- striction is practised or ice-bags applied. Pee. 160. ‘Transverse fone Fro, (61--Comminyted frse. ture of paxella, (AFowtiOn) tire of pabelis, (Mow) As soon as the acute symptoms have subsided, which is after three to five days, massage is instituted and daily applied, Begin with gentle constriction of the joint with the hands by an upward movement, and ending with more vigorous pres- sure of the sides of the patella and the joint, In the intervals the limb should be maintained on a posterior splint. After from four to six weeks ‘of treatment, he immobilizes the joint in a plaster cast, preferably for two weeks more, and subsequently he recommends a morning and evening massage and flannel bandaging until the functions are practically restored. The operative treatment is by no meanssimple, yet hy no means beyond the skill of anyone who knows how to secure asepsis and to apply a bone suture. Begin with a semilunar inci- sion, concave upward, well below the 4 line of fracture and reaching to either ya 62,—Practure of the p: border of the patella. Ralse the cuta- Syn eise'wrroviat ma Ute neous flap and expose the patella. ‘The articulation is carefully wiped out and freed of all fragments and clots. é 234 FRACTURES. Fixing the upper fragment between the finger and thumb, two slight incisions are made in the periosteum at the points where the drill * is expected to enter, ‘Two tunnels are now drilled from above, emerg~ ing on the face of the fracture well outside the line of the cartilage. ‘The sutures are drawn through these openings and the process is re~ peated in the lower fragment, bat great care must be used in securing Pra, n63.—theiure of yatta] Methoxt of ceitiag ant puulog wutuame, (Laken) a correspondence with the first two drill holes or the coaptation will be imperiect (Pig. 163). By traction on the sutures the fragments are brought together, and great care is necessary to avoid including eureds of fascia. ‘The sutures are tied, twisted firmly, and pressed down upon the bone. ‘The periosteum and fibrous coverings are next sutured with catgut (Pig. 164). feel sats SUTURE OF THE PATELLA, 235 Ford prefers not to wire, but, after approximation, sutures the lateral fascia with No. 3 forty-day chromicized catgut and the aponeurosis in front with No. a. A No. r forty-day suture, 18 inches long, is then threaded on a strong, half-curved needle which ig entered into the aponeurosis just above and on a tine with the outer edge of the patella and follows the upper border of the patella to the inner side where it emerges; is re-entered and carried down the inner side; again around the lower fragment, passing through the ligamentum patella Fo, 264 —Suture of patella, Completing repair by enture of pesomeurn ‘and tous evverings (Lote) and emerging at its outer border. This retention suture is now tled tightly at this last point of emergence (Fig. 165). The skin wound is next repaired without drainage. The limb is subsequently immobil- ized for two weeks when massage is to be begun. Ford lays down these rules respecting the treatment of simple transverse fracture: (2) Operative treatment should never be undertaken except under the best conditions for maintaining ascpsis, 236 FRACTURES, E. (2) Even under aseptic conditions not every case should be operated ‘on, but only those in which the separation is at Jeast one-balf iach and the “reserve extension apparatus" is compromised by lateral tears. (3) Operative treatment fulfills all the indications in a degree which the non-operative treatment can only partially achieve. Fie r6p—Pencture of gutella. Cirovlar swture, (Lathe) (4) Early massage favors complete restoration of function and shoald be used in all cases, (5) In operative treatment open arthrotomy should be practised. (6) Absorbable suture material applied only to the soft parts is sufficient in nearly every case. FRACTURES OF THE LEG. Fractures of the leg present many variations, but the prognosis and the difficulties of treatment depend chiefly upon whether the fracture is transverse or oblique, If transverse there is usually slight displacement, easily reduced and easily maintained; if oblique there may be much displacement which is dificult to reduce and held, and often results in much loss of function. FRACTURE OF THE LEG. 237 ‘Transverse fractures more commonly are due to direct force and the lesion corresponds to the application of force. Oblique fractures ‘are more commonly due to indirect force and the two bones give way at their point of least resistance, which in the case of the tibia is at the junction of the middle and lower third; in the case of the fibula in the upper third. In general, displacement is always favored if both bones are fractured. The diagnosis of these injuries usually offers but little difficulty, The deformity, loss of function, pain and crepitus, and préternatural mobility leave but little doubt except when the injury is at the upper end, and where the joint may be involved, or when Poe. 166,--Cloth cat to ft the timband gored at the ankle in order te be more easily adjusted to the malieolt when it ts soaked with plaster, (L¢jars.) the fibula alone is fractured. A useful test for fracture of the fibula is compression of the two bones some distance from the suspected site; the pain occurs not at the point of pressure but at the point of fracture. Reduction.—The assistant grasps the leg at the knee, the surgeon the foot, selzing the foot with one hand and the heel with the other; or two assistants may make the necessary traction while the surgeon manipu- lates the fragments. What is the test of good coaptation? ‘The crest of the tibia forms a continuous line without projections or depressions. This line pro- 238 FRACTURES. longed strikes the first metacarpal space. The internal surface of the tibia Is smooth and uniform. With the foot at a right angle, a line dropped from the anterior superior iliac spine to the inner border of the great toe touches the inner border of the patella. Dressing.—This will vary somewhat, depending upon the situation and tendency to displacement, In the simple case of fracture of the ed with see plaster tusdage, Note manner Pio. 16.—Plaster eptint appiied am aad apelyiog roller. (Eefured ef suapeportioge Leet’ shaft of the tibia, following the counsel of Stimson (Fractures and Dis- location, page 38x ef seg.), it is best to put the patient to bed with the limb in a Volkmann splint for about a week until the swelling has sub- , and then fo encase it in plaster of Paris. Immediate applica- plaster of Paris is objectionable because it cannot be deter- mined from the first whether the swelling will increase or diminish, ‘The two dressings may be combined by applying a plaster splint from the first. PLASTER SPLINT FOR THE LEO. 239 Lejars describes the construction of such a splint, He measures from the middle of the thigh down to the heel and up the sole to the toes, and this will be the length of the sixteen layers of crinoline from whieh the splint is to be made, ‘Take the circumference of the thigh, the knee, the middle of the leg, the ankle, and transfer the measures to the crinoline which was cut wide enough in the first place to encircle the thigh. Connect the ends of these cross measurements with a chalk line and in this manner one forms a rough outline of the limb, and the bandage is cut accordingly. ‘Some prefer to apply the material to the sound limb and mark it off im that way. Opposite the anklea notch should be cut in the dressing, running toward the heel, that the dressing may be more readily fitted (Fig. 166), This is soaked with liquid plaster and applied while the ex- tension and counterextension are maintained and the foot fixed at