CHAPTER XIIL. (Part 7)

a right angle. ‘This tension must not be relaxed until the plaster has hardened. The dressing is com- pleted by applying a roller bandage (Fig. 167). Oblique fractures, which are hard to hold, are likely to be near the lower end, for the quadriceps extensor pulls the upper fragment the sole to allow for effective traction and buckles to which the upper extension is attached, (Sowsder.) forward, and the gastrocnemius pulls the lower fragment backward. ‘The special form of dressing which Scudder recommends for this form of fracture is made by a combination of plaster and adhesive strips, 240 FRACTURES. ‘The adhesive strips are applied as indicated (Fig. 168). A thick rod of sheet wadding is applied to the sole of the foot, and a plaster bandage applied from the toes to above the knee, A buckle looking upward is incorporated in the plaster just above the level of the knee. A slit is P49, 1¢9.—Prneture of the tubercle ur anterior tuberoty of the tibia; polat of insertion of the ligamentum gavel left in cach side at the ankle { the lower extension strips to come through, When the plaster has hardened, the upper extension strips are fastened in the buckles and the lower extension strips pulled out through the slits and drawn tight around the foot piece after the wad= PoTT'S FRACTURE. 24t ding at the sole has been removed, The purpose of this arrangement is to maintain extension. Whatever form of dressing is used the limb must be watehed to see that no displacement occurs. While a simple fracture usually F10. #79.—Pott's fracture, Practare of the fibula and of the foternal malleolus. firmly unites within six weeks, those which have been hard to keep reduced will remain weak much longer. As soon as there is sufficient union to prevent displacement, then massage should be begun and con- tinued till the limb’s functions are restored. 16 242 PRACTURES. Port's Fracture.—Fracture of the fibula with eversion and ab- duction has a character of itsown. As Stimson remarks, the diagnosis can usually be made at a glance (Fig. 172). Three paints of tenderness ON pressure are constant and characteristic: one in the groove between the shalt of tee fibvaia. Too igh fora Putte the tibia and external malleolus; another wt the base of the internal malleolus; the third over the outer aspect of the fibula marking the point of fracture. Marked ecchymosis appears beneath the external malleolus and sometimes beneath the internal (Figs. 170, 174). Port's FRACTURE. 243 Reduction, —Grasp the foot in one hand, the heel in the other, and while the leg is steadied by the assistant, draw the foot forward and inward. If this does not entirely succeed, the fragments may be pressed into place. With the foot at a right angle and the malleoli In their normal relations, the dressing is applied. his dressing, to quote Stimson further, is preferably a posterior and lateral plaster splint although the plaster cast may be used, ‘The plaster splint may be made from twelve to thirteen layers, cut from a four-inch plaster roller, The posterior splint should be long enough to extend from the toes along the sole and up the calf nearly to the knee (Fig. 173). The lateral one should begin just in front of the external malleolus, Fite tye sHett's teach, pass over the dorsum of the foot to the inner side, under the whole and up along the outer side of the leg to the same height as the posterior (Fig. 174), ‘They are snugly molded and bound to the limb while still wet, with a.roller bandage. In the meantime, till the plaster sets, the reduction must be main- tained. Dupuytren’s splint is often of great service in this fracture, especially a8 a temporary dressing. 11 consists of internal lateral splint, well padded over the ankle and which extends from above the knee and projects beyond the foot. It is held in place by a bandage at the knee and above the anklc, The foot is then put in abduction at right angles to the leg and secured to the splint by a third bandage (Fig. 175). FRACTURE OF THT SCAPULA. Fracture of the neck of the scapula might be mistaken for fracture or dislocation of the humerus (Fig. 176). ‘The head, however, can be | 244 FRACTURES. Fio, 173.—-Posterlor splint apotied Fin, 174—Lateral lint (Selnuson) applied (sKimeom) Pia. 175.—Dapuytren's splint. ‘Temporary dressing for'Pott's fracture. PRACTURE OF THE SCAPULA. 245 felt to rotate, which it would not do in dislocation, The deformity disappears on lifting the arm forcibly upward with the elbow flexed, which does not happen in a case of fracture of the humerus; the arm hangs vertically at the side and is mobile. There is no notching of the deltoid. In the case of fracture of the sur gical neck of the humerus with over- riding, the arm is shortened, In case of fracture of the scapular neck, the arm is lengthened. Generally speaking, the diagnosis of any fracture of the acapula is to be made from crepitus, abnormal y mobility, local tenderness, and more Pv. 116“ Pemeture sf the week of the ‘or Tess complete loss of certain i functions. Begin the examination by inspection and measurement. Note any lass of contour; any lengthening or shortening of arm. To elicit crepitus, apply one hand to the body of scapula and with the other make traction on the arm. In thin subjects the lower end of the seapula may be readily grasped. Treatment.—The flexed elbow should be well supported by a sling, and the arm fixed at the side. Massage will relieve the pain and hasten repair. Mayor's sling furnishes an excellent dressing. FRACTURE OF THE PELVIS. Fracture of the pelvis may be suspected from the character of the injury, which is usually a fall or a crush. The diagnosis is to be con- firmed by external palpation of the ilium, pubes, and ischium on each side, and by careful rectal and vaginal examination. Disturbance of normal relations, tenderness on pressure, crepitation perhaps, and difficulty in walking indicate fracture (Fig. 177). ‘The treatment in uncomplicated cases is quite simple, rest in bed and some kind of pelvic immobilization such as adhesive strapping, ag6 FRACTURES. represent the elements of relief. It is quite different if there are com- plications. If a catheter cannot be passed (and this should always be tried), it will be necessary to do am external urethrotomy for the ruptured urethra. If the catheter finds the bladder empty and ruptured, a lap- arotomy is imperative. If the exact complications cannot be deter- Puc. a77—Practure of thee pelvis throwgh the cbtwwator foramen aod disonathon at Ube mctoiliae goiete (Af umilin,) mined and yet shock, pain, and increasing abdominal tension, with signs of sepsis, point to a lesion of bladder or rectum, the abdomen must be opened, and the visceral injury found and repaired. Following a variety of traumatisms there is often a condition now well recognized as relaxation of the sacre-iliac synchendrosis which simulates fracture and which may become quite chronk. It is re- lieved by adhesive strapping. COMPOUND FRACTURES. Every compound fracture, whether the skin wound be large or amall, increases the danger over simple fractures, both with respect to function and evea life, = | TREATMENT OF COMPOUND FRACTURES. 247 The outcome, as has so often been said, depends largely on the first (reatwent. The indications are various and depend upon the amount of fragmentation, the degree of destruction of the soft parts and the injury to the blood vessels. It is necessary to divide these injuries into several clinical groups. (See Lejars, Chirurgie d’Urgence, p. 1017 ef seg.) x. Compound comminuted fracture with no injury to the vessels, with slight injury to the soft parts, and small skin wound is most commonly ‘seen in oblique fractures of the tibia (Fig. 178). The break in the skin skin is slight and yet it is actual and must be regarded as infected. Pro: t7&—Compoun fracture of tibia. {Monllin) Do not be satisfied with merely washing the skin or applying a simple occlusive dressing. This may be sufficient in the case of gun- shot wounds; the circumstances may permit of no further Weatment; and many cases will get well with nothing more, but that is significant of only one thing—that by good luck the wound was not infected. Whether the wound is or is not infected, one can never tell, He must ‘await the eventualities. Therefore, that chance may not enter in, one must exercise the same care as if he were certain the germs were there. A general anesthesia is usually not necessary. Begin by carefully ster- ilizing the surface about the wound. Scrub with soap and water, wash with ether and then with alcohol and finally with bichloride, Ealarge the wound sufficiently that it may be irrigated with hot sterile water or normal salt solution. Carefully clear out all débris with as little injury as possible to all the tissues concerned. When the 248 FRACTURES, =~ cleaning Js complete, if circumstances are favorable, the wound Is sutured and drainage employed. Occasionally, it may be closed completely without drainage. Sometimes it must be left wide open, packed with sterile gauze and bandaged. Adjustment and Immobilization —Reposition requires great care and jit must be exact, Unless the fragments are extremely difficult to hold in place, requiring wiring, the limb may be immobilized with a plaster splint, leaving an opening sufficient for the inspection of the wound. Gangrene is little to be feared unless, indeed, the bandages are care- Jessly applied, interfering with the circulation. Immobilization is the best method for relieving pain. Carry out a careful disinfection, a careful adjustment of the fragments, a careful immobilization in a good position, and one may confidently expect in such cases an excellent result, 2. Compound Prachere with muck Comminution and Great Destruction to the Soft Parts, Little Injury to the Blood Vessels.—A general anesthesia will be necessary. Prepare the field as before and flush out the wound cavity with hot sterilized water. ‘Trim away the fragments of fascia and musele, but in this do not be too radical. Such of these shreds as retain their blood supply can help Later to fill the wound, Especially do not remove with too free a hand the fragments of the bone. Only such fragments as are completely isolated and deprived of their peri- osjeam are to be extracted so that later they may not play the part of foreign bodies (Fig. 179). Lowery, of Carbondale, injects the cavities with a mixture of carbolic acid 95 per cent, and glycerine 5 per cent... following this with alcohol. A glass syringe is used, and the aim is to force the solutions into the deepest recesses of the wound (J. A.M. A., Oct. 31, 1909). ‘Phe second step consists of reposition and adjustment, often with difficulty accomplished and many times requiring wiring or suturing, The wound may be sutured, but must be drained. More important even than accurate coaptation in these cases is continuous extension; for that reason the fixation dressing must be given special attention, If no fever arises, leave the dressing undisturbed for eight to ten days. ‘The danger from infection is then passed and the immobilization and extension may be continued as long as necessary. TREATMENT OF COMPOUND FRACTURES, 249 3. Compound Frachire, Obviously Infected —You see the case per- haps some days after the injury. It has been neglected. Marked inflammation is present. You are confronted by the possibilities of phlegmon or tetanus. ‘These may develop with the greatest rapidity and continue uninterruptedly to death. How shall one act in the presence of these filthy or already infected or inflamed fractures? To amputale would have been in pre-antiseptic Fie. t7a—Compound fracture and dislocation at the wrirt, Hand saved, (Sendider.) days the proper procedure, but not to-day and especially not in the recent case. Enlarge the wound freely. Remove the coarsest dirt by irrigation and then patiently and perseveringly, wiping with sterile compresses while flushing, complete the toilet of the individual tissues, one at a time, The fragments of bone must be separated and the remotest nook of the wound sought out, that the cleansing may be complete, Do not spare time or patience. If the projecting fragment of bone is saturated with dirt, manifestly devitalized, resect it, not transversely, 250 FRACTURES. however, after the manner of an amputation, but following same type ‘of plastic operation which will diminish, as much as possible, the los af bone and consequent shortening of the limb, Finally the wound is flushed with peroxide of hydrogen and with sterile gauze saturated with the same solution. With the frag- ments coapted as much as may be by simple manccuvres, though one cannot hope to achieve much in this respect, the drainage is applied and must be ample, ‘The limb is put at rest, and with anxiety the out- come i awaited. The issue may be fortunate. General and local infection may be successfully combated and later the bone union may be secured. On the other hand, should general infection be imminent or gangrene ‘ensue or the limb be from the first manifestly destroyed, there is no choice but to amputate. COMPOUND FRACTURE ABOUT THE ANKLE AND FOOT. Fractures of this variety are frequent; always serious; and the prog- nosis more or less uncertain, depending upon the degree of infection and destruction of the soft parts. Suppose fracture of the inner mallcolus: the soft parts are widely separated, the joint cavity exposed, the astragalus dislocated. Such an injury must be 2s conservatively treated as an abdominal wound. Under no circumstances must the wound be explored with unclean fingers or without careful cleansing of the field, Only after all the preparations for definite treatment are made is the wound to be ex- amined. If transportation is necessary, a temporary splint is pro- vided, but at least do not cover the wound with a dirty handkerchief. If there is much hemorrhage, circular constriction of the leg about the knee will temporarily suffice. ‘The first dressing will determine the future of the limb, perhaps even the life or death of the wounded. The whole foot and the lower half of the leg are most carefully disinfected and the fracture and joint cavity irrigated with bot sterile water, exposing every nook and corper in order to Gush out foreign bodies, splinters of bone and clots of BI fe | TREATMENT OF COMPOUND FRACTURES. 251 In this case, merely chosen for example, the destruction of tissue is unusually light. After the cleansing, replace the parts, leave one or two drains in the partly sutured wound, bandage amply and place the limb at rest. ‘The situation is less simple where there is much destruction of tissue, as in the case where the ankle is crushed. Begin with hot irrigations. Do not fear to enlarge the wound freely. It is of great importance that one be able to determine definitely the conditions in the wound and to see what he is doing. You may find large fragments deformed and overlapping. Try to replace them and often you will be thus enabled to restore the con- tour of the joint, To retain these fragments, wiring or nailing the fragments, if in a position to carry it out, will be an almost indispen- sable aid, Another case: The epiphyses are reduced to fragments of various sizes and forms. In irrigating, they flow away with the solution, so Joosened are they. ‘The rest hang by a mere shred. Reposition is here useless. ‘The wreck is too great. You must proceed to do an atypical resection, Do your best to spare the malleoli of at least two processes which will serve to prevent lateral dislocation when the joint is healed. After this operation insert two drainage-tubes, one on either side ;and if there is considerable oozing, add un aseptic tamponade, The prognosis is worse if infection has developed and there is fever, redness, and swelling in the limb, Amputation will be the measure of last resort and yet do not amputate until free opening has again been tried. Irrigate with peroxide, The removal of dead bone, ete., is followed by deep drainage but this must be done without delay. It is nol union, or consolidation, or function of the limb which is the chief oacera. It is infection against which all the forces of antisepsis are marshalled. Osteomyelitis or myelitis is the contingency feared. In such a case, do not employ a typical amputation or resection, but an atypical one, removing only such tissues as must be removed, and later when the infection has disappeared, the necessary operations may be done.