CHAPTER XLV. (Part 3)

time. In the exceptional case in which the surgeon may be in doubt as to the best time for the resumption of function, an X-ray plate will afford the desired information concerning the con- dition and progress of callus formation. 656 FRACTURES AND DISLOCATIONS Fig. 720. — Old fracture of the tibia and fibula with discharging: sinus eight years later. The condition has been an intermittent source of trouble during the entire "eight years. This is a good example of a type of case requiring operation for the removal of necrotic bone. Fig. 721.- — Picture taken to show the swelling which so frequenth- persists follow- ing fractures of the bones of the leg especially with patients past middle life. Picture taken some months following the accident. The ring about the leg corresponds to the upper end of the elastic stocking. FRACTURES OF SHAFTS OF THE BONES OF LEG 657 Prognosis. — The prognosis in fractures of the leg is extremely variable and depends largely on the associated injuries to the soft tissues and "whether or not a compound fracture becomes infected. Persistent swelling is common and may last for years. It is de- pendent on the damage done to the circulation at the time of the injury and on the development of venous thrombosis following the accident. The more severe these conditions, the more pronounced and persistent will be the swelling when function is resumed. Pain in the leg may persist for months or even years following the acci- dent. Considerable disturbance in function usually follows vicious union of the fragments and is due to the mechanical strain imposed Fig. 722. Fig. 723. Fig. 724. Fig. 725. Figs. 722, 723, 724 and 725. — Show the mechanical disturbances which follow union with deformity. When the leg diverges from the weight-hearing line the leg will be mechanically "off" and as a result there will be more or less permanent disturbance in function. on both muscle and bone by this faulty position. The more per- fect the apposition of the fragments and the less the damage to soft tissues at the time of the accident, the less pronounced will these annoying sequelae be. The percentage of cases in which perfect and prompt restoration of function occurs, has greatly increased since the advent of open treatment for the accurate correction of deformity. In compound infected cases, sinuses may persist until the necrotic bone from which they lead is removed by operation. Refracture of the bones of the leg may occur if sufficient strain is sustained before the callus becomes thoroughly hardened. Refrac- ture is through the callus and not the fragments. About one-half 658 FRACTURES AND DISLOCATIONS to two-thirds the time required for union in the original break is necessary for union in a fractured callus. Embolism from a de- tached portion of thrombus or a fat embolus may produce immedi- ate death. Infection in compound cases may result in the loss of the leg, or if severe, even death. Destruction of the circulation in severe crushing injuries calls for immediate amputation.