PART IV. SPECIAL SUBJECTS. (Part 1)

PART IV. SPECIAL SUBJECTS. CHAPTER LVII. TERMS AND DEFINITIONS. Fracture. — No better definition can be given than the meaning of the Latin word {f rang ere, to break) from which the term is de- rived. A breaking of bone or cartilage. Dislocation or Luxation. — Is a condition in which the articular surfaces are completely displaced from each other. These terms are often looselj^ used, and in many instances an incomplete dis- placement of the articular surfaces is spoken of as a dislocation when it should be designated as a subluxation. Subluxations are dislocations in which the articular surfaces re- main partly in contact with each other. Complete and incomplete are terms used to indicate the degree of fracture or luxation. In incomplete fractures the line of frac- ture only partially separates the fragments. Congenital fractures and luxations are conditions which exist at birth. In many instances it is difficult to state whether or not the lesion was intra-uterine. Congenital fractures and luxations may be the result of prenatal disease, defective development or of trauma at birth, or of a combination of these causes. Spontaneous fractures and dislocations occur as a result of dis- ease or paralysis. In some instances, notably fracture of the hip, the bone may break under normal strain as a result of the absorp- tion and rarefication of bone which takes place in the aged. Pathologic fractures are caused by diseases of the bone such as osteo-sarcoma, carcinoma, osteo-myelitis, etc. Pathologic luxations result from diseases which cause degener- ation of the ligaments or alterations of the articular surfaces. Recurrent or hahitual luxations are conditions in which the same dislocation takes place repeatedly, following incomplete healing of the ligaments after the initial lesion. Recurrent luxations are com- mon in the shoulder joint following improper treatment of the first displacement. Diastasis and distraction are terms used to indicate a condition 725 726 FRACTURES AND DISLOCATIONS in which the joint surfaces are forcibly torn from each other and remain separated without overriding- deformity. A good example of diastasis is sometimes seen in the lower tibio-fibular articulation Fig. 783. Fig. 789. Fig. 788. — Example of a simple transverse fracture. Fig. 789. — Example of multiple fracture of the shaft. when the ligaments are torn and the lower ends of the tibia and fibula separated. The term compound or open is used when the fracture or lux- ation is connected with the outside air by means of a wound. The wound may be made by the vulnerant body penetrating to the TERMS AND DEFINITIONS 727 bone, or the end of the fragment or articnlar surface of the bone may penetrate the skin from within. The term closed is used in contradistinction to open or com- pound. Fig. 791. Figs. 790 and 791. — Surface form and section of fracture united in deformity. Old fractured tibia sawed in the coronal plane. Note how the rough fractured surfaces not originally in apposition have been absorbed, filled in and rounded off, as the middle of the callus became more dense. _ When union takes place with deformity, as in this case, the callus is of necessity heavier and more dense than when good reduction has been accomplished. This specimen was obtained from the dissecting room and is probably many years old yet the medullary canal has not reopened. _ In fractures of the shafts of long bones the medullary canal reopens some years following the injury provided the reduction is good. In this case the deformity is pronounced and the medullary canal remains occluded by the internal callus. A good example of the reopening of the canal is seen in the X-ray plates (Figs. 636 to 639), The term simple is used in contradistinction to both compound and complicated. The term complicated is rather indefinite in its meaning. It is used w^hen the fracture is compound or open and is also employed 728 FRACTURES AND DISLOCATIONS to indicate associated injury to arteries, veins, nerves or muscles. It is also used when the fracture is infected. A green-stick fracture is one in which the line of fracture re- sembles that seen when a green-stick is broken. The bone is bent Fig. 792. — Carcinoma of ,the liumerus with spontaneous fracture. Fig. 793. — Carcinoma of the humerus with spontaneous fracture. and the fracture involves only the convex side of the shaft. Many fractures are called green-stick which are in reality of the sub- periosteal type. Siihperiosteal fracture. — This term is used when the fracture is TERMS AND DEFINITIONS 729 bone. Fig. 794. — Carcinoma of the lower end of tlie femur with extensive destruction 730 FRACTURES AND DISLOCATIONS Fig. 795. — Syphilitic dactylitis with spontaneous fracture. Fig. 796. — Spontaneous fracture following osteosarcoma. TERMS AND DEFINITIONS 731 not accompanied by appreciable tearing of the periosteum or dis- placement of the fragments. It occurs in children and is the result of bending force applied to the bone. AVhen this type of violence Fig. 797. — Osteocarcinoma with spontaneous fracture. Much destruction of bone. is applied to a young bone (young bones are tough rather than brittle) the convex side of the shaft is under tension strain while the concave side is under compression strain. Fracture may 732 FRACTURES AND DISLOCATIONS TERMS AND DEFINITIONS 733 Fig. 7 'J 9 Fig. 799. — Same case as shown in Fig. 798. Note fracture of femnr Fig. 800. — ^Same case. Note fracture of femur. mms;:< Fig. 801. Fig. 802. Fig._ 801. — Same case. Note bowing of tibia and point in shaft which is ready to break with the slightest strain. Fig. 802, — Same case. Same conditioia as seen in tibia of opposite leg in Fig, 801. 734 FRACTURES AND DISLOCATIONS occur on the convex side from tension or on the concave side from compression. When the former type of fracture occurs and is incomplete we have the typical green-stick fracture. When the latter type occurs we have the subperiosteal form of fracture. The difference is well illustrated by the manner in which different forms of iron break. Wrought iron girders break on the concave side from "buckling," while steel girders break on the convex side with clean fracture. The more brittle the material the more likely the fracture is to begin on the convex side of the column and to be complete. The more rapid the bending the greater the proba- bility of a complete fracture and of the break beginning on the convex side. Various terms are used to indicate the nature of the fracture, the character of the deformity and the line of the break. Such commonly used terms as : comminuted, multiple, transverse, oblique, spiral, overriding, angular, depressed, etc., are self-explanatory. CHAPTER LVIII. THE USE OF THE X-RAY. BY H. G. STOVER, M.D. After the lapse of some eighteen years since Rontgen's discovery, it ought not to be required, in a work upon fractures and disloca- tions, to insist upon the absolute necessity for the routine use of this indispensable diagnostic means in every instance of possible bone or joint injury. Yet even in this day, when the benefits of Rontgenology are avail- able in so many localities, the use of this agent is far from as general as it should be. In the early days of the Rontgen ray there was some excuse for the surgeon who did not rely upon it : the users of the ray were not in possession of efficient apparatus ; exposures were long, and often resulted in harm; and, owing to imperfect technique and small experience, the information afforded by a Rontgenologic examina- tion was in many instances incomplete, and at times misleading. These excuses do not hold now; in every center of population there are installations capable of giving useful Rontgenograms, and men who are competent to make the examinations skillfully and without danger to the patients. The advantages of the Rontgenologic examination are many and vital. The Rontgen examination does away with the need for manipu- lation of injured parts in the attempt to elicit pain, crepitus and preternatural mobility; it not only affords all the information of value to be gained from the ordinary methods of examination, but it brings forth facts impossible to be elicited in any other way : certain fractures Avithout displacement ; certain impacted fractures ; certain incomplete fractures; certain fractures, which, by their very nature cannot give the usual clinical signs ; it reveals the inter- position of small fragments between the ends of fractured bones; and avoids the bruising and laceration of tissues which must occur in some instances if there be a prolonged manipulative examination, 735 736 FRACTURES AND DISLOCATIONS It has been argued by some that a surgeon ought not allow his manual dexterity to suffer the atrophy of disuse, by relying upon the Rontgen ray ; one might as well say that an internist ought not use the microscope to look for plasmodia in the blood, but ought rather nurse his skill in eliciting subjective and objective clinical symptoms upon which to formulate his diagnosis. At the same time, it must be insisted that the Rontgen examination is not to supplant the clinical methods ; rather must it supplement them. The skilled hand of the surgeon has done its wonders through the ages; it cannot be neglected now; the practised eye discovers ex- ternal signs of internal conditions in a marvelous way as evidenced by the photographs in this book. The time is coming when failure to make appropriate use of Rontgenology, when accessible, will be counted as negligence, and this not only in surgery, but in many departments of internal medicine. Even the laity are coming now to criticise their attend- ants for delay or neglect in this matter. After attempted reposition of fracture or dislocation, the Rontgen examination affords a means of ascertaining if position is correct without disturbing retentive dressings or apparatus, enables one to watch the course of healing, and to know the final anatomical result. In many of the fractures met with, a clinical diagnosis sufficiently accurate for preliminar}^ treatment can be made ; in these cases the Rontgen examination should be made after reposition in order to check up the clinical diagnosis and to make certain that satisfactory reposition has been accomplished. But there are not a few in- stances in which the Rontgen examination should be made before anything else is done ; in this class are many of the injuries about the elbow, hip, and pelvis, and those severe traumata in which there is suspicion of grave damage to vital soft tissues, and further injury through manipulation might result in gangrene, or other detri- mental sequelae. As the Rontgen ray produces no sensory impression upon the retina, it is necessary to use intermediate means to transform the results of its energy into visible records. There are three physical factors which render this possible : First : all substances absorb the Rontgen ray practically in rela- tive amounts corresponding directly to the ratio existing between their atomic weights. Second : the Rontgen ray causes certain substances to fluoresce. THE USE OF THE X-RAY 737 Third : the Rontgen ra}^ has the power of producing a paralyzing effect, or a latent, developable image, upon the chemicals used in the sensitive emulsion of photographic plates and certain photo- graphic papers. If a substance is so placed that it will intercept rays directed toward a screen coated with fluorescent material, or a photographic plate, the absorption which occurs leaves areas on the screen or emulsion, which are not affected ; these areas on the fluorescent screen are dark; in the emulsion of the plate no latent image is produced ; if the substance under examination is made up of areas of various densities, the amount of fluorescence upon the screen or of alteration in the silver salt of the emulsion of a plate, in corre- sponding areas, varies in an inverse proportion to the densities of these areas, or in direct ratio to the amount of rays which these areas permit to pass. At the present time the fluoroscope is not used in this branch of surgical Rontgenology, except for roughly and quickly estimating the approximate location of a foreign body, or obtaining some general facts regarding a bone injury; the screen image is not so rich in detail as is that upon the plate; it can be studied during only a short period of time ; it is not a permanent record ; its fre- quent use is dangerous to the operator; long or repeated exposure may lead to injury of the patient's skin, as for example, when the operator, the attending physician, perhaps a consulting surgeon, and probably from one to a dozen relatives and friends, must all ' ' have a look. ' ' On the other hand the sensitive plate gives all the details; it can be studied as long or as often as needed and at any time ; it is a permanent record of the condition ; it is demonstrable evidence that such an examination has been made; in addition to this, the accumulation of a large library of plates furnishes rich material for scientific study and for the writing of papers. The great part of Rontgen diagnosis in medicine and surgery must be done by specialists in this line, and indeed before long there will be subspecialties in Rontgenology, so great is the field and so complicated the technical details of diagnosis-making. Most physicians and surgeons will find it impracticable to make their own Rontgen examinations. A complete equipment is costly in apparatus and space and its maintenance expensive. One's own patients will not contribute as liberally to this for these examina- tions as they will do when referred to a specialist for the purpose. 738 FRACTURES AND DISLOCATIONS and men cannot give time from a busy practice to carry out the work. The physician who does not have reasonably ready access to a competent Rontgenologist may well, however, prepare and equip himself to examine fractures and dislocations by this method. He will not need the powerful generating machines, the complicated auxiliary apparatus or the costly tubes necessary for instantaneous Rontgenography of the lungs and stomach. Yet let not such an Fig. 803. — The Rose portable coil. one imagine that he is taking up a simple problem ! For this man the author would ad^dse the Rose Portable Coil (Fig. 803), It may be used on either direct or alternating current; it is of the compact ' ' suit-case ' ' type and can be carried in the hand for short distances without overfatigue, so it may be used either in the office or at the beside where electric current is available. In Fig. 804 is shown a larger apparatus of the same type. It is more powerful but is THE USE OF THE X-RAY 739 more weighty and heavier fuses must be placed in house circuits in which it is used. Another box for carrying the Crooke's tube and the plate-hokiers is a convenience. The apparatus requires a special type of Crooke's tube, calculated to suppress inverse current (Fig. 805). Fig. 804. — This apparatus is similar to that shown in preceding figure. It is. liow- ever, more powerful and more weighty. Heavier fuses must be placed in the house circuits on which it is used. The Cramer, the Forbes, or the "Agfa" X-ray plates will be found quite satisfactory, permitting of some latitude in exposure time. These plates are to be enclosed in the black and yellow envelopes, 740 FRACTURES AND DISLOCATIONS opaque to ordinary actinic light, which may be procured from the plate makers. Always put the plate in the black envelope (in the dark-room, of course) so that the film of the plate is next to the smooth side of the envelope ; then put the black envelope into the yellow one so that their smooth and unprinted sides are tog-ether; Fi^. 805. — Special type of Crookes tube, calculated to suppress inverse current. this is important, as in this way one is always certain as to which side of the package carries the film side of the plate. If Rontgeno- grams are made with the film side of the plate down in some examinations and up in others, when using envelopes, there might be no way of knowing, in a subsequent stud}' of the plate, whether I'ig. 806. — Metallic; numbers for marking X-ray plates. the right or left side of the body had been examined, a point which it is quite necessary to know when making reports to insurance companies, or when the physician is called to the witness stand. It is a very good plan to mark the plates, at the time of making the exposure, by means of leaden letters "L" and "R." THE USE OF THE X-RAY 741 For several reasons it is quite important that plates be carefully so marked that their future identification is always positive. Metal- lic numbers (Fig. 806) may be placed on the plate at the time of the exposure, thus obtaining a Rontgenogram of the number as a part of the image produced; if this is not practicable the number of the plate or the patient's name, should be written upon the film side of the plate, in the dark-room, wdth a lead pencil, immediately before developing it. When the Rontgenogram has been made, the following points should be noted upon the envelope, for a record : name of patient ; address; occupation; if a minor or a dependent, the name and address of the financially responsible party ; the date ; the part examined; the nature of the view^ — whether antero-posterior, postero-anterior, lateral, etc. ; the condition suspected; the diagno- sis ; and other facts may be added if desired, such as, history of the injury; description of the dressings applied, etc. The plates should be filed aw^ay in a safe place in