PART IV. SPECIAL SUBJECTS. (Part 3)

a very little hypo is carried into your developer you will find your plates displaying some very peculiar appearances. Plates which are not quite perfect in certain respects may be improved by intensification or reduction, as indicated by the quality of the density, but really in order to obtain a correct plate the exposure must have been very nearly correct in the first place ; after- manipulations will not make a good plate out of a bad one. In studying plates, put them in a window against a clear sky, north light preferred. A box fronted with ground glass and con- taining electric lamps is a convenience as it may be used at any time. ]Make plenty of experimental plates of normal parts in order to have a standard. It is well, in injury cases, to examine the corre- sponding normal part until one becomes familiar with normal Rontgenologic anatomy, and has a collection of normal plates. There are no "high lights" in Rontgenograms ; these are impor- tant in camera photography ; the corresponding condition in a Ront- genogram is the black part of the plate outside the field of the image ; in Rontgenography we are dealing with what photographers call "shadow detail." In studying plates, look out for the appearances (artefacts) caused by air bubbles adhering to the plate during development, finger marks, scratches, light-struck spots due to holes in the envelopes, and chemical stain and fog. Look out for confusing lines where the shadows of two or more bones are superimposed. Do not be deceived by the heavy (white) shadow of a ridge for muscular attachment, which at times may appear to be the margin of a fracture shadow. Remember that epiphyses unite at varying periods in the develop- ment of the individual. Do not mistake a normal center of ossification of a condyle for a displaced fragment of bone. Remember that a patient may have more than one fracture. Remember that a fracture may be located at some distance from the seat of pain. Remember that a functionally perfect result may appear very far from being an anatomically perfect result. Just because your plates show good apposition in a fracture located near a joint, do not be over-optimistic in your prognosis. CHAPTER LIX. THE OPEN TREATMENT OF FRxVCTURES. The use of the X-ray and operative treatment have, of recent years, greatly improved the results in certain fractures and disloca- tions. Open treatment is particularly adapted to the correction of deformity in instances in which simpler methods cannot accomplish reduction or fail in preventing subsequent displacement during the after-treatment. Cases in which operation is performed may be divided into two groups: the first includes cases in which this method has been chosen soon after the injury because of the im- proved results which it ma}^ offer; the second includes cases which are operated upon as a last resort after non-operative methods have been tried and proven unsuccessful, or in Avhich operation was demanded because the condition was compound from the first. The results of these two groups of cases are quite different and should not be confounded when deliberating upon the advantages of opera- tive treatment. Consideration at this time is only given to cases in which operation is performed as an initial measure because it offers better results than non-operative procedures. Operation done in compound fractures will be taken up under the headings of ' ' Treat- ment of Compound Fractures and Dislocations," page 789. All forms of treatment give a higher proportion of functionally perfect results in children, and hence the difference between opera- tive and non-operative results is less marked before puberty. AVith advancing years the proportion of cases in which a better result can be obtained by operation increases. Mechanical means for the direct or internal fixation of the fragments have been known and employed for many years, but it is only recently" that improved technique, both as to appliance and asepsis, have demonstrated the real value of the operative method. AYire, nails, screws, pegs, clamps, ferrules, and absorbable suture materials, have all been used, and even now have their appropriate places. But the develop- ment of the Lane plate has proven, undoubtedly, the greatest stride in the open treatment of fractures. It is a well known fact that 754 THE OPEN TREATMENT OF FRACTURES 755 perfect anatomic reduction is not always essential to the complete restoration of function, yet the more cases in which absolutely exact reduction is obtained, the greater will be the decrease in the per- centage of cases showing loss of function. AVe should, therefore, endeavor in each and every case to secure as accurate an anatomic result as is possible. Proper operative treatment not only accom- plishes more perfect apposition and fixation of the fragments but shortens the period of disability, gives better functional results and lessens the suffering of the patient. Prohahly the best time for operation is fro))i seven to ten days following the accident. This allows the tissues to recover from the initial shock and gives time for the development of local resistance. In operating on simple fractures the surgeon should fully appreciate that he is rendering the condition compound, and that infection following open treat- ment is often productive of much worse results than would be the case if surgical measures had not been instituted. For this reason the most strictly aseptic surroundings are demanded and the oper- ator should be skilled in this particular branch of surgery. Those unaccustomed to bone work should not attempt these cases. The surgeon should possess a mechanical sense peculiar to this particular type of work, and an appreciation of the relative strengths of the materials operated upon and employed. This mechanical sense, referred to, is easier to illustrate than to define. For example : if we observe an experienced mechanic at work, we never see him tighten a nut until the threads strip or the shaft of the bolt twists in two, and yet he tightens nuts of all sizes and threads, each one requiring a different degree of force to properly seat it. In like manner the expert cabinet maker saws and shapes his wood to fit the desired places and yet a nail is never driven without due consid- eration for the strength and nature of the material through which it passes and the function which it is to perform, nor is a screw driven home so that the last turn strips the thread, breaks the shaft or causes the w^ood to split. On the other hand, if we watch the apprentice learning his trade, the lack of mechanical sense is ap- parent in the frequency with which he spoils materials and ruins his tools. Any one who has seen the last screw of a Lane plate split the shaft of a bone, or a bone graft broken just as it is being brought into position will appreciate the value of this mechanical sense and see what can be learned by the surgeon from the artisan. One 756 FRACTURES AND DISLOCATIONS desirous of increasing his proficiency in this particular branch of surgery should obtain fresh bones from the butcher and then with chisel, saw, nail and screw determine to his own practical satisfac- tion the relative strength of bone, and just what it will, and will not stand. Later on fresh specimens from the dissecting room should be procured and the same experiments conducted. In addition the various types of fixation may be tried out on different portions of the bone and the security of the fixation tested. The difference between cancellous and compact tissue may be appreciated in this way and in no other, outside the operating room. When this experience has been gained further obstacles to progress may be minimized by assisting or observing some surgeon of experience in bone work, until a satisfactory technique is obtained. The question of when, and when not to operate in a given case depends upon the general condition of the patient and the degree of reduction which is possible by non-operative methods. Diseased states, such as diabetes, erysipelas, advanced nephritis, etc., offer contraindications to operation, in the open treatment of fractures, the same as they do in other fields of surgery. If the general health of the patient allows of an operation, the question then arises: "Can an equally good result be obtained by the non- operative method as is possible with open treatment ? ' ' and secondl}^, * ' Are the proper surgical surroundings and skill available ? ' ' In conclusion, then, we might state that with the proper health of the patient and available surgical facilities, all cases of fracture should be operated, in which an equally good result cannot other- wise be expected. The site of the operation should be carefully shaved, and painted with a three and a half percent solution of iodine (half strength tr. iodi) the day preceding the operation. The parts are then covered with sterile dressings until the time of operation. The parts are again painted with tincture of iodine (five percent) before the incision is made. As soon as the skin is divided the cutaneous edges should be covered with gauze or towels which are secured in position by small tenaculse, thus preventing infection of the deeper struc- tures from the cut edges of the skin. Rubber gloves are demanded, the hands should be kept out of the w^ound, as far as possible, and instruments having come in contact with the gloves should not enter the wound. In other words, the most strict aseptic precautions should be observed in every detail, gloves should be worn and then, THE OPEN TREATMENT OF FRACTURES 757 while operating, the surgeon should consider his gloved hands capable of infecting the wound. The danger in this particular work lies largely in the fact that a glove may be torn by one of the serrated fragments while attempting reduction, and when this occurs the pent-up perspiration from the hand is poured out into the wound. A pin-hole in the glove may cause leakage onto the field of operation during the entire procedure. The details of the operation and the exact form of internal fixa- tion which will best meet the requirements of the case in hand are often only determined after the bone has been exposed. The exact nature of the fracture, with the fragments exposed, frequently appears difterent from the conditions anticipated, even though care- ful examination has been previously made and the X-ray employed. The surgeon should, therefore, have a number of appliances ready that he may choose from among them to more perfectly meet the requirements of the conditions encountered. If an internal fixation appliance is employed it should secure the fragments as solidly as may be, even to the extent of sustaining the weight of the extremity. In the subsequent treatment, however, splints should be employed in such a manner as to relieve the internal fixation appliance from as much strain as possible. In other words, internal fixation should never be called upon to do the work of splints or other forms of external fixation. The fact that internal fixation is so often used in the open treatment of fractures does not necessarily indicate that the objects of operation may not sometimes be attained without its employment. In some instances accurate engagement of the ser- rated ends of the fragments during operation, will be sufficient to prevent lateral or overriding deformity, and the proper application of appropriate splints may be relied upon to prevent angular dis- placement. Reduction of deformity and fixation are thus obtained by operation, but without the use of any type of internal or direct fixation. It is essential that the anatomy of the parts operated upon be understood so that important structures, such as nerves and vessels, may be avoided and the displacing action of the muscles attached to the fragments may be appreciated. The internal structure of the bone should be understood as well as its surface form, since so much depends on the nature of the portion of the bone operated. Irrigation of the wound, just before closure, with a gallon or so of hot sterile physiological salt solution will promote hemostasis and 758 FRACTURES AND DISLOCATIONS tend to remove any infection which might have gained entrance during the operation. The use of the so-called antiseptic solutions within the wound are not only useless, but tend to damage the tissues. When possible a running suture of catgut should approxi- mate the muscles before the skin is closed. Deep through and through sutures are most objectionable. The large majority of operations done on fractures pass through heavy muscular tissue which is highly vascular. Extravasation of blood into the wound is almost sure to follow, even though hemostasis seems perfect at the time of closure. Living blood within the vessels possesses distinct bactericidal activity, but when extravasated this quality soon disappears, the result being that collections of dead blood within a wound act as most excellent culture media, at body tem- perature, thus favoring subsequent suppuration. It is evident, therefore, that fluids forming within the wound following closure should be allowed to escape at the earliest possible moment. If a few strands of silkworm-gut be so placed within the wound that they act as drains, this most important requisite will have been ful- filled. The field of operation should be inspected within twenty- four or forty-eight hours and gentle pressure exerted in such a manner that any fluids which may have collected in the meantime will be expressed. 'VvVyV- Methods of using Avire in tlie internal fixation of fractures. The Use of Wire has been largely supplanted by the Lane plate, though it still retains its place of preference in certain fractures, notably those of the olecranon and patella, and in some cases of fractures in the extremities of the long bones. The different ways in which wire may be used are shown in the accompanying plates (Fig. 823). In fractures near the expanded extremities of the long bones a single loop of wire properly placed may be sufficient to prevent displacement (see Fig. 825). In wiring the shafts of THE OPEN TREATMENT OF FRACTURES 759 the long bones it is almost essential that two points of fixation be employed to secure proper leverage (see Fig. 638). The circular wire has the advantage of not entering the medullary cavity, and of not requiring the destruction of bone tissue by drilling. In most instances the firmest hold is obtained by having the wire pass perpendicularly through the plane of fracture whether spiral, oblique or transverse. If the fracture approaches the transverse type or the serrations are coarse enough to permit of firm engagement a single loop of wire may be sufficient to prevent lateral displacement, angular deformity being prevented by the proper use of splints. Fig. 825. Figs. 824 and 82 5. — An example of how, a single loop of wire can be made to hold the end of a bone in ijosition. The essentials in the use of wire are firstly, that the material be heavy enough to withstand the strain to which it is subjected, and secondly, that it be firmly placed and secure proper leverage on the fragments. These points are best appreciated by referring to the accompanying diagrams. Heavy wire is as well tolerated by the tissues as if the material used were light and inadequate. Virgin silver wire has for years been considered the best, but recently bronze-aluminum wire has been preferred by many, be- cause of its greater torsion strength. Nails, Pegs, Screws and Staples have all been used to secure the fragments in position, but at the present time the development of 760 FRACTURES AND DISLOCATIONS more perfect appliances has rendered their use more limited. They are only now employed for the purpose of securing a small, dis- placed fragment such as a fractured condyle, tubercle or tuber- Fig. 826. — Instruments which have been found of considerable service in operating on fractures. On the left is shown a lion-jawed bone forceps with ratchet in the handle. By means of this instrument it is often possible to hold the fragments in reduction while applying internal fixation apparatus. The instruments to the right are ordinary retractors with the handle ends shaped and drilled so that they may be used in passing wire about the shafts of long bones. osity. A good example of the appropriate use of a nail is shown in Fig. 219. In this case the external condyle of the humerus was broken off and so displaced that the elbow would have remained useless if operation had not been performed. The nail has been driven at right angles to the displacing pull of the muscles attached THE OPEN TREATMENT OF FRACTURES 761 to the fragment, and in this position securely holds the condyle against the recurrence of deformity. In the use of nails the hole drilled in the bone should be only a trifle smaller than the size of the nail to be used, otherwise the bone may be split when the nail is driven home. The same holds true in the use of screws, pegs and staples. Screws and nails have been used with some success in the treat- ment of fractures of the femoral neck, the nail or screw being Fiff. 828. — Bone forceps. Fig. 829. — Bone forceps. driven through the great trochanter to enter the neck parallel to its long axis. The reason that success has not been more constant in operating on this portion of the femur is because of the soft, cancellous tissue of which the internal structure of the upper end of the femur is composed. Screws, nails and pegs depend for their hold mainly on compact tissue, and in regions of the skeleton in which cancellated structure predominates, little reliance can be placed upon them if the displacing action is considerable. Thus when a nail