Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.
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Title: Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.
Author: Alexis Thomson
Alexander Miles
Release date: March 29, 2009 [eBook #28428]
Language: English
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OXFORD MEDICAL PUBLICATIONS
MANUAL OF SURGERY
BY
ALEXIS THOMSON, F.R.C.S.Ed. AND Eng.
_PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
SURGEON EDINBURGH ROYAL INFIRMARY
AND
ALEXANDER MILES, F.R.C.S.Ed.
SURGEON EDINBURGH ROYAL INFIRMARY
VOLUME SECOND
EXTREMITIES--HEAD--NECK
_SIXTH EDITION REVISED AND ENLARGED_
_WITH 288 ILLUSTRATIONS_
LONDON
HENRY FROWDE and HODDER & STOUGHTON
THE _LANCET_ BUILDING
1 & 2 BEDFORD STREET, STRAND, W.C.2
First Edition 1904
Second Edition 1907
Third Edition 1909
Fourth Edition 1912
" " Second Impression 1913
Fifth Edition 1915
" " Second Impression 1919
Sixth Edition 1921
PRINTED IN GREAT BRITAIN BY
MORRISON AND GIBB LTD., EDINBURGH
CONTENTS
PAGE
CHAPTER I
INJURIES OF BONES 1
CHAPTER II
INJURIES OF JOINTS 32
CHAPTER III
INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM 44
CHAPTER IV
INJURIES IN THE REGION OF THE ELBOW AND FOREARM 79
CHAPTER V
INJURIES IN THE REGION OF THE WRIST AND HAND 102
CHAPTER VI
INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH 122
CHAPTER VII
INJURIES IN THE REGION OF THE KNEE AND LEG 155
CHAPTER VIII
INJURIES IN REGION OF ANKLE AND FOOT 185
CHAPTER IX
DISEASES OF INDIVIDUAL JOINTS 201
CHAPTER X
DEFORMITIES OF THE EXTREMITIES 241
CHAPTER XI
THE SCALP 319
CHAPTER XII
THE CRANIUM AND ITS CONTENTS 328
CHAPTER XIII
INJURIES OF THE SKULL 361
CHAPTER XIV
DISEASES OF THE BRAIN AND MEMBRANES 373
CHAPTER XV
DISEASES OF THE CRANIAL BONES 406
CHAPTER XVI
THE VERTEBRAL COLUMN AND SPINAL CORD 411
CHAPTER XVII
DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD 431
CHAPTER XVIII
DEVIATIONS OF THE VERTEBRAL COLUMN 461
CHAPTER XIX
THE FACE, ORBIT, AND LIPS 474
CHAPTER XX
THE MOUTH, FAUCES, AND PHARYNX 496
CHAPTER XXI
THE JAWS, INCLUDING THE TEETH AND GUMS 507
CHAPTER XXII
THE TONGUE 528
CHAPTER XXIII
THE SALIVARY GLANDS 543
CHAPTER XXIV
THE EAR 553
CHAPTER XXV
THE NOSE AND NASO-PHARYNX 567
CHAPTER XXVI
THE NECK 582
CHAPTER XXVII
THE THYREOID GLAND 604
CHAPTER XXVIII
THE OESOPHAGUS 616
CHAPTER XXIX
THE LARYNX, TRACHEA, AND BRONCHI 634
INDEX 645
LIST OF ILLUSTRATIONS
FIG. PAGE
1. Multiple Fracture of both Bones of Leg 4
2. Radiogram showing Comminuted Fracture of both Bones of 5
Forearm
3. Oblique Fracture of Tibia; with partial Separation of 6
Epiphysis of Upper End of Fibula; and Incomplete Fracture
of Fibula in Upper Third
4. Excess of Callus after Compound Fracture of Bones of 9
Forearm
5. Multiple Fractures of both Bones of Forearm showing 11
Mal-union
6. Radiogram of Un-united Fracture of Shaft of Ulna 13
7. Excessive Callus Formation after Infected Compound 27
Fracture of both Bones of Forearm
8. Partial Separation of Epiphysis, with Fracture running 29
into Diaphysis
9. Complete Separation of Epiphysis 29
10. Partial Separation with Fracture of Epiphysis 29
11. Complete Separation with Fracture of Epiphysis 29
12. Os Innominatum showing new Socket formed after 41
Old-standing Dislocation
13. Oblique Fracture of Right Clavicle in Middle Third, 45
united
14. Fracture of Acromial End of Clavicle 46
15. Adhesive Plaster applied for Fracture of Clavicle 49
16. Forward Dislocation of Sternal End of Right Clavicle 51
17. Diagram of most common varieties of Dislocation of the 53
Shoulder
18. Sub-coracoid Dislocation of Right Shoulder 55
19. Sub-coracoid Dislocation of Humerus 56
20. Kocher's Method of reducing Sub-coracoid 57
Dislocation--First Movement
21. Kocher's Method--Second Movement 58
22. Kocher's Method--Third Movement 59
23. Miller's Method of reducing Sub-coracoid 60
Dislocation--First Movement
24. Miller's Method--Second Movement 61
25. Dislocation of Shoulder with Fracture of Neck of Humerus 64
26. Transverse Fracture of Scapula 68
27. Fracture of Surgical Neck of Humerus, united with 70
Angular Displacement
28. Impacted Fracture of Neck of Humerus 71
29. Ambulatory Abduction Splint for Fracture of Humerus 72
30. Radiogram of Separation of Upper Epiphysis of Humerus 73
31. "Cock-up" Splint 77
32. Gooch Splints for Fracture of Shaft of Humerus; and
Rectangular Splint to secure Elbow 77
33. Radiogram of Supra-condylar Fracture of Humerus in a 81
Child
34. Radiogram of T-shaped Fracture of Lower End of Humerus 83
35. Radiogram of Fracture of Olecranon Process 86
36. Backward Dislocation of Elbow in a Boy 89
37. Bony Outgrowth in relation to insertion of Brachialis 90
Muscle
38. Radiogram of Incomplete Backward Dislocation of Elbow 91
39. Forward Dislocation of Elbow, with Fracture of Olecranon 93
40. Radiogram of Forward Dislocation of Head of Radius, with 95
Fracture of Shaft of Ulna
41. Greenstick Fracture of both Bones of the Forearm 98
42. Gooch Splints for Fracture of both Bones of Forearm 99
43. Colles' Fracture showing Radial Deviation of Hand 103
44. Colles' Fracture showing undue prominence of Ulnar 103
Styloid
45. Radiogram showing the Line of Fracture and Upward 104
Displacement of the Radial Styloid in Colles' Fracture
46. Radiogram of Chauffeur's Fracture 107
47. Radiogram of Smith's Fracture 108
48. Manus Valga following Separation of Lower Radial 109
Epiphysis in Childhood
49. Radiogram showing Fracture of Navicular (Scaphoid) Bone 111
50. Dorsal Dislocation of Wrist at Radio-carpal Articulation 113
51. Radiogram showing Forward Dislocation of Navicular Bone 114
52. Extension Apparatus for Oblique Fracture of Metacarpals 117
53. Radiogram of Bennett's Fracture of Base of Metacarpal 118
of Right Thumb
54. Splints for Bennett's Fracture 119
55. Multiple Fracture of Pelvis through Horizontal and 123
Descending Rami of both Pubes, and Longitudinal Fracture
of left side of Sacrum
56. Fracture of Left Iliac Bone; and of both Pubic Arches 124
57. Many-tailed Bandage and Binder for Fracture of Pelvic 125
Girdle
58. Nelaton's Line 128
59. Bryant's Line 129
60. Section through Hip-Joint to show Epiphyses at Upper 130
End of Femur, and their relation to the Joint
61. Fracture through Narrow Part of Neck of Femur on Section 131
62. Impacted Fracture through Narrow Part of Neck of Femur 132
63. Fracture of Neck of Right Femur, showing Shortening, 133
Abduction, and Eversion of Limb
64. Fracture of Narrow Part of Neck of Femur 134
65. Coxa Vara following Fracture of Neck of Femur in a Child 136
66. Non-impacted Fracture through Base of Neck 137
67. Fracture through Base of Neck of Femur with Impaction 137
into the Trochanters
68. Non-impacted Fracture through Base of Neck 138
69. Fracture of the Femur just below the small Trochanter, 140
united, showing Flexion and Lateral Rotation of Upper
Fragment
70. Adjustable Double-inclined Plane 141
71. Diagram of the most Common Dislocations of the Hip 142
72. Dislocation of Right Femur on to Dorsum Ilii 143
73. Dislocation on to Dorsum Ilii 144
74. Dislocation into the Vicinity of the Ischiatic Notch 145
75. Longitudinal Section of Femur showing Fracture of Shaft 148
with Overriding of Fragments
76. Radiogram of Steinmann's Apparatus applied for Direct 150
Extension to the Femur
77. Hodgen's Splint 151
78. Long Splint with Perineal Band 152
79. Fracture of Thigh treated by Vertical Extension 153
80. Section of Knee-joint showing Extent of Synovial Cavity 156
81. Extension applied by means of Ice-tong Callipers for
Fracture of Femur 158
82. Radiogram of Separation of Lower Epiphysis of Femur, 160
with Backward Displacement of the Diaphysis
83. Separation of Lower Epiphysis of Femur, with Fracture 161
of Lower End of Diaphysis
84. Radiogram of Fracture of Head of Tibia and upper Third 163
of Fibula
85. Radiogram illustrating Schlatter's Disease 164
86. Diagram of Longitudinal Tear of Posterior End of Right 171
Medial Semilunar Meniscus
87. Radiogram of Fracture of Patella 173
88. Fracture of Patella, showing wide Separation of Fragments 175
89. Radiogram of Transverse Fracture of both Bones of Leg 178
by Direct Violence
90. Radiogram of Oblique Fracture of both Bones of Leg by 178
Indirect Violence
91. Box Splint for Fractures of Leg 180
92. Box Splint applied 181
93. Section through Ankle-joint showing relation of 186
Epiphyses to Synovial Cavity
94. Radiogram of Pott's Fracture, with Lateral Displacement 187
of Foot
95. Ambulant Splint of Plaster of Paris 189
96. Dupuytren's Splint applied to Correct Eversion of Foot 190
97. Syme's Horse-shoe Splint applied to Correct Backward 191
Displacement of Foot
98. Radiogram of Fracture of Lower End of Fibula, with 192
Separation of Lower Epiphysis of Tibia
99. Radiogram of Backward Dislocation of Ankle 195
100. Compound Dislocation of Talus 197
101. Radiogram of Fracture-Dislocation of Talus 198
102. Radiogram of Dislocation of Toes 199
103. Arthropathy of Shoulder in Syringomyelia 203
104. Radiogram of Specimen of Arthropathy of Shoulder in 204
Syringomyelia
105. Radiogram showing Multiple partially Ossified 205
Cartilaginous Loose Bodies in Shoulder-joint
106. Diffuse Tuberculous Thickening of Synovial Membrane of 206
Elbow
107. Contracture of Elbow and Wrist following a Burn in 207
Childhood
108. Advanced Tuberculous Disease of Acetabulum with Caries 210
and Perforation into Pelvis
109. Early Tuberculous Disease of Right Hip-joint in a Boy 212
110. Disease of Left Hip; showing Moderate Flexion and 213
Lordosis
111. Disease of Left Hip; Disappearance of Lordosis on 213
further Flexion of the Hip
112. Disease of Left Hip; Exaggeration of Lordosis 214
113. Thomas' Flexion Test, showing Angle of Flexion at 214
Diseased Hip
114. Tuberculous Disease of Left Hip: Third Stage 215
115. Advanced Tuberculous Disease of Left Hip-joint in a Girl 216
116. Extension by Adhesive Plaster and Weight and Pulley 220
117. Stiles' Double Long Splint to admit of Abduction of 221
Diseased Limb
118. Thomas' Hip-splint applied for Disease of Right Hip 222
119. Arthritis Deformans, showing erosion of Cartilage and 225
lipping of Articular Edge of Head of Femur
120. Upper End of Femur in advanced Arthritis Deformans 226
of Hip
121. Femur in advanced Arthritis Deformans of Hip and Knee 227
Joints
122. Tuberculous Synovial Membrane of Knee 230
123. Lower End of Femur from an Advanced Case of Tuberculous 231
Arthritis of the Knee
124. Advanced Tuberculous Disease of Knee, with Backward 233
Displacement of Tibia
125. Thomas' Knee-splint applied 236
126. Tuberculous Disease of Right Ankle 239
127. Female Child showing the results of Poliomyelitis 243
affecting the Left Lower Extremity
128. Radiogram of Double Congenital Dislocation of Hip in 249
a Girl
129. Innominate Bone and Upper End of Femur from a case of 250
Congenital Dislocation of Hip
130. Congenital Dislocation of Left Hip in a Girl 251
131. Contracture Deformities of Upper and Lower Limbs 255
resulting from Spastic Cerebral Palsy in Infancy
132. Rachitic Coxa Vara 258
133. Coxa Vara, showing Adduction Curvature of Neck of Femur 260
associated with Arthritis of the Hip and Knee
134. Bilateral Coxa Vara, showing Scissors-leg Deformity 260
135. Genu Valgum and Genu Varum 265
136. Female Child with Right-sided Genu Valgum, the result of 266
Rickets
137. Double Genu Valgum; and Rickety Deformities of Arms 267
138. Radiogram of Case of Double Genu Valgum in a Child 268
139. Genu Valgum in a Child. Patient standing 269
140. Genu Valgum. Same Patient as Fig. 139, sitting 270
141. Bow-knee in Rickety Child 271
142. Bilateral Congenital Club-foot in an Infant 274
143. Radiogram of Bilateral Congenital Club-foot in an Infant 275
144. Congenital Talipes Equino-varus in a Man 277
145. Bilateral Pes Equinus in a Boy 280
146. Extreme form of Pes Equinus in a Girl 281
147. Skeleton of Foot from case of Pes Equinus due to 282
Poliomyelitis
148. Pes Calcaneo-valgus with excessive arching of Foot 284
149. Pes Calcaneo-valgus, the result of Poliomyelitis 285
150. Pes Cavus in Association with Pes Equinus, the Result 286
of Poliomyelitis
151. Radiogram of Foot of Adult, showing Changes in the 286
Bones in Pes Cavus
152. Adolescent Flat-Foot 287
153. Flat-Foot, showing Loss of Arch 288
154. Imprint of Normal and of Flat Foot 290
155. Bilateral Pes Valgus and Hallux Valgus in a Girl 293
156. Radiogram of Spur on Under Aspect of Calcaneus 295
157. Radiogram of Hallux Valgus 296
158. Radiogram of Hallux Varus or Pigeon-Toe 298
159. Hallux Rigidus and Flexus in a Boy 299
160. Hammer-Toe 300
161. Section of Hammer-Toe 301
162. Congenital Hypertrophy of Left Lower Extremity in a Boy 302
163. Supernumerary Great Toe 303
164. Congenital Elevation of Left Scapula in a Girl: also 304
shows Hairy Mole over Sacrum
165. Winged Scapula 305
166. Arrested Growth and Wasting of Tissues of Right Upper 307
Extremity
167. Lower End of Humerus from case of Cubitus Varus 309
168. Intra-Uterine Amputation of Forearm 310
169. Radiogram of Arm of Patient shown in Fig. 168 310
170. Congenital Absence of Left Radius and Tibia in a Child 311
171. Club-Hand, the Result of Imperfect Development of Radius 312
172. Congenital Contraction of Ring and Little Fingers 314
173. Dupuytren's Contraction 315
174. Splint used after Operation for Dupuytren's Contraction 316
175. Supernumerary Thumb 317
176. Trigger Finger 318
177. Multiple Wens 324
178. Adenoma of Scalp 325
179. Relations of the Motor and Sensory Areas to the 330
Convolutions and to Chiene's Lines
180. Diagram of the Course of Motor and Sensory Nerve Fibres 333
181. Chiene's Method of Cerebral Localisation 336
182. To illustrate the Site of Various Operations on the Skull 337
183. Localisation of Site for Introduction of Needle in Lumbar 338
Puncture
184. Contusion and Laceration of Brain 343
185. Charts of Pyrexia in Head Injuries 348
186. Relations of the Middle Meningeal Artery and Lateral 353
Sinus to the Surface as indicated by Chiene's Lines
187. Extra-Dural Clot resulting from Haemorrhage from the 354
Middle Meningeal Artery
188. Depressed Fracture of Frontal Bones with Fissured 365
Fracture
189. Depressed and Comminuted Fracture of Right Parietal 365
Bone: Pond Fracture
190. Pond Fracture of Left Frontal Bone, produced during 366
Delivery
191. Transverse Fracture through Middle Fossa of Base of Skull 368
192. Diagram of Extra-Dural Abscess 374
193. Pott's Puffy Tumour in case of Extra-Dural Abscess 375
following Compound Fracture of Orbital Margin
194. Diagram of Sub-Dural Abscess 376
195. Diagram illustrating sequence of Paralysis, caused by 380
Abscess in Temporal Lobe
196. Chart of case of Sinus Phlebitis following Middle Ear 384
Disease
197. Occipital Meningocele 388
198. Frontal Hydrencephalocele 389
199. Naevus at Root of Nose, simulating Cephalocele 390
200. Hydrocephalus in a Child 391
201. Patient suffering from Left Facial Paralysis 402
202. Skull of Woman illustrating the appearances of Tertiary 408
Syphilis of Frontal Bone--Corona Veneris--in the Healed
Condition
203. Sarcoma of Orbital Plate of Frontal Bone in a Child at 409
Age of 11 months and 18 months
204. Destruction of Bones of Left Orbit, caused by Rodent 410
Cancer
205. Distribution of the Segments of the Spinal Cord 417
206. Attitude of Upper Extremities in Traumatic Lesions of 418
the Sixth Cervical Segment
207. Compression Fracture of Bodies of Third and Fourth 426
Lumbar Vertebrae
208. Fracture-Dislocation of Ninth Thoracic Vertebra 428
209. Fracture of Odontoid Process of Axis Vertebra 429
210. Tuberculous Osteomyelitis affecting several Vertebrae at 432
Thoracico-Lumbar Junction
211. Osseous Ankylosis of Bodies (_a_) of Dorsal Vertebrae, 434
(_b_) of Lumbar Vertebrae following Pott's Disease
212. Radiogram of Museum Specimen of Pott's Disease in a Child 435
213. Radiogram of Child's Thorax showing Spindle-shaped 437
Shadow at Site of Pott's Disease of Fourth, Fifth, and
Sixth Thoracic Vertebrae
214. Attitude of Patient suffering from Tuberculous Disease 441
of the Cervical Spine
215. Thomas' Double Splint for Tuberculous Disease of the 442
Spine
216. Hunch-back Deformity following Pott's Disease of Thoracic 443
Vertebrae
217. Attitude in Pott's Disease of Thoracico-Lumbar Region of 444
Spine
218. Arthritis Deformans of Spine 449
219. Meningo-Myelocele of Thoracico-Lumbar Region 454
220. Meningo-Myelocele of Cervical Spine 454
221. Meningo-Myelocele in Thoracic Region 456
222. Tail-like Appendage over Spina Bifida Occulta in a Boy 457
223. Congenital Sacro-Coccygeal Tumour 458
224. Scoliosis following upon Poliomyelitis affecting Right 463
Arm and Leg
225. Rickety Scoliosis in a Child 464
226. Vertebrae from case of Scoliosis showing Alteration in 466
Shape of Bones
227. Adolescent Scoliosis in a Girl 467
228. Scoliosis with Primary Curve in Thoracic Region 468
229. Scoliosis showing Rotation of Bodies of Vertebrae, and 469
widening of Intercostal Spaces on side of Convexity
230. Diagram of Attitudes in Klapp's Four-Footed Exercises for 473
Scoliosis
231. Head of Human Embryo about 29 days old 475
232. Simple Hare-Lip 476
233. Unilateral Hare-Lip with Cleft Alveolus 477
234. Double Hare-Lip in a Girl 478
235. Double Hare-Lip with Projection of the Os Incisivum 479
236. Asymmetrical Cleft Palate extending through Alveolar 480
Process on Left Side
237. Illustrating the Deformities caused by Lupus Vulgaris 483
238. Sarcoma of Orbit causing Exophthalmos and Downward 488
Displacement of the Eye, and Projecting in Temporal
Region
239. Sarcoma of Eyelid in Child 489
240. Dermoid Cyst at Outer Angle of Orbital Margin 490
241. Macrocheilia 492
242. Squamous Epithelioma of Lower Lip in a Man 493
243. Advanced Epithelioma of Lower Lip 494
244. Recurrent Epithelioma in Glands of Neck adherent to 495
Mandible
245. Cancrum Oris 497
246. Perforation of Palate, the Result of Syphilis, and Gumma 498
of Right Frontal Bone
247. Cario-necrosis of Mandible 510
248. Diffuse Syphilitic Disease of Mandible 512
249. Epulis of Mandible 513
250. Sarcoma of the Maxilla 515
251. Malignant Disease of Left Maxilla 516
252. Dentigerous Cyst of Mandible containing Rudimentary Tooth 517
253. Osseous Shell of Myeloma of Mandible 518
254. Multiple Fracture of Mandible 520
255. Four-Tailed Bandage applied for Fracture of Mandible 522
256. Defective Development of Mandible from Fixation of Jaw 526
due to Tuberculous Osteomyelitis in Infancy
257. Leucoplakia of the Tongue 531
258. Papillomatous Angioma of Left Side of Tongue in a Woman 538
259. Dermoid Cyst in Middle Line of Neck 539
260. Temporary Unilateral Paralysis of Tongue 541
261. Series of Salivary Calculi 545
262. Acute Suppurative Parotitis 546
263. Mixed Tumour of Parotid 550
264. Mixed Tumour of the Parotid of over twenty years' 551
duration
265. Acute Mastoid Disease showing Oedema and Projection of 565
Auricle
266. Rhinophyma or Lipoma Nasi 569
267. The Outer Wall of Left Nasal Chamber after removal of 571
the Middle Turbinated Body
268. Congenital Branchial Cyst in a Woman 584
269. Bilateral Cervical Ribs 586
270. Transient Wry-Neck 587
271. Congenital Wry-Neck in a Boy 589
272. Congenital Wry-Neck seen from behind to show Scoliosis 590
273. Recovery from Suicidal Cut-Throat after Low Tracheotomy 596
and Gastrostomy
274. Hygroma of Neck 599
275. Lympho-Sarcoma of Neck 600
276. Branchial Carcinoma 601
277. Parenchymatous Goitre in a Girl 606
278. Larynx and Trachea surrounded by Goitre 607
279. Section of Goitre shown in Fig. 278 to illustrate 607
Compression of Trachea
280. Multiple Adenomata of Thyreoid in a Woman 611
281. Cyst of Left Lobe of Thyreoid 612
282. Exophthalmic Goitre 614
283. Radiogram of Safety-Pin impacted in the Gullet and 620
Perforating the Larynx
284. Denture Impacted in Oesophagus 621
285. Radiogram, after swallowing an Opaque Meal, in a Man 626
suffering from Malignant Stricture of Lower End of Gullet
286. Diverticulum of the Oesophagus at its Junction with the 627
Pharynx
287. Larynx from case of Sudden Death due to Oedema of 637
Ary-Epiglottic Folds
288. Papilloma of Larynx 641
MANUAL OF SURGERY
CHAPTER I
INJURIES OF BONES
Contusions--Wounds--FRACTURES: _Pathological_; _Traumatic_;
_Varieties_--Simple fractures--Compound fractures--Repair of
fractures--Interference with repair--Gun-shot
fractures--SEPARATION OF EPIPHYSES.
The injuries to which a bone is liable are Contusions, Open Wounds,
and Fractures.
#Contusions of Bone# are almost of necessity associated with a similar
injury of the overlying soft parts. The mildest degree consists in a
bruising of the periosteum, which is raised from the bone by an
effusion of blood, constituting a _haematoma of the periosteum_. This
may be absorbed, or it may give place to a persistent thickening of
the bone--_traumatic node_.
#Open Wounds of Bone# of the incised and contused varieties are
usually produced by sabres, axes, butcher's knives, scythes, or
circular saws. Punctured wounds are caused by bayonets, arrows, or
other pointed instruments. They are all equivalent to compound,
incomplete fractures.
FRACTURES
A fracture may be defined as a sudden solution in the continuity of a
bone.
PATHOLOGICAL FRACTURES
A pathological fracture has as its primary cause some diseased state
of the bone, which permits of its giving way on the application of a
force which would be insufficient to break a healthy bone. It cannot
be too strongly emphasised that when a bone is found to have been
broken by a slight degree of violence, the presence of some
pathological condition should be suspected, and a careful examination
made with the X-rays and by other means, before arriving at a
conclusion as to the cause of the fracture. Many cases are on record
in which such an accident has first drawn attention to the presence of
a new-growth, or other serious lesion in the bone. The following
conditions, which are more fully described with diseases of bone, may
be mentioned as the causes of pathological fractures.
_Atrophy_ of bone may proceed to such an extent in old people, or in
those who for long periods have been bed-ridden, that slight violence
suffices to determine a fracture. This most frequently occurs in the
neck of the femur in old women, the mere catching of the foot in the
bedclothes while the patient is turning in bed being sometimes
sufficient to cause the bone to give way. Atrophy from the pressure of
an aneurysm or of a simple tumour may erode the whole thickness of a
bone, or may thin it out to such an extent that slight force is
sufficient to break it. In general paralysis, and in the advanced
stages of locomotor ataxia and other chronic diseases of the nervous
system, an atrophy of all the bones sometimes takes place, and may
proceed so far that multiple fractures are induced by comparatively
slight causes. They occur most frequently in the ribs or long bones of
the limbs, are not attended with pain, and usually unite
satisfactorily, although with an excessive amount of callus.
Attendants and nurses, especially in asylums, must be warned against
using force in handling such patients, as otherwise they may be
unfairly blamed for causing these fractures.
Among diseases which affect the skeleton as a whole and render the
bones abnormally fragile, the most important are rickets,
osteomalacia, and fibrous osteomyelitis. In these conditions multiple
pathological fractures may occur, and they are prone to heal with
considerable deformity. In osteomalacia, the bones are profoundly
altered, but they are more liable to bend than to break; in rickets
the liability is towards greenstick fractures.
Of the diseases affecting individual bones and predisposing them to
fracture may be mentioned suppurative osteomyelitis, hydatid cysts,
tuberculosis, syphilitic gummata, and various forms of new-growth,
particularly sarcoma and secondary cancer. It is not unusual for the
sudden breaking of the bone to be the first intimation of the presence
of a new-growth. In adolescents, fibrous osteomyelitis affecting a
single bone, and in adults, secondary cancer, are the commonest local
causes of pathological fracture.
_Intra-uterine fractures_ and fractures occurring _during birth_ are
usually associated with some form of violence, but in the majority of
cases the foetus is the subject of constitutional disease which
renders the bones unduly fragile.
TRAUMATIC FRACTURES
Traumatic fractures are usually the result of a severe force acting
from without, although sometimes they are produced by muscular
contraction.
When the bone gives way at the point of impact of the force, the
violence is said to be _direct_, and a "fracture by compression"
results, the line of fracture being as a rule transverse. The soft
parts overlying the fracture are more or less damaged according to the
weight and shape of the impinging body. Fracture of both bones of the
leg from the passage of a wheel over the limb, fracture of the shaft
of the ulna in warding off a stroke aimed at the head, and fracture of
a rib from a kick, are illustrative examples of fractures by direct
violence.
When the force is transmitted to the seat of fracture from a distance,
the violence is said to be _indirect_, and the bone is broken by
"torsion" or by "bending." In such cases the bone gives way at its
weakest point, and the line of fracture tends to be oblique. Thus both
bones of the leg are frequently broken by a person jumping from a
height and landing on the feet, the tibia breaking in its lower third,
and the fibula at a higher level. Fracture of the clavicle in its
middle third, or of the radius at its lower end, from a fall on the
outstretched hand, are common accidents produced by indirect violence.
The ribs also may be broken by indirect violence, as when the chest is
crushed antero-posteriorly and the bones give way near their angles.
In fractures by indirect violence the soft parts do not suffer by the
violence causing the fracture, but they may be injured by displacement
of the fragments.
In fractures by _muscular action_ the bone is broken by "traction" or
"tearing." The sudden and violent contraction of a muscle may tear off
an epiphysis, such as the head of the fibula, the anterior superior
iliac spine, or the coronoid process of the ulna; or a bony process
may be separated, as, for example, the tuberosity of the calcaneus,
the coracoid process of the scapula, or the larger tubercle (great
tuberosity) of the humerus. Long bones also may be broken by muscular
action. The clavicle has snapped across during the act of swinging a
stick, the humerus in throwing a stone, and the femur when a kick has
missed its object. Fractures of ribs have occurred during fits of
coughing and in the violent efforts of parturition.
Before concluding that a given fracture is the result of muscular
action, it is necessary to exclude the presence of any of the diseased
conditions that lead to pathological fracture.
Although the force acting upon the bone is the primary factor in the
production of fractures, there are certain subsidiary factors to be
considered. Thus the age of the patient is of importance. During
infancy and early childhood, fractures are less common than at any
other period of life, and are usually transverse, incomplete, and of
the nature of bends. During adult life, especially between the ages of
thirty and forty, the frequency of fractures reaches its maximum. In
aged persons, although the bones become more brittle by the marrow
spaces in their interior becoming larger and filled with fat,
fractures are less frequent, doubtless because the old are less
exposed to such violence as is likely to produce fracture.
Males, from the nature of their occupations and recreations, sustain
fractures more frequently than do females; in old age, however,
fractures are more common in women than in men, partly because their
bones are more liable to be the seat of fatty atrophy from senility
and disease, and partly because of their clothing--a long skirt--they
are more exposed to unexpected or sudden falls.
[Illustration: FIG. 1.--Multiple Fracture of both Bones of Leg.]
#Clinical Varieties of Fractures.#--The most important subdivision of
fractures is that into simple and compound.
In a _simple_ or subcutaneous fracture there is no communication,
directly or indirectly, between the broken ends of the bone and the
surface of the skin. In a _compound_ or open fracture, on the other
hand, such a communication exists, and, by furnishing a means of
entrance for bacteria, may add materially to the gravity of the
injury.
A simple fracture may be complicated by the existence of a wound of
the soft parts, which, however, does not communicate with the broken
bone.
Fractures, whether simple or compound, fall into other clinical
groups, according to (1) the degree of damage done to the bone, (2)
the direction of the break, and (3) the relative position of the
fragments.
(1) _According to the Degree of Damage done to the Bone._--A fracture
may be incomplete, for example in _greenstick fractures_, which occur
only in young persons--usually below the age of twelve--while the
bones are still soft and flexible. They result from forcible bending
of the bone, the osseous tissue on the convexity of the curve giving
way, while that on the concavity is compressed. The clavicle and the
bones of the forearm are those most frequently the seat of greenstick
fracture (Fig. 41). _Fissures_ occur on the flat bones of the skull,
the pelvic bones, and the scapula; or in association with other
fractures in long bones, when they often run into joint surfaces.
_Depressions_ or indentations are most common in the bones of the
skull.
The bone at the seat of fracture may be broken into several pieces,
constituting a _comminuted_ fracture. This usually results from severe
degrees of direct violence, such as are sustained in railway or
machinery accidents, and in gun-shot injuries (Fig. 2).
[Illustration: FIG. 2.--Radiogram of Comminuted Fracture of both Bones
of Forearm.]
_Sub-periosteal_ fractures are those in which, although the bone is
completely broken across, the periosteum remains intact. These are
common in children, and as the thick periosteum prevents displacement,
the existence of a fracture may be overlooked, even in such a large
bone as the femur.
A bone may be broken at several places, constituting a _multiple_
fracture (Fig. 1).
_Separation of bony processes_, such as the coracoid process, the
epicondyle of the humerus, or the tuberosity of the calcaneus, may
result from muscular action or from direct violence. _Separation of
epiphyses_ will be considered later.
(2) _According to the Direction of the Break._--_Transverse_ fractures
are those in which the bone gives way more or less exactly at right
angles to its long axis. These usually result from direct violence or
from end-to-end pressure. _Longitudinal_ fractures extending the
greater part of the length of a long bone are exceedingly rare.
_Oblique_ fractures are common, and result usually from indirect
violence, bending, or torsion (Fig. 3). _Spiral_ fractures result from
forcible torsion of a long bone, and are met with most frequently in
the tibia, femur, and humerus.
[Illustration: FIG. 3.--Showing (1) Oblique fracture of Tibia; (2)
Oblique fracture with partial separation of Epiphysis of upper end of
Fibula; (3) Incomplete fracture of Fibula in upper third. Result of
railway accident. Boy aet. 16.]
(3) _According to the Relative Position of the Fragments._--The bone
may be completely broken across, yet its ends remain in apposition,
in which case there is said to be _no displacement_. There may be an
_angular_ displacement--for example, in greenstick fracture. In
transverse fractures of the patella or of the olecranon there is often
_distraction_ or pulling apart of the fragments (Fig. 35). The broken
ends, especially in oblique fractures, may _override_ one another, and
so give rise to shortening of the limb (Fig. 2). Where one fragment is
acted upon by powerful muscles, a _rotatory_ displacement may take
place, as in fracture of the radius above the insertion of the
pronator teres, or of the femur just below the small trochanter. The
fragments may be _depressed_, as in the flat bones of the skull or the
nasal bones. At the cancellated ends of the long bones, particularly
the upper end of the femur and humerus, and the lower end of the
radius, it is not uncommon for one fragment to be _impacted_ or wedged
into the substance of the other (Fig. 28).
_Causes of Displacement._--The factors which influence displacement
are chiefly mechanical in their action. Thus the direction and nature
of the fracture play an important part. Transverse fractures with
roughly serrated ends are less liable to displacement than those which
are oblique with smooth surfaces. The direction of the causative force
also is a dominant factor in determining the direction in which one or
both of the fragments will be displaced. Gravity, acting chiefly upon
the distal fragment, also plays a part in determining the
displacement--for example, in fractures of the thigh or of the leg,
where the lower segment of the limb rolls outwards, and in fractures
of the shaft of the clavicle, where the weight of the arm carries the
shoulder downwards, forwards, and medially. After the break has taken
place and the force has ceased to act, displacement may be produced by
rough handling on the part of those who render first aid, the careless
or improper application of splints or bandages, or by the weight of
the bedclothes.
In certain situations the contraction of unopposed, or of unequally
opposed, groups of muscles plays a part in determining displacement.
For example, in fracture immediately below the lesser trochanter of
the femur, the ilio-psoas tends to tilt the upper fragment forward and
laterally; in supra-condylar fracture of the femur, the muscles of the
calf pull the lower fragment back towards the popliteal space; and in
fracture of the humerus above the deltoid insertion, the muscles
inserted into the inter-tubercular (bicipital) groove adduct the upper
fragment.
REPAIR OF INJURIES OF BONE
In a _simple fracture_ the vessels of the periosteum and the marrow
being torn at the same time as the bone is broken, blood is poured
out, and clots around and between the fragments. This clot is soon
permeated by newly formed blood vessels, and by leucocytes and
fibroblasts, the latter being derived from proliferation of the cells
of the marrow and periosteum. The granulation tissue thus formed
resembles in every particular that described in the repair of other
tissues, except that the fibroblasts, being the offspring of cells
which normally form bone, assume the functions of _osteoblasts_, and
proceed to the formation of bone. The new bone may be formed either by
a direct conversion of the fibrous tissue into osseous tissue, the
osteoblasts arranging themselves concentrically in the recesses of the
capillary loops, and secreting a homogeneous matrix in which lime
salts are speedily deposited; or there may be an intermediate stage of
cartilage formation, especially in young subjects, and in cases where
the fragments are incompletely immobilised. The newly formed bone is
at first arranged in little masses or in the form of rods which unite
with each other to form a network of spongy bone, the meshes of which
contain marrow.
The reparative material, consisting of granulation tissue in the
process of conversion into bone, is called _callus_, on account of its
hard and unyielding character. In a fracture of a long bone, that
which surrounds the fragments is called the _external_ or _ensheathing
callus_, and may be likened to the mass of solder which surrounds the
junction of pipes in plumber-work; that which occupies the position of
the medullary canal is called the _internal_ or _medullary callus_;
and that which intervenes between the fragments and maintains the
continuity of the cortical compact tissue of the shaft is called the
_intermediate callus_. This intermediate callus is the only permanent
portion of the reparative material, the external and internal callus
being only temporary, and being largely re-absorbed through the agency
of giant cells.
Detached fragments or splinters of bone are usually included in the
callus and ultimately become incorporated in the new bone that bridges
the gap.
In time all surplus bone is removed, the medullary canal is re-formed,
the young spongy bone of the intermediate callus becomes more and more
compact, and thus the original architectural arrangement of the bone
may be faithfully reproduced. If, however, apposition is not perfect,
some of the new bone is permanently required and some of the old bone
is absorbed in order to meet the altered physiological strain upon the
bone resulting from the alteration in its architectural form. In
overriding displacement, even the dense cortical bone intervening
between the medullary canal of the two fragments is ultimately
absorbed and the continuity of the medullary canal is reproduced.
The amount of callus produced in the repair of a given fracture is
greater when movement is permitted between the broken ends. It is also
influenced by the character of the bone involved, being less in bones
entirely ossified in membrane, such as the flat bones of the skull,
than in those primarily ossified in cartilage.
If the fragments are widely separated from one another, or if some
tissue, such as muscle, intervenes between them, callus may not be
able to bring about a bony union between the fragments, and
_non-union_ results.
Bones divided in the course of an operation, for example in osteotomy
for knock-knee, or wedge-shaped resection for bow-leg, are repaired by
the same process as fractures.
#Excess of Callus.#--In comminuted fractures, and in fractures in
which there is much displacement, the amount of callus is in excess,
but this is necessary to ensure stability. In fractures in the
vicinity of large joints, such as the hip or elbow, the formation of
callus is sometimes excessive, and the projecting masses of new bone
restrict the movements of the joint. When exuberant callus forms
between the bones in fractures of the forearm, pronation and
supination may be interfered with (Fig. 4). Certain nerve-trunks, such
as the radial (musculo-spiral) in the middle of the arm, or the ulnar
at the elbow-joint, may become included in or pressed upon by callus.
[Illustration: FIG. 4.--Excess of Callus after compound fracture of
Bones of Forearm.]
#Absorption of Callus.#--It sometimes happens that when an acute
infective disease, especially one of the exanthemata, supervenes while
a fracture is undergoing repair, the callus which has formed becomes
softened and is absorbed. This may occur weeks or even months after
the bone has united, with the result that the fragments again become
movable, and it may be a considerable time before union finally takes
place.
#Tumours of Callus.#--Tumours, such as chondroma and sarcoma, and
cysts which are probably of the same nature as those met with in
osteomyelitis fibrosa, are liable to occur in callus, or at the seat
of old fractures, but the evidence so far is inconclusive as to the
causative relationship of the injury to the new-growth. They are
treated on the same lines as tumours occurring independently of
fracture.
#Badly United Fracture--Mal-Union.#--Union with marked displacement of
the fragments is most common in fractures that have not been properly
treated--as, for example, those occurring in sailors at sea; and in
cases in which the comminution was so great that accurate apposition
was rendered impossible. It may also result from imperfect reduction,
or because the apparatus employed permitted of secondary displacement.
Restlessness on the part of the patient from intractability, delirium
tremens, or mania, is the cause of mal-union in some cases; sometimes
it has resulted because the patient was expected to die from some
other lesion and the fracture was left untreated.
Whether or not any attempt should be made to improve matters depends
largely on the degree of deformity and the amount of interference with
function.
When interference is called for, if the callus is not yet firmly
consolidated, it may be possible, under an anaesthetic, to bend the
bone into position or to re-break it, either with the hands or by
means of a strong mechanical contrivance known as an osteoclast. In
the majority of cases, however, an open operation yields results which
are more certain and satisfactory. When the deformity is comparatively
slight, the bone is divided with an osteotome and straightened; when
there is marked bending or angling, a wedge is taken from the
convexity, as in the operation for bow-leg. To maintain the fragments
in apposition it may be necessary to employ pegs, plates, bone-grafts,
or other mechanical means. Splints and extension are then applied, and
the condition is treated on the same lines as a compound fracture.
[Illustration: FIG. 5.--Multiple Fractures of both Bones of Forearm
showing mal-union.]
#Delayed Union.#--At the time when union should be firm and solid, it
may be found that the fragments are only united by a soft
cartilaginous callus, which for a prolonged period may undergo no
further change, so that the limb remains incapable of bearing weight
or otherwise performing its functions. The normal period required for
union may be extended from various causes. The most important of these
is general debility, but the presence of rickets or tuberculosis, or
an intercurrent acute infectious disease, may delay the reparative
process. The influence of syphilis, except in its gummatous form, in
interfering with union is doubtful. The influence of old age as a
factor in delaying union has been overestimated; in the great majority
of cases, fractures in old people unite as rapidly and as firmly as
those occurring at other periods of life.
_Treatment._--The general condition of the patient should be improved,
by dieting and tonics. One of the most reliable methods of hastening
union in these cases is by inducing passive hyperaemia of the limb
after the method advocated by Bier, and this plan should always be
tried in the first instance. An elastic bandage is applied above the
seat of fracture, sufficiently tightly to congest the limb beyond,
and, to concentrate the congestion in the vicinity of the fracture, an
ordinary bandage should be applied from the distal extremity to within
a few inches of the break. The hyperaemia should be maintained for
several hours (six to twelve) daily. An apparatus should be adjusted
to enable the patient to get into the open air, and in fractures of
the lower extremity the patient should move about with crutches in the
intervals, putting weight on the fractured bone. This method of
treatment should be persevered with for three or four weeks, and the
limb should be massaged daily while the constricting bandage is off.
Among the other methods which have been recommended are the injection
between the fragments of oil of turpentine (Mikulicz), a quantity of
the patient's own blood (Schmieden), or alcohol and iodine; the
forcible rubbing of the ends together, under an anaesthetic if
necessary; and the administration of thyreoid extract. If these
methods fail, the case should be treated as one of un-united fracture.
As a rule, satisfactory union is ultimately obtained, although much
patience is required.
#Non-Union.#--Sometimes the fragments become united by a dense band of
fibrous tissue, and the reparative process goes no further--_fibrous
union_. This is frequently the case in fractures of the patella, the
olecranon, and the narrow part of the neck of the femur.
_False Joint--Pseudarthrosis._--In rare cases the ends of the
fragments become rounded and are covered with a layer of cartilage.
Around their ends a capsule of fibrous tissues forms, on the inner
aspect of which a layer of endothelium develops and secretes a
synovia-like fluid. This is met with chiefly in the humerus and in the
clavicle.
_Failure of Union--"Un-united Fracture."_--As the time taken for union
varies widely in different bones, and ossification may ultimately
ensue after being delayed for several months, a fracture cannot be
said to have failed to unite until the average period has been long
overpassed and still there is no evidence of fusion of the fragments.
Under these conditions failure of union is a rare complication of
fractures. In adults it is most frequently met with in the humerus,
the radius and ulna (Fig. 6), and the femur; in children in the bones
of the leg and in the forearm.
[Illustration: FIG. 6.--Radiogram of Un-united Fracture of Shaft of
Ulna of fifteen years' duration.]
In a radiogram the bones in the vicinity of the fracture, particularly
the distal fragment, cast a comparatively faint shadow, and there may
even be a clear space between the fragments. When the parts are
exposed by operation, the bone is found to be soft and spongy and the
ends of the fragments are rarefied and atrophied; sometimes they are
pointed, and occasionally absorption has taken place to such an extent
that a gap exists between the fragments. The bone is easily penetrated
by a bradawl, and if an attempt is made to apply plates, the screws
fail to bite. These changes are most marked in the distal fragment.
The want of union is evidently due to defective activity of the
bone-forming cells in the vicinity of the fracture. This may result
from constitutional dyscrasia, or may be associated with a defective
blood supply, as when the nutrient artery is injured. Interference
with the trophic nerve supply may play a part, as cases are recorded
by Bognaud in which union of fractures of the leg failed to take place
after injuries of the spinal medulla causing paraplegia. The condition
has been attributed to local causes, such as the interposition of
muscle or other soft tissue between the fragments, or to the presence
of a separated fragment of bone or of a sequestrum following
suppuration. In our experience such factors are seldom present.
If the treatment recommended for delayed union fails, recourse must be
had to operation, the most satisfactory procedure being to insert a
bone graft in the form of an intra-medullary splint. In certain cases
met with in the bones of the leg in children, the degree of atrophy of
the bones is such that it has been found necessary to amputate after
repeated attempts to obtain union by operative measures have failed.
In the tibia we have found that with the double electric saw a rod of
bone can be rapidly and accurately cut, extending well above as well
as below the site of fracture but unequally in the two directions; the
rod is then reinserted into the trough from which it was taken _with
the ends reversed_, so that a strong bridge of bone is provided at the
seat of non-union.
CLINICAL FEATURES OF SIMPLE FRACTURES
In the first place, the _history of the accident_ should be
investigated, attention being paid to the nature of the
violence--whether a blow, a twist, a wrench, or a crush, and whether
the violence was directly or indirectly applied. The degree of the
violence may often be judged approximately from the instrument
inflicting it--whether, for example, a fist, a stick, a cart wheel, or
a piece of heavy machinery. The position of the limb at the time of
the injury; whether the muscles were braced to meet the blow or were
lax and taken unawares; and the patient's sensations at the moment,
such as his feeling something snap or tear, may all furnish
information useful for purposes of diagnosis.
_Signs of Fracture._--The most characteristic signs of fracture are
unnatural mobility, deformity, and crepitus.
_Unnatural mobility_--that is, movement between two segments of a limb
at a place where movement does not normally occur--may be evident when
the patient makes attempts to use his limb, or may only be elicited
when the fragments are seized and moved in opposite directions.
_Deformity_, or the part being "out of drawing" in comparison with the
normal side, varies with the site and direction of the break, and
depends upon the degree of displacement of the fragments. _Crepitus_
is the name applied to the peculiar grating or clicking which may be
heard or felt when the fractured surfaces are brought into contact
with one another.
The presence of these three signs in association is sufficient to
prove the existence of a fracture, but the absence of one or more of
them does not negative this diagnosis. There are certain fallacies to
be guarded against. For example, a fracture may exist and yet
unnatural mobility may not be present, because the bones are impacted
into one another, or because the fracture is an incomplete one. Again,
the extreme tension of the swollen tissues overlying the fracture may
prevent the recognition of movement between the fragments. Deformity
also may be absent--as, for instance, when there is no displacement of
the fragments, or when only one of two parallel bones is broken, as in
the leg or forearm. Similarly, crepitus may be absent when impaction
exists, when the fragments completely override one another, or are
separated by an interval, or when soft tissues, such as torn
periosteum or muscle, are interposed between them. A sensation
simulating crepitus may be felt on palpating a part into which blood
has been extravasated, or which is the seat of subcutaneous emphysema.
The creaking which accompanies movements in certain forms of
teno-synovitis and chronic joint disease, and the rubbing of the
dislocated end of a bone against the tissues amongst which it lies,
may also be mistaken for the crepitus of fracture.
It is not advisable to be too diligent in eliciting these signs,
because of the pain caused by the manipulations, and also because
vigorous handling may do harm by undoing impaction, causing damage to
soft parts or producing displacement which does not already exist, or
by converting a simple into a compound fracture.
It is often necessary for purposes of diagnosis to administer a
general anaesthetic, particularly in injuries of deeply placed bones
and in the vicinity of joints. Before doing so, the appliances
necessary for the treatment of the injury should be made ready, in
order that the fracture may be reduced and set before the patient
regains consciousness.
_Radiography in the Diagnosis of Fractures._--While radiography is of
inestimable value in the diagnosis of many fractures and other
injuries, particularly in the vicinity of joints, the student is
warned against relying too implicitly on the evidence it seems to
afford.
A radiogram is not a photograph of the object exposed to the X-rays
but merely a picture of its shadow, or rather of a series of shadows
of the different structures, which vary in opacity. As the rays
emanate from a single point in the vacuum tube, and as they are not,
like the sun's rays, approximately parallel, the shadows they cast are
necessarily distorted. Hence, in interpreting a radiogram, it is
necessary to know the relative positions of the point from which the
rays proceed, the object exposed, and the plate on which the shadow is
registered. The least distortion takes place when the object is in
contact with the plate, and the shadow of that part of the object
which lies perpendicularly under the light is less distorted than that
of the parts lying outside the perpendicular. The light and the plate
remaining constant, the amount of distortion varies directly with the
distance between the object and the plate.
To ensure accuracy in the diagnosis of fracture by the X-rays, it is
necessary to take two views of the limb--one in the sagittal and the
other in the coronal plane. By the use of the fluorescent screen, the
best positions from which to obtain a clear impression of the fracture
may be determined before the radiograms are taken. Stereoscopic
radiograms may be of special value in demonstrating the details of a
fracture that is otherwise doubtful.
Imperfect technique and faulty interpretation of the pictures obtained
lead to certain fallacies. In young subjects, for example, epiphysial
lines may be mistaken for fractures, or the ossifying centres of
epiphyses for separated fragments of bone. The os trigonum tarsi has
been mistaken for a fracture of the talus. In the vicinity of joints
the bones may be crossed by pale bands, due to the rays traversing the
cavity of the joint. In this way fracture of the olecranon or of the
clavicle may be simulated. The neck of the femur may appear to be
fractured if a foreshortened view is taken.
It is possible, on the other hand, to overlook a fracture--for
example, if there is no displacement, or if the line of fracture is
crossed by the shadow of an adjacent bone. In deeply placed bones such
as those about the hip, or in bones related to dense, solid
viscera--for example, ribs, sternum, or dorsal vertebrae--it is
sometimes difficult to obtain conclusive evidence of fracture in a
radiogram.
It is to be borne in mind also, and especially from the medico-legal
point of view, that, as early callus does not cast a deep shadow in a
radiogram, the appearance of fracture may persist after union has
taken place. The earliest shadow of callus appears in from fourteen to
twenty-one days, and can hardly be relied upon till the fourth or
sixth week. The disturbed perspective produced by divergence of the
rays may cause the fragments of a fracture to appear displaced,
although in reality they are in good position. If the limb and the
plate are not parallel, the bones may appear to be distorted, and
errors in diagnosis may in this way arise. In this relation it should
be mentioned that perfect apposition of the fragments and anatomically
accurate restoration of the outline of the bones are not always
essential to a good functional result.
* * * * *
As most of the remaining signs are common to all the lesions from
which fractures have to be distinguished, their diagnostic value must
be carefully weighed.
_Interference with Function._--As a rule, a broken bone is incapable
of performing its normal function as a lever or weight-bearer; but
when a fracture is incomplete, when the fragments are impacted, or
when only one of two parallel bones is broken, this does not
necessarily follow. It is no uncommon experience to find a patient
walk into hospital with an impacted fracture of the neck of the femur
or a fracture of the fibula; or to be able to pronate and supinate the
forearm with a greenstick fracture of the radius or a fracture of the
ulna.
_Pain._--Three forms of pain may be present in fractures: pain
independent of movement or pressure; pain induced by movement of the
limb; and pain elicited on pressure or "tenderness." In injuries by
direct violence, pain independent of movement and pressure is never
diagnostic of fracture, as it may be due to bruising of soft tissues.
In injuries resulting from indirect violence, however, pain localised
to a spot at some distance from the point of impact is strongly
suggestive of fracture--as, for example, when a patient complains of
pain over the clavicle after a fall on the hand, or over the upper end
of the fibula after a twist of the ankle. Pain elicited by attempts to
move the damaged part, or by applying pressure over the seat of
injury, is more significant of fracture. Pain elicited at a particular
point on pressing the bone at a distance, "pain on distal
pressure,"--for example, pain at the lower end of the fibula on
pressing near its neck, or at the angle of a rib on pressing near the
sternum,--is a valuable diagnostic sign of fracture. When nerve-trunks
are implicated in the vicinity of a fracture, pain is often referred
along the course of their distribution.
_Localised swelling_ comes on rapidly, and is due to displacement of
the fragments and to haemorrhage from the torn vessels of the marrow
and periosteum.
_Discoloration_ accompanies the swelling, and is often widespread,
especially in fracture of bones near the surface and when the tension
is great. It is not uncommon to find over the ecchymosed area,
especially over the shin-bone, large blebs containing blood-stained
serum. In fractures of deep-seated bones, discoloration may only show
on the surface after some days, and at a distance from the break.
Alterations in the relative position of _bony landmarks_ are valuable
diagnostic guides. Alteration in the _length_ of the limb, usually in
the direction of shortening, is also an important sign. Before drawing
deductions, care must be taken to place both limbs in the same
position and to determine accurately the fixed points for measurement,
and also to ascertain if the limbs were previously normal.
_Shock_ is seldom a prominent symptom in uncomplicated fractures,
although in old and enfeebled patients it may be serious and even
fatal. During the first two or three days after a fracture there is
almost invariably some degree of traumatic _fever_, indicated by a
rise of temperature to 99 deg. or 100 deg. F.
#Complications.#--_Injuries to large arteries_ are not common in
simple fractures. The popliteal artery, however, is liable to be
compressed or torn across in fractures of the lower end of the femur;
extravasation of blood from the ruptured artery and gangrene of the
limb may result. If large _veins_ are injured, thrombosis may occur,
and be followed by pulmonary embolism.
_Injuries to nerve-trunks_ are comparatively common, especially in
fractures of the arm, where the radial (musculo-spiral) nerve is
liable to suffer.
The nerve may be implicated at the time of the injury, being
compressed, bruised, lacerated, or completely torn across by broken
fragments, or it may be involved later by the pressure of callus. The
symptoms depend upon the degree of damage sustained by the nerve, and
vary from partial and temporary interference with sensation and motion
to complete and permanent abrogation of function.
In rare instances _fat embolism_ is said to occur, and fat globules
are alleged to have been found in the urine. In persons addicted to
excess of alcohol, _delirium tremens_ is a not infrequent
accompaniment of a fracture which confines the patient to bed.
#Prognosis in Simple Fractures.#--_Danger to life_ in simple fractures
depends chiefly on the occurrence of complications. In old people, a
fracture of the neck of the femur usually necessitates long and
continuous lying on the back, and bronchitis, hypostatic pneumonia,
and bed-sores are prone to occur and endanger life. Fractures
complicated with injury to internal organs, and fractures in which
gangrene of the limb threatens, are, of course, of grave import.
The prognosis as regards the _function of the limb_ should always be
guarded, even in simple fractures. Incidental complications are liable
to arise, delaying recovery and preventing a satisfactory result, and
these not only lead to disappointment, but may even form a ground for
actions for malpraxis.
The chief and most frequent cause of permanent disability after
fracture is angular displacement. A comparatively small degree of
angularity may lead to serious loss of function, especially in the
lower limb; the joints above and below the fracture are placed at a
disadvantage, arthritic changes result from the abnormal strain to
which they are subjected, and rarefaction of the bone may also ensue.
Fibrous union is a common result in fractures of the neck of the femur
in old people and in certain other fractures, such as fracture of the
patella, of the olecranon, coronoid and coracoid processes, and
although this does not necessarily involve interference with function,
the patient should always be warned of the possibility.
Impairment of growth and eventual shortening of the limb may result
from involvement of an epiphysial junction.
Stiffness of joints is liable to follow fractures implicating
articular surfaces, or it may result from arthritic changes following
upon the injury.
Osseous ankylosis is not a common sequel of simple fractures, but
locking of joints from the mechanical impediment produced by the
union of imperfectly reduced fragments, or from masses of callus, is
not uncommon, especially in the region of the elbow.
Wasting of the muscles and oedema of the limb often delay the complete
restoration of function. Delayed union, want of union, and the
formation of a false joint have already been referred to.
#Treatment.#--The treatment of a fracture should be commenced as soon
after the accident as possible, before the muscles become contracted
and hold the fragments in abnormal positions, and before the blood and
serum effused into the tissues undergo organisation.
Care must be taken during the transport of the patient that no further
damage is done to the injured limb. To this end the part must be
secured in some form of extemporised splint, the apparatus being so
designed as to control not only the broken fragments, but also the
joints above and below the fracture.
When the ordinary method of removing the clothes involves any risk of
unduly moving the injured part, they should be slit open along the
seams.
The patient should be placed on a firm straw, horse-hair, or spring
mattress, stiffened in the case of fractures of the pelvis or lower
limbs by fracture-boards inserted beneath the mattress. Special
mattresses constructed in four pieces, to facilitate the nursing of
the patient, are sometimes used.
In many cases, particularly in muscular subjects, in restless
alcoholic patients, and in those who do not bear pain well, a general
anaesthetic is a valuable aid to the accurate setting of a fracture, as
well as a means of rendering the diagnosis more certain.
The procedure popularly known as "setting a fracture" consists in
restoring the displaced parts to their normal position as nearly as
possible, and is spoken of technically as the _reduction_ of the
fracture.
_The Reduction of Fractures._--In some cases the displacement may be
overcome by relaxing the muscles acting upon the fragments, and this
may be accomplished by the stroking movements of massage. In most
cases, however, it is necessary, after relaxing the muscles, to employ
_extension_, by making forcible but steady traction on the distal
fragment, while _counter-extension_ is exerted on the proximal one,
either by an assistant pulling upon that portion of the limb, or by
the weight of the patient's body. The fragments having been freed, and
any shortening of the limb corrected in this way, the broken ends are
moulded into position--a process termed _coaptation_.
The reduction of a recent greenstick fracture consists in forcibly
straightening the bend in the bone, and in some cases it is necessary
to render the fracture complete before this can be accomplished.
In selecting a means of retaining the fragments in position after
reduction, the various factors which tend to bring about
re-displacement must be taken into consideration, and appropriate
measures adopted to counteract each of these.
In addition to retaining the broken ends of the bone in apposition,
the after-treatment of a fracture involves the taking of steps to
promote the absorption of effused blood and serum, to maintain the
circulation through the injured parts, and to favour the repair of
damaged muscles and other soft tissues. Means must also be taken to
maintain the functional activity of the muscles of the damaged area,
to prevent the formation of adhesions in joints and tendon sheaths,
and generally to restore the function of the injured part.
_Practical Means of Effecting Retention--By Position._--It is often
found that only in one particular position can the fragments be made
to meet and remain in apposition--for example, the completely supine
position of the forearm in fracture of the radius just above the
insertion of the pronator teres. Again, in certain cases it is only by
relaxing particular groups of muscles that the displacement can be
undone--as, for instance, in fracture of the bones of the leg, or of
the femur immediately above the condyles, where flexion of the knee,
by relaxing the calf muscles, permits of reduction.
_Massage and Movement in the Treatment of
Fractures._--Lucas-Championniere, in 1886, first pointed out that a
certain amount of movement between the ends of a fractured bone
favours their union by promoting the formation of callus, and
advocated the treatment of fractures by massage and movement,
discarding almost entirely the use of splints and other
retentive appliances. We were early convinced by the teaching of
Lucas-Championniere, and have adopted his principles in fractures.
In the majority of cases the massage and movement are commenced at
once, but circumstances may necessitate their being deferred for a few
days. The measures adopted vary according to the seat and nature of
the fracture, but in general terms it may be stated that after the
fracture has been reduced, the ends of the broken bone are retained in
position, and gentle massage is applied by the surgeon or by a trained
masseur. The lubricant may either be a powder composed of equal parts
of talc and boracic acid, or an oily substance such as olive oil or
lanolin. The rubbing should never cause pain, but, on the contrary,
should relieve any pain that exists, as well as the muscular spasm
which is one of the most important causes of pain and of displacement
in recent fractures. The parts on the proximal side of the injured
area are first gently stroked upwards to empty the veins and
lymphatics, and to disperse the effused blood and serum. The process
is then applied to the swollen area, and gradually extended down over
the seat of the fracture and into the parts beyond. In this way the
circulation through the damaged segment of the limb is improved, the
veins are emptied of blood, the removal of effused fluid is
stimulated, and the muscular irritability allayed. The joints of the
limb are gently moved, care being taken that the broken ends of the
bone are not displaced. After the rubbing has been continued for from
fifteen to twenty minutes, the limb is placed in a comfortable
position, and retained there by pillows, sand-bags, or, if found more
convenient, by a light form of splint.
The massage is repeated once each day; the sittings last from ten to
fifteen minutes. The sequence should be, first, massage; second,
passive movement; and third, active movement. At first massage
predominates, and more passive than active movement; gradually massage
is lessened and movements are increased, active movements ultimately
preponderating.
_Splints and other Appliances._--The appropriate splints for
individual fractures and the method of applying them will be described
later; but it may here be said that the general principle is that when
dealing with a part where there is a single bone, as the thigh or
upper arm, the splint should be applied in the form of a _ferrule_ to
surround the break; while in situations where there are two parallel
bones, as in the forearm and leg, the splint should take the form of a
_box_.
_Simple wooden splints_ of plain deal board or yellow pine, sawn to
the appropriate length and width; or _Gooch's splinting_, which
consists of long strips of soft wood, glued to a backing of
wash-leather, are the most useful materials. Gooch's splinting has the
advantage that when applied with the leather side next the limb it
encircles the part as a ferrule; while it remains rigid when the
wooden side is turned towards the skin. Perforated sheet lead or tin,
stiff wire netting, and hoop iron also form useful splints.
When it is desirable that the splint should take the shape of the part
accurately, a plastic material may be employed. Perhaps the most
convenient is _poroplastic felt_, which consists of strong felt
saturated with resin. When heated before a fire or placed in boiling
water, it becomes quite plastic and may be accurately moulded to any
part, and on cooling it again becomes rigid. The splint should be cut
from a carefully fitted paper pattern. Millboard, leather, or
gutta-percha softened in hot water, and moulded to the part, may also
be employed.
In conditions where treatment by massage and movement is
impracticable, and where movable splints are inconvenient, splints of
_plaster of Paris_, _starch_, or _water-glass_ are sometimes used,
especially in the treatment of fractures of the leg. When employed in
the form of an immovable case, they are open to certain
objections--for example, if applied immediately after the accident
they are apt to become too tight if swelling occurs; and if applied
while swelling is still present, they become slack when this subsides,
so that displacement is liable to occur.
When it is desired to enclose the limb in a plaster case, coarse
muslin bandages, 3 yards long, and charged with the finest quality of
thoroughly dried plaster of Paris, are employed. The "acetic plaster
bandages" sold in the shops set most quickly and firmly. Boracic lint
or a loose stocking is applied next the skin, and the bony prominences
are specially padded. The plaster bandage is then placed in cold water
till air-bubbles cease to escape, by which time it is thoroughly
saturated, and, after the excess of water is squeezed out, is applied
in the usual way from below upward. From two to four plies of the
bandage are required. In the course of half an hour the plaster should
be thoroughly set. To facilitate the removal of a plaster case the
limb should be immersed for a short time in tepid water.
A convenient and efficient splint is made by moulding two pieces of
poroplastic felt to the sides of the limb, and fixing them in position
with an elastic webbing bandage; this apparatus can be easily removed
for the daily massage.
_Padding_ is an essential adjunct to all forms of splints. The whole
part enclosed in the splint must be covered with a thick layer of soft
and elastic material, such as wool from which the fat has not been
removed. All hollows should be filled up, and all bony projections
specially protected by rings of wadding so arranged as to take the
pressure off the prominent point and distribute it on the surrounding
parts. Opposing skin surfaces must always be separated by a layer of
wool or boracic lint. A bandage should never be applied to the limb
underneath the splints and pads, as congestion or even gangrene may be
induced thereby.
#Operative Treatment of Simple Fractures.#--Operation in simple
fracture is specially called for (1) in fracture into or near a joint
where a permanently displaced fragment will cause locking of the
joint; (2) when fragments are drawn apart, as in fractures of the
patella or olecranon; (3) when displacement, especially shortening,
cannot be remedied by other means; (4) when complications are present,
such as a torn nerve-trunk or a main artery; (5) when non-union is to
be feared, as in certain cases of fracture of the neck of the femur in
old people. Under such circumstances it is necessary to expose the
fracture by operation, and to place the fragments in accurate
apposition, if necessary, fixing them in position by wires, pegs,
plates, or screws (_Op. Surg._, p. 52). Operative interference is
usually delayed till about five to seven days after the injury, by
which time the effect of other measures will have been estimated,
accurate information obtained by means of the X-rays regarding the
nature of the lesion and the position of the fragments, and the
tissues recovered their normal powers of resistance. Such operations,
however, are not to be undertaken lightly, as they are often
difficult, and if infection takes place the results may be disastrous.
Arbuthnot Lane and Lambotte advocate a more general resort to
operative measures, even in simple and uncomplicated fractures, and it
must be conceded that in many fractures an open operation affords the
only means of securing accurate apposition and alignment of the
fragments.
Both before and after operation, massage and movement are to be
carried out, as in fractures treated by other methods.
COMPOUND FRACTURES
The essential feature of a compound fracture is the existence of an
open wound leading down to the break in the bone. The wound may vary
in size from a mere puncture to an extensive tearing and bruising of
all the soft parts.
A fracture may be rendered compound _from without_, the soft parts
being damaged by the object which breaks the bone--as, for example, a
cart wheel, a piece of machinery, or a bullet. Sloughing of soft parts
resulting from the pressure of improperly applied splints, also, may
convert a simple into a compound fracture. On the other hand, a simple
fracture may be rendered compound _from within_--for example, a sharp
fragment of bone may penetrate the skin; this is the least serious
variety of compound fracture.
As a rule, it is easy to recognise that the fracture is compound, as
the bone can either be seen or felt.
The _prognosis_ depends on the success which attends the efforts to
make and to keep the wound aseptic, as well as on the extent of damage
to the tissues. When asepsis is secured, repair takes place as in
simple fracture, only it usually takes a little longer; sometimes the
reason for the delay is obvious, as when the compound fracture is the
result of a more severe form of violence and where there is
comminution and loss of one or more portions of bone that would have
contributed to the repair. Sometimes the delay cannot be so explained;
Bier suggested that it is due to the escape of blood at the wound,
whereas in simple fractures the blood is retained and assists in
repair.
If sepsis gains the upper hand in a compound fracture there is,
firstly, the risk of infection of the marrow--osteomyelitis--which in
former times was liable to result in pyaemia; in the second place, not
only do loose fragments tend to die and be thrown off as sequestra,
but the ends of the fragments themselves may undergo necrosis;
involving as this does the dense cortical bone of the shaft, the dead
bone is slow in being separated, and until it is separated and thrown
off, no actual repair can take place. The sepsis stimulates the
bone-forming tissues and new bone is formed in considerable amount,
especially on the surface of the shaft in the vicinity of the
fracture; in macerated specimens it presents a porous, crumbling
texture. Sometimes the new bone--which corresponds to the involucrum
of an osteomyelitis--imprisons a sequestrum and prevents its
extrusion, in which case one or more sinuses may persist indefinitely.
Cases are met with where such sinuses have existed for the best part
of a long life and have ultimately become the seat of epithelioma.
It should be noted that all the above changes can be followed in
skiagrams.
_Treatment._--The leading indication is to ensure asepsis. Even in the
case of a small punctured wound caused by a pointed fragment coming
through the skin it is never wise to assume that the wound is not
infected. It is much safer to enlarge such a wound, pare away the
bruised edges, and disinfect the raw surfaces.
In cases of extensive laceration of the soft parts, all soiled,
bruised, or torn portions of tissue should be clipped away with
scissors, blood-clots removed, and the bleeding arrested by
forci-pressure or ligature. If there is any reason to believe that
the wound is infected, any fragments of bone completely separated from
the periosteum should be removed. In comminuted fractures, extension
applied by strips of plaster or by means of ice-tong callipers or
Steinmann's apparatus (p. 150) often facilitates replacement of the
fragments and their retention in position. Plates and screws are not
recommended for comminuted fractures, owing to the mechanical
difficulty of fixing a number of small fragments and the risks of
infection. The wound should be purified with eusol, and the
surrounding parts painted with iodine. On the whole, it is safer not
to attempt to obtain primary union by completely closing such wounds,
but rather to drain or pack them. To increase the local leucocytosis
and so check the spread of infection, a Bier's constricting bandage
may be applied.
In other respects the treatment is carried out on the same lines as in
simple fractures, provision being made for dressing the wound without
disturbance of the fracture. Massage and movement should be commenced
after the wound is healed and the condition has become analogous to a
simple fracture.
#Question of Amputation in Compound Fractures.#--Before deciding to
perform primary amputation of a limb for compound fracture, the
surgeon must satisfy himself (1) that the attainment of asepsis is
impossible; (2) that the soft parts are so widely and so grossly
damaged that their recovery is improbable; (3) that the vascular and
nervous supply of the parts beyond has been rendered insufficient by
destruction of the main blood vessels and nerve-trunks; (4) that the
bones have been so shattered as to be beyond repair; and (5) that the
limb, even if healing takes place, will be less useful than an
artificial one.
In attempting to save the limb of a young subject, it is justifiable
to run risks which would not be permissible in the case of an older
person. To save an upper limb, also, risks may be run which would not
be justifiable in the case of a lower limb, because, while a
serviceable artificial leg can readily be procured, any portion of the
natural hand or arm is infinitely more useful than the best substitute
which the instrument-maker can contrive. The risk involved in
attempting to save a limb should always be explained to the patient or
his guardian, in order that he may share the responsibility in case of
failure.
Whether or not the amputation should be performed at once, depends
upon the general condition of the patient. If the injury is a severe
one, and attended with a profound degree of shock, it is better to
wait for twenty-four or forty-eight hours. Meanwhile the wound is
purified, and the limb wrapped in a sterile dressing. Means are taken
to counteract shock and to maintain the patient's strength, and
evidence of infection or of haemorrhage is carefully watched for. When
the shock has passed off, the operation is then performed under more
favourable auspices. Clinical experience has proved that by this means
the mortality of primary amputations may be materially diminished,
especially in injuries necessitating removal of an entire limb.
Having decided to amputate, it is important to avoid having bruised,
torn, or separated tissues in the flaps, as these are liable to slough
or to become the seat of infection. In this connection it should be
borne in mind that the damage to soft tissues is always wider in
extent than appears from external examination.
The attempt to save a limb may fail and amputation may be called for
later because of spreading infective processes, osteomyelitis, or
gangrene; to prevent exhaustion from prolonged suppuration and toxin
absorption; or on account of secondary haemorrhage.
#Gun-shot Injuries of Bone.#--Fractures resulting from the impact of
bullet or fragments of shell are of necessity compound, and are
usually infected from the outset by organisms carried in by the
missile or by portions of clothing or other foreign material. Not
infrequently the missile lodges in the bone.
[Illustration: FIG. 7.--Excessive Callus Formation after infected
Compound Fracture of both Bones of Forearm--result of gun-shot wound.
Fusion of Bones across Interosseous Space.]
The extent of the injury to the bone varies infinitely, from a mere
chip or gutter-shaped wound to complete pulverisation of the portion
struck. The fracture is of the comminuted and fissured variety, the
cracks radiating from the point of impact and extending for a
considerable distance, sometimes even implicating the articular
surface of the bone some inches away. In comminuted fractures of the
shafts of long bones there is often a large wedge-shaped fragment
completely isolated from the rest, and in the presence of infection
this may form a sequestrum. Healing is often delayed by the separation
of sequestra, which takes place slowly, and union is attended with
excessive formation of callus. When a considerable section of the
shaft has been lost, want of union, fibrous union, or the formation of
a false joint may result.
The treatment is carried out on the same lines as in other forms of
compound fracture, except that mention should be made of the
irrigation method of Carrel, found to be the most potent means of
overcoming the associated infection.
SEPARATION OF EPIPHYSES[1]
[1] We do not employ the term "diastasis," which has been used in
different senses by different writers.
In young subjects before the bones are fully developed the epiphyses
may be separated from the diaphyses. The use of the X-rays has added
greatly to our knowledge of these lesions.
It is useful to remember that in the upper extremity the epiphyses in
the regions of the shoulder and wrist, and, in the lower extremity,
those in the region of the knee, are the latest to unite; and that it
is in these situations that growth in length of the bone goes on
longest and most actively (twenty to twenty-one years). Injuries of
these epiphyses, therefore, are most liable to interfere with the
growth of the limb.
An epiphysis is nourished from the articular arteries and through the
vessels of the periosteum.
_Pathological Separation of Epiphyses._--There are certain
pathological conditions, such as rickets, scurvy, congenital syphilis,
tubercle, suppurative conditions, and tumour growths, which render
separation of the epiphyses liable to occur from injuries altogether
insufficient to produce such lesions under normal conditions.
#Traumatic Separations.#[2]--Speaking generally, it may be said that
injuries which in an adult would be liable to produce dislocation, are
in a young person more apt to cause separation of an epiphysis.
Indirect violence, especially when exerted in such a way as to combine
traction with torsion,--for example, when the foot is caught in the
spokes of a carriage wheel,--is the commonest cause of epiphysial
separation. Direct violence is a much less frequent cause. Muscular
action occasionally produces separation of the epiphyses--for example,
the anterior superior iliac spine, the small trochanter of the femur,
or the upper end of the fibula.
[2] We desire here to acknowledge our indebtedness to Mr. John
Poland's work on _Traumatic Separation of the Epiphyses_.
[Illustration: FIG. 8.--Partial Separation of Epiphysis, with Fracture
running into Diaphysis.]
[Illustration: FIG. 9.--Complete Separation of Epiphysis.]
[Illustration: FIG. 10.--Partial Separation with Fracture of
Epiphysis.]
[Illustration: FIG. 11.--Complete Separation with Fracture of
Epiphysis.]
The majority of separations take place between the eleventh and the
eighteenth years, chiefly because during this period the injuries
liable to produce such lesions are most common. They do not occur
after twenty-five, because by that time all the epiphyses have united.
In females this form of injury is rare, and almost invariably occurs
before puberty.
The following are the most common seats of separation in the order of
their frequency: (1) the lower end of the femur; (2) the lower end of
the radius; (3) the upper end of the humerus; (4) the lower end of the
humerus; (5) the lower end of the tibia; and (6) the upper end of the
tibia.
_Morbid Anatomy._--In a true separation the epiphysial cartilage
remains attached to the epiphysis. As a rule the epiphysis is not
completely separated from the diaphysis, the common lesion being a
separation along part of the epiphysial line, with a fracture running
into the diaphysis (Fig. 8). It is not uncommon for more than one
epiphysis to be separated by the same accident--for example, the lower
end of the femur and the upper ends of the tibia and fibula.
Epiphysial separations, like fractures, may be _simple_ or _compound_.
Incomplete separations are liable to be overlooked at the time of the
accident, but there is reason to believe that they may form the
starting-point of disease. Strain of the epiphysial junction--the
_juxta-epiphysial strain_ of Ollier--is a common injury in young
children.
_Clinical Features._--The symptoms simulate those of dislocation
rather than of fracture. Thus, _unnatural mobility_ at an epiphysial
junction may closely resemble movement at the adjacent joint,
especially when the epiphysis is an intra-capsular one. The
relationship of the bony points, however, serves to indicate the
nature of the lesion. The degree of _deformity_ is often slight,
because the transverse direction of the lesion, the breadth of the
separated surfaces, and the firmness of the periosteal attachment
along the epiphysial line often prevent displacement. In many cases a
distinct, rounded, smooth, and regular ridge, caused by the projection
of the diaphysis, can be felt. The peculiar "muffled" nature of the
_crepitus_ is one of the most characteristic signs. The older the
patient, and the further ossification has progressed, the more does
the crepitus resemble that of fracture.
Of the subsidiary signs, _loss of power_ in the limb is one of the
most constant; indeed, in young children it is sometimes the first,
and may be the only, sign that attracts attention. _Pain_ and
_tenderness_ along the epiphysial line are valuable signs,
particularly when the lesion is due to indirect or muscular violence
and there is no bruising of soft parts. Localised _swelling_,
accompanied by _ecchymosis_, is often marked; and the adjacent joint
may be distended with fluid.
As distinguishing this injury from a dislocation, it may be noted that
in epiphysial separation there is no snap felt when the deformity is
reduced, the tendency to re-displacement is greater, and the amount of
relief given by reduction less than in dislocation. The use of the
Roentgen rays at once establishes the diagnosis.
_Prognosis and Results._--In the majority of cases union takes place
satisfactorily by the formation of callus in the spongy tissue of the
diaphysis and on the deep surface of the periosteum. In spite of the
favourable nature of the prognosis in general, however, the friends of
the patient should be warned that a completely satisfactory result
cannot always be relied upon.
Deformity, with stiffness and locking at the adjacent joint,
especially at the elbow, may result from imperfect reduction, or from
exuberant callus. Arrest of growth of the bone in length is a rare
sequel, and when it occurs, it is due, not to premature union of the
epiphysis with the shaft, but to diminished action at the ossifying
junction.
When the growth of one of the bones of the leg or forearm is arrested
after separation of its epiphysis while the other bone continues to
grow, the foot or hand is deviated towards the side of the shorter
one.
Partial separations may be overlooked at the time of the accident and
cause trouble later from bending of the bone, as in one variety of
coxa vara. The epiphysis at the lower end of the femur may be
displaced into the ham and press on the popliteal vessels.
_Treatment._--The general principles which govern the treatment of
fractures apply equally to epiphysial separations, the essential being
the accurate replacement of the epiphysis.
In _compound separations of epiphysis_, the end of the diaphysis may
be pushed through the skin. The entrance of sepsis may prove an
obstacle to any operative measure that would otherwise be indicated.
CHAPTER II
INJURIES OF JOINTS
SURGICAL ANATOMY--INJURIES: _Contusions_; _Wounds_; _Sprains_;
_Dislocations_--TRAUMATIC DISLOCATIONS: _Causes_: _Varieties_;
_Clinical features_; _Treatment_--Compound
dislocations--Old-standing dislocations.
#Surgical Anatomy.#--The function of a joint is to permit of the
movement of one bone upon another. The articular surfaces are covered
with a thin layer of hyaline cartilage, and are retained in apposition
by the tension of ligaments and of the muscles surrounding the joint.
The articular capsule (capsular ligament) is directly continuous with
the periosteum, and is lined by a synovial layer, which at the line of
attachment of the capsule is reflected on to the bone as far as the
articular cartilage. The synovial layer invests intra-articular
ligaments, and is projected into the interior of the joint in the form
of loose folds wherever the articulating surfaces are not in immediate
contact. The surface of the synovial layer is covered with minute
processes or villi, which in diseased conditions may become
hypertrophied. The synovia owes its lubricating property to mucin,
derived from the solution of the endothelial cells on the free surface
of the synovial layer. The opposing surfaces of a joint being always
in accurate contact, the so-called cavity is only a potential one. If
fluid is poured out into the joint, the synovial layer and the capsule
are put upon the stretch, causing discomfort or actual pain, which is
partly relieved by slightly flexing the joint. If the distension
persists, the ligaments become elongated and the joint unstable.
The common origin of bone, cartilage, periosteum, and synovial layer
from one parent tissue of the embryo, accords with the readiness with
which any one of these tissues may be converted into another under
traumatic or pathological influences; and how in ligaments and in
synovial membrane foci of hyaline cartilage may form and, after
increasing in size, undergo ossification.
Joints derive an abundant blood supply through the articular arteries.
The lymphatics, which take origin in the synovial layer, pass to
efferent vessels which run in the intermuscular and other
connective-tissue planes of the limb. The nerve supply is derived
chiefly from the nerves distributed to the muscles acting on the joint
and to the skin over it.
#Sources of Joint Strength.#--The capacity of a joint to resist
dislocation depends upon (1) the shape of its osseous elements; (2)
the strength and arrangement of its ligaments; (3) the support it
receives from muscles or tendons placed in relation to it; and (4) the
relative stability of adjacent structures. While all these factors
contribute to the strength of a given joint, one or other of them
usually predominates, so that certain joints are osseously strong,
others are ligamentously strong, while a few depend chiefly upon
adjacent muscles for their stability.
The hip and elbows are the best examples of joints deriving their
strength mainly from the architectural arrangement of the constituent
bones. These joints are dislocated only by extreme degrees of
violence, and not infrequently--especially in the elbow--portions of
the bones are fractured before the articular surfaces are separated.
The knee, the wrist, the carpal, the tarsal, and the clavicular joints
depend for their stability almost entirely on the strength of their
ligaments. These joints are rarely dislocated, but as the main
incidence of the violence falls on the ligaments they are frequently
sprained.
The shoulder is the typical example of a joint depending for its
security chiefly upon the muscles and tendons passing over it, and
hence the frequency with which it is dislocated when the muscles are
taken unawares. At the same time the great mobility of the scapula and
clavicle materially increases the stability of the shoulder-joint. The
tendons passing in relation to the knee, ankle, and wrist add to the
stability of these joints.
The proximity of an easily fractured bone also contributes to prevent
dislocation of certain joints--for example, fracture of the clavicle
prevents an impinging force expending itself on the shoulder-joint;
and the frequency of Colles' fracture of the radius, and of Pott's
fracture of the fibula, doubtless accounts to some extent for the
rarity of dislocation of the wrist and ankle-joints respectively. The
immunity from dislocation which the joints of young subjects enjoy is
partly due to the ease with which an adjacent epiphysis is separated.
The mechanical axiom that "what is gained in movement is lost in
stability" applies to joints, those which have the widest range of
movement being the most frequently dislocated.
* * * * *
The injuries to which a joint is liable are Contusions, Wounds,
Sprains, and Dislocations.
#Contusions of Joints.#--Contusion is the mildest form of injury to a
joint. Whether the violence is transmitted from a distance, as in
contusion of the hip from a fall on the feet, or acts more directly,
as in a fall on the great trochanter, the bones are violently driven
against one another, and the force expends itself on their articular
surfaces. The articular cartilages and the underlying spongy bone, as
well as the synovial lining, are bruised, and there is an effusion of
blood and serous fluid into the joint and surrounding tissues.
The most prominent _clinical features_ are swelling and discoloration.
The swelling, especially in superficially placed joints, is an early
and marked symptom, and is mainly due to the effusion of blood into
the joint (_haemarthrosis_). In deeply placed joints, discoloration may
not appear on the surface for some days, especially if the violence
has been indirect. The joint is kept in the flexed position, and is
painful only when moved. In haemophilic subjects, considerable effusion
of blood into a joint may follow the most trivial injury.
A slight degree of serous effusion into the joint (_hydrarthrosis_)
often persists for some time, and tuberculous affections of joints not
infrequently date from a contusion.
The _treatment_ is the same as for sprains (p. 36).
#Wounds of Joints.#--The importance of accidental wounds of
joints--such, for example, as result from a stab with a penknife or
the spike of a railing--lies in the fact that they are liable to be
followed by infection of the synovial cavity. The infection may
involve only the synovial layer (_septic synovitis_), or may spread to
all the elements of the joint (_septic arthritis_). These conditions
are described with diseases of joints.
Penetration of the joint may sometimes be recognised by the escape of
synovia from the wound, or the synovial layer or articular cartilage
may be exposed. When doubt exists, the wound should be enlarged. The
use of the probe is to be avoided, on account of the risk of carrying
infective material from the track of the wound into the joint.
Penetrating wounds of joints are treated on the same lines as compound
fractures. If the penetrating instrument is to be regarded as
infected,--as, for example, when the spoke of a motor bicycle is
driven through the upper pouch of the knee,--the injury is to be
looked upon as serious and capable of endangering the function of the
joint, loss of the limb, or even life itself. Reliance is chiefly laid
on primary excision of the edges and track of the wound, and other
measures employed in the treatment of gun-shot wounds. While the wound
in the synovialis and capsule is sutured, that in the soft parts is
left open. If drainage is employed, the tube extends down to the
opening in the synovialis, but not into the joint itself. If sepsis
supervenes, the joint is opened and irrigated by Carrel's method. Some
form of splint and a Bier's bandage are valuable adjuncts. The final
recourse is to amputation.
#Gun-shot injuries# of joints vary in severity from a mere puncture of
the synovial layer by a chip of shell to complete shattering of the
articular surfaces. Between these extremes are cases in which the
capsular and synovial layer are extensively lacerated without
involvement of the bones, and others in which the bones are implicated
without serious damage being done to ligaments or synovial layer--for
example, by a bullet passing through and through the cancellated part
of one of the constituent bones, or by a fissure extending into the
articular surface.
In all degrees the great risk is from septic infection, which may be
assumed to be present in all but the last-named variety.
The _treatment_ consists in immediately cleansing the wound by
excising grossly damaged tissue and removing any foreign body that may
have lodged; disinfecting the exposed part of the joint cavity with
eusol, "bipp," or other antiseptic, and closing the wound or
establishing drainage, according to circumstances. The joint is then
immobilised till the wound has healed, after which massage and
movement are commenced. When the bones are shattered or when sepsis
gets the upper hand and disorganises the joint, amputation is called
for.
#Sprains.#--A sprain results from a stretching or twisting form of
violence which causes the joint to move beyond its physiological
limits, or in some direction for which it is not structurally adapted.
The main incidence of the force therefore falls upon the ligaments,
which are suddenly stretched or torn. The synovial layer also is torn,
and the joint becomes filled with blood and synovial fluid.
Muscles and tendons passing over the joint are stretched or torn, and
their sheaths filled with serous effusion. It is not uncommon for
portions of bone to be torn off at the site of attachment of strong
ligamentous bands or tendons, constituting a "sprain fracture"; or for
intra-articular cartilages to be torn and displaced, as in the knee.
_Clinical Features._--The injury is accompanied by intense sickening
pain, and this may persist for a considerable time. At first it is
aggravated by moving the joint, but if the movement is continued it
tends to pass off. The particular ligaments involved may be recognised
by the tenderness which is elicited on making pressure over them, or
by putting them on the stretch. In this way a sprain may often be
diagnosed from a fracture in which the maximum tenderness is over the
injury to the bone.
The effusion of blood and synovia into the joint and into the tissues
around gives rise to swelling and discoloration, and the fluid effused
into tendon sheaths often produces a peculiar creaking sensation,
which may be mistaken for the crepitus of fracture. In sprains, the
bony points about the joint retain their normal relations to one
another, and this usually enables these injuries to be diagnosed from
dislocations. When the swelling is great, it is often necessary to
have recourse to the Roentgen rays to make certain that there is no
fracture or dislocation. The special features and complications of
sprains of the knee are discussed with other injuries of that joint.
_Repair of Sprains._--Blood and synovia are absorbed and torn
structures become reunited, but in this process adhesions may form
inside the joint and in the surrounding tendon sheaths and interfere
with the movement of the joint.
_Prognosis._--Stiffness, lasting for a longer or shorter time, follows
most sprains, but may be largely prevented by proper treatment. In old
and rheumatic persons, changes of the nature of arthritis deformans
are liable to supervene, interfering greatly with movement. While
suppuration is rare, tuberculous disease is alleged to have resulted
from a sprain.
_Treatment._--If seen immediately after the accident, firm pressure
should be applied by means of an elastic bandage over a thick layer of
cotton wool, to prevent bleeding and effusion of synovia. Later the
best treatment is by massage and movement. In the ankle, for example,
massage should be commenced at once, the part being gently stroked
upwards. If the massage is light enough there is no pain, it is
actually soothing. The rubbing is continued for from fifteen to twenty
minutes, and the patient is encouraged to move the toes and ankle; a
moderately firm elastic bandage is then applied. The massage is
repeated once or twice a day, the sittings lasting for about fifteen
minutes. The patient should be encouraged to move the joint from the
first, beginning with the movements that put least strain upon the
damaged ligaments, and gradually increasing the range. In the course
of a few days he is encouraged to walk or cycle, or otherwise to use
the joint without subjecting it to strain, or to a repetition of the
movement that caused the accident. Alternate hot and cold douching, or
hot-air baths, followed by massage, are also useful. Complete rest and
prolonged immobilisation are to be condemned.
TRAUMATIC DISLOCATIONS
A dislocation or luxation is a persistent displacement of the opposing
ends of the bones forming a joint. We are here concerned only with
such dislocations as immediately follow upon injury. Those that are
congenital or that result from disease will be studied later.
_Causes._--The majority of dislocations are the result of _indirect_
violence, the more movable bone acting as a lever, on a fulcrum
furnished by the natural check to movement in the form of ligament,
bone, or muscle. It is in this way that most dislocations of the
shoulder, hip, and elbow are produced.
At the moment the violence is applied, the muscles are relaxed or
otherwise taken at a disadvantage, so that the joint is for the time
being deprived of their support. The joint is moved beyond its
physiological range, and the end of one of the bones being brought to
bear upon the capsule, tears it, and passes through the rent thus
made. The muscles then contract reflexly, and pull the head of the
bone into an unnatural position outside the capsule. The position
assumed will depend upon such factors as the direction of the force,
the structure of the joint, the position of the limb at the time of
the accident, and the relative strength of the different groups of
muscles acting upon the bone which is displaced.
Violence applied _directly_ to the joint is a much less frequent cause
of dislocation. In this way, however, the knee-joint may be
dislocated, one bone being driven past the other--for example, by a
kick from a horse; or the acromio-clavicular joint by a blow on the
shoulder.
_Muscular contraction_ is not often the sole cause of dislocation,
although, as has been mentioned, it plays an important role in the
production of the majority of these injuries. The shoulder, mandible,
and patella are, however, not infrequently displaced by muscular
action alone. Acrobats sometimes acquire the power of dislocating
certain joints by voluntary contraction of their muscles.
_Age and Sex._--Dislocations occur most frequently in adult males,
doubtless on account of the nature of their occupations and
recreations. In children the epiphyses are separated, and in old
people the bones are broken by such forms of violence as cause
dislocation in the middle-aged.
Muscular debility and undue laxness of ligaments resulting from
disease or previous dislocation are also predisposing factors.
_Clinical Varieties._--The separation between the bones may be
_complete_ or _partial_. When partial, portions of the articular
surfaces remain in apposition, and the injury is known as a
_sub-luxation_. Like fractures, dislocations may be _simple_ or
_compound_, the latter being specially dangerous on account of the
risk of infection. When seen within a few days of its occurrence, a
dislocation is looked upon as _recent_; but when several weeks or
months have elapsed, it is spoken of as an _old-standing_ dislocation.
The latter will be described later.
Dislocations, like fractures, may be _complicated_ by injuries to
large blood vessels or nerve-trunks, by injuries to internal organs,
or by a wound of the soft tissues which does not communicate with the
joint. Further, a fracture may coexist with a dislocation--a most
important complication.
_Clinical Features._--The most characteristic signs of dislocation are
_preternatural rigidity_, or want of movement where movement should
naturally take place; _mobility in abnormal directions_; and
_deformity_, the part being "out of drawing" as compared with the
uninjured side (Fig. 18). The bony landmarks lose their normal
relationship to one another; and the deformity is characteristic, and
is common to all examples of the same dislocation.
Although any of the subsidiary signs may occur in lesions other than
dislocations, due weight must be given to them in making a diagnosis.
_Loss of function_ is complete as a rule. _Pain_ is much more intense
than in fracture, usually because the displaced bone presses upon
nerve-trunks, and from the same cause there is often numbness and
partial paralysis of the limb beyond. _Swelling_ of the soft parts due
to effused blood is usually less marked in dislocation than in
fracture, but is often sufficiently great to interfere with diagnostic
manipulations. The displaced bone, and sometimes the empty socket, may
be palpable. _Discoloration_ is usually later of appearing than in
fractures. _Alteration in the length_ of the injured limb--usually in
the direction of shortening--is a common feature; while girth
measurements usually show an increase. A peculiar soft _grating_ or
_creaking sensation_ is often felt on attempting to move the joint;
this is due to cartilaginous or ligamentous structures rubbing on one
another, and must not be mistaken for the crepitus of fracture. In the
majority of cases, although not in all, after reduction has been
effected, the bones retain their proper relations without external
support, a point in which a dislocation differs from a fracture. A
careful investigation of the kind of force which produced the injury,
particularly as regards its intensity and direction of action, may aid
in the diagnosis. The diagnosis can always be verified by the use of
the Roentgen rays, and this should be had recourse to whenever
possible, as a fracture may be shown that otherwise would escape
recognition.
_Prognosis._--After having once been dislocated, a joint is seldom as
strong as it was formerly, although for all practical purposes the
limb may be as useful as ever. Some degree of stiffness, of limited
movement, or of muscular weakness, and occasional arthritic changes
and a liability to re-dislocation, are the commonest sequelae.
Prolonged immobilisation is liable to lead to stiffness by permitting
of the formation of adhesions; while too early movement tends to
produce a laxity of the ligaments which favours re-displacement from
slight causes.
_Treatment._--Reduction should be attempted at the earliest possible
moment. Every hour of delay increases the difficulty. The guiding
principle is to cause the displaced bone to re-enter its socket by
the same route as that by which it left it--that is, through the
existing rent in the capsule. This is done by carrying out certain
manipulations which depend upon the anatomical arrangement of the
parts, and which vary, not only with different joints, but also with
different varieties of dislocation of the same joint. In general terms
it may be said that the main impediments to reduction are: the
contraction of the muscles acting upon the displaced bone; the
entanglement of the bone among tendons or ligamentous bands which fix
it in its abnormal position; and the rent in the capsule being small
or valvular, so that it forms an obstacle to the bone reentering the
socket.
Muscular contraction is best overcome by the administration of a
general anaesthetic, and in all but the simplest cases this should be
given to ensure accurate and painless reduction. Failing this,
however, the muscles may be wearied out by the surgeon making steady
and prolonged traction on the limb, while an assistant makes
counter-extension on the proximal segment of the joint. Advantage may
also be taken of such muscular relaxation as occurs when the patient
is already faint, or when his attention is diverted from the injured
part, to carry out the manipulations necessary to restore the bone to
its normal position.
The appropriate manoeuvres for disengaging the head of the bone from
tendons, ligaments, or bony processes with which it may be entangled,
will be suggested by a consideration of the anatomy of the particular
joint involved, and will be described with individual dislocations.
In reducing a dislocation, no amount of physical force will compensate
for a want of anatomical knowledge. All tugging, twisting, or
wrenching movements are to be avoided, as they are liable to cause
damage to blood vessels, nerves, or other soft parts, or even--and
especially in old people--to fracture one of the bones concerned.
After reduction, great benefit is gained by the systematic use of
_massage_ and movement. Before any restraining apparatus is applied
the whole region should be gently stroked in a centrifugal direction
for fifteen or twenty minutes; and this is to be repeated daily, each
sitting lasting for about twenty minutes. From the first day onward,
movement of the joint is carried out in every direction, except that
which tends to bring the head of the bone against the injured part of
the capsule; and the patient is encouraged to move the joint as early
as possible. The appropriate apparatus and the period during which it
should be worn will be considered with the individual dislocations.
_Operation in Simple Dislocations._--In a limited number of cases,
even with the aid of an anaesthetic, reduction by manipulation is found
to be impossible. Resort must then be had to operation, which is a
comparatively safe and satisfactory proceeding, although often
difficult. It may happen in rare instances that the undoing of the
displacement is only possible after the removal of a portion of one or
other of the bones.
#Compound Dislocations.#--Compound dislocations are usually the result
of extreme violence produced by machinery or railway accidents, or by
a fall from a height. In the majority of cases they are complicated by
fracture of one or more of the constituent bones of the joint, as well
as by laceration of muscles, tendons, and blood vessels. In the region
of the ankle, wrist, and joints of the thumb, however, compound
dislocation is sometimes met with uncomplicated by other lesions. The
great risk is infection, which may result in serious impairment of the
usefulness of the joint or even in its complete destruction, results
towards which the concomitant injuries materially contribute. In many
instances where infection has occurred, ankylosis is the best result
that can be hoped for.
_Treatment._--As a rule, the first question that arises is whether
amputation is necessary or not, and the considerations that determine
this point are the same as in compound fractures (p. 26). If an
attempt is to be made to save the limb, the treatment is the same as
in compound fracture (p. 25).
#Dislocation complicated by Fracture.#--In certain dislocations the
separation of small portions of bones or of epiphyses is of common
occurrence--for example, fracture of the tip of the coronoid process
in dislocation of the elbow backwards, and chipping off of a portion
of the edge of the acetabulum in dislocation of the hip.
The most important example of a fracture complicating a dislocation is
fracture of the surgical neck of the humerus coexisting with
dislocation of the shoulder. Here the difficulty of diagnosis is
greatly increased, and the treatment of both injuries requires to be
modified. The dislocation must be reduced--by operation if
necessary--before the fracture is treated, and in many cases it is
advisable to secure the fragments of the broken bone by pegs, or
plates, to admit of movement being commenced early, and so to prevent
stiffness of the joint.
#Old-standing Dislocations.#--When, from want of recognition--and,
curiously enough, a dislocation is much more liable to be overlooked
than would have been thought possible--or from unsuccessful treatment,
a dislocation is left unreduced, changes take place in and around the
joint which render reduction increasingly difficult or impossible. The
rent in the capsule closes upon the neck of the bone, and fibrous
adhesions form between muscles, tendons, and other structures that
have been torn. The articular cartilage of the head, being no longer
in contact with an opposing cartilage, tends in time to be converted
into fibrous tissue, and may become adherent to other fibrous
structures in its vicinity. By pressing on adjacent structures it may
form for itself a new socket of dense fibrous tissue which in time
becomes lined with a secreting membrane. When the displaced head lies
against a bone, the continuous pressure produces a new osseous socket,
from the margins of which osteophytic outgrowths may spring, and as
the surrounding fibrous tissue becomes condensed and forms a strong
capsule, a new joint results. The occurrence of these changes in the
direction of a new ball-and-socket joint is largely dependent on the
behaviour of the patient: a vigorous man, anxious to recover the use
of the limb, will employ it with a degree of determination and
indifference to pain that could not be expected in a sensitive elderly
female. The most perfect example of a new ball-and-socket joint,
following upon an unreduced dislocation at the hip, that has come
under our observation, was in a hunting dog, given one of us by an
Australian pupil, who testified that the animal was as fleet with the
new joint as it had been with the original one. Meanwhile the
cartilage of the original socket is converted into fibrous tissue,
which may come to fill up the cavity. Changes resembling those of
arthritis deformans may occur. The large blood vessels and nerves in
the vicinity may be pressed upon or stretched by the displaced bone,
or may be implicated in fibrous adhesions. In course of time they
become lengthened or shortened in accordance with the altered attitude
of the limb.
[Illustration: FIG. 12.--Os Innominatum showing new socket formed
after old-standing dislocation. The acetabulum is almost obliterated.]
In many cases the new joint is remarkably mobile and useful; but in
others, pain, limited movement, and atrophy of muscles render it
comparatively useless, and surgical intervention is called for.
_Treatment._--It is always a difficult problem to determine the date
after which it is inadvisable to attempt reduction by manipulation in
an old dislocation and no rules can be laid down which will cover all
cases. Rather must each case be decided on its own merits, due
consideration being had to the risks that attend this line of
treatment. The chief of these are: rupture of a large blood vessel or
nerve that has formed adhesions with the displaced bone, or has become
shortened in adaptation to the altered shape or length of the limb;
tearing of muscles or tendons, or even of skin; fracture of the bone,
especially in old people; and separation of epiphyses in the young.
Before carrying out the manipulations appropriate to the particular
dislocation, all adhesions must first be broken down; and during the
proceedings no undue force is to be employed. The first attempt at
reduction may fail, and yet subsequent efforts, at intervals of a few
days, may ultimately prove successful; the vigorous traction and
twisting of the soft parts, matted together as they are by
scar-tissue, causes reactive changes in the vessels and tissues which
render them more liable to yield on subsequent attempts at reduction.
In old people, and where there is an absence of suffering from
pressure on nerves or vessels, it may be wiser to leave the
dislocation unreduced, and strive rather by massage and movement to
obtain a useful variety of false joint. If the conditions are
otherwise, it may be better to improve the function of the limb by an
_open operation_. Tight ligaments and other structures are divided,
and the socket is cleared out. If reduction is still impossible, a
partial excision may be performed and a flap of fascia lata introduced
to prevent ankylosis (arthroplasty). In the case of the hip, the
dislocation may be left alone and the femur divided below the
trochanter, especially if there is pronounced flexion.
#Habitual or recurrent dislocation# is almost exclusively met with in
the shoulder, and will be described with the injuries of that joint.
#Pathological Dislocations.#--Joints may become dislocated in the
course of certain diseases. These pathological dislocations fall into
different groups: (1) those due to gradual stretching of the capsular
and other ligaments weakened by inflammatory and suppurative
processes, such as sometimes follow on typhoid, scarlet fever, or
diphtheria, and in pyaemia; (2) those due to destructive changes in the
ligaments and bones--typically seen in tuberculous arthritis, in
arthritis deformans, in Charcot's disease, and in nerve lesions,
_e.g._ dislocation of the hip in spastic conditions, such as Little's
disease; (3) those associated with deformed attitudes of the limb; (4)
those due to changes in the articular surfaces, _e.g._ the phalanges
in arthritis deformans. These will be considered with the conditions
which give rise to them.
#Congenital Dislocations.#--Congenital dislocations are believed to be
the result of abnormal or arrested development _in utero_, and are to
be distinguished from dislocations occurring during birth, which are
essentially traumatic in origin. They will be described along with the
Deformities of the Extremities.
CHAPTER III
INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM
Surgical Anatomy--FRACTURES OF CLAVICLE: _Varieties_--DISLOCATION OF
CLAVICLE: _Varieties_--DISLOCATION OF SHOULDER:
_Varieties_--Sprains and contusions of shoulder--FRACTURE OF
SCAPULA: Sites--FRACTURE OF UPPER END OF HUMERUS: _Surgical neck_;
_Separation of epiphysis_; _Fracture of head, anatomical neck, or
tuberosities_--FRACTURES OF SHAFT OF HUMERUS.
The injuries met with in the region of the shoulder include fractures
and dislocations of the clavicle, fractures of the scapula,
dislocations and sprains of the shoulder-joint, and fractures of the
upper end of the humerus.
#Surgical Anatomy.#--For the examination of an injury in the region of
the shoulder the patient should be seated on a low stool or chair.
After inspecting the parts from the front, the surgeon stands behind
the patient and systematically examines by palpation the shoulder
girdle and upper end of the humerus. The uninjured side should be
examined along with the other for purposes of comparison.
Immediately lateral to the supra-sternal notch, the sterno-clavicular
articulation may be felt, the large end of the clavicle projecting to
a varying degree beyond the margins of the small and shallow articular
surface on the sternum. Any dislocation of this joint is at once
recognised. The clavicle being subcutaneous throughout its whole
length, any irregularity in its outline can be easily detected. A
small tubercle (deltoid tubercle) which frequently exists near the
acromial end is liable to suggest the presence of a fracture. The
lateral end forms with the acromion the acromio-clavicular joint,
which, however, is not always readily identified. The fingers are now
carried over the acromion, which often exhibits in the situation of
its epiphysial cartilage a prominent ridge, which must not be mistaken
for a fracture. The tip of the acromion is usually employed as a fixed
point in measuring the length of the upper arm.
The outline of the spine of the scapula can be traced back to the
vertebral border; and the body of the bone may be manipulated, and its
movements tested by moving the arm.
The coracoid process can be recognised in the upper and lateral angle
of the triangular depression bounded by the pectoralis major, the
deltoid, and the clavicle.
The head and surgical neck of the humerus may now be felt from the
axilla, if the axillary fascia is relaxed by bringing the arm to the
side. The great tuberosity can be indistinctly felt on the lateral
aspect of the shoulder through the fibres of the deltoid. It lies
vertically above the lateral epicondyle, and may be felt to rotate
with the shaft. The inter-tubercular (bicipital) groove looks forward,
and lies in a line drawn vertically through the biceps muscle.
The subclavian artery, with its vein to the median side and the cords
of the brachial plexus to the lateral side, passes under the middle of
the clavicle, and may be compressed against the first rib immediately
above this bone.
FRACTURE OF THE CLAVICLE
Fracture of the clavicle is one of the commonest injuries met with in
practice. As about one-third of the cases occur in children, the
fracture is often of the greenstick variety. The fractures are seldom
compound or complicated, unless as a result of gun-shot injuries; but
occasionally one of the fragments pierces the skin, or comes to press
upon the subclavian vessels or the cords of the brachial plexus,
arresting the pulsation in the vessels of the limb, and causing severe
pain in the arm.
[Illustration: FIG. 13.--Oblique Fracture of Right Clavicle in Middle
Third, united.]
The most common site of fracture is in the _middle third_ (Fig. 13),
and this usually results from indirect violence, such as a fall on the
outstretched hand, the elbow, or the outer aspect of the shoulder, the
force being transmitted through the glenoid cavity to the scapula, and
thence by the coraco-clavicular ligaments to the clavicle. The
violence is therefore of a twisting character, and the bone gives way
near the junction of the lateral and middle thirds, just where the two
natural curves of the bone meet, and where the supporting muscular and
ligamentous attachments are weakest.
The fracture so produced is usually oblique from above, downwards and
inwards. The sternal fragment may be slightly drawn upwards by the
clavicular fibres of the sterno-mastoid, while the acromial fragment
falls by the weight of the arm, and the fragments usually overlap to
the extent of about half an inch. The shoulder, having lost the
buttressing support of the clavicle, falls in towards the chest wall,
narrowing the axillary space, while the weight of the arm pulls it
downward, and the muscles inserted in the region of the bicipital
groove pull it forward.
Fracture of the middle third may result also from a direct stroke,
such as the recoil of a gun, or from violent muscular contraction, the
fracture as a rule being transverse, and the displacement less marked
than in fracture by indirect violence.
_Clinical Features._--The attitude of the patient is characteristic:
the elbow is flexed and is supported by the opposite hand, while the
head is inclined towards the affected shoulder to relax the muscles of
the neck. Crepitus is elicited on bracing back the shoulders, or on
attempting to raise the arm beyond the horizontal, and these movements
cause pain. Tenderness is elicited on making pressure over the seat of
fracture, and also on distal pressure. The sternal fragment almost
invariably overrides the acromial, and can usually be palpated through
the skin; on measurement, the clavicle is found to be shortened. When
the fracture is incomplete (greenstick) or transverse, the symptoms
are less marked.
[Illustration: FIG. 14.--Fracture of Acromial End of Clavicle. Shows
forward rotation of lateral fragment, and line of fracture united by
bone.]
Fracture of the _lateral_ or _acromial third_ of the clavicle is a
common form of accident at football matches, and usually results from
direct violence, the bone being driven down against the coracoid
process, and broken as one breaks a stick over the knee. The fracture
may take place through the attachment of the conoid and trapezoid
ligaments, in which case the only symptoms are pain and tenderness at
the seat of fracture, with impaired movement of the limb. Displacement
and crepitus are prevented by the splinting action of the ligaments.
When the break is lateral to the attachment of the trapezoid ligament,
the fracture is usually transverse, and is almost always due to a fall
on the back of the shoulder--the angle between the spine and the
acromion process striking the ground. The acromial fragment rotates
forward (Fig. 14), sometimes even to a right angle, causing the tip of
the shoulder to pass forwards, and so to lie slightly nearer the
middle line. The integrity of the coraco-clavicular ligaments prevents
any marked drooping of the shoulder. It is noteworthy that the
displacement is not always evident at first.
Fractures of the _medial_ or _sternal third_ are rare, are usually
oblique, and result either from an indirect force acting in the line
of the clavicle, or, less frequently, from direct violence or muscular
action. As a rule, the deformity is insignificant, except when the
costo-clavicular ligament is torn, in which case the medial end of the
distal fragment is tilted up by the weight of the arm. The shoulder
passes downwards, forwards, and medially. When close to the sternal
end, this fracture may simulate a dislocation of the sterno-clavicular
joint or a _separation of the clavicular epiphysis_. This last is a
rare accident, which may occur between the seventeenth and the
twenty-fifth years, and is usually the result of violent muscular
action. It differs from the other injuries in this region in being
more easily reduced and retained in position, the epiphysis lying
entirely within the limits of the articular capsule of the
sterno-clavicular joint.
_Simultaneous fracture of both clavicles_ usually results from a
severe transverse crush of the upper part of the thorax or from a fall
on the outstretched hands--for example, in hunting. The middle third
of the bone is implicated, and there is marked displacement and
overriding. The patient is rendered helpless, and from the extrinsic
muscles of respiration being thrown out of action and the weight of
the powerless limbs pressing on the chest, there is considerable
difficulty in breathing, and this is often increased by the fracture
being complicated by injuries of the lung or pleura.
The _prognosis_ as to union in all these injuries is good. Firm bony
union usually occurs within twenty-one days. Non-union, false-joint,
or fibrous union is but rarely met with. At the same time it is to be
borne in mind that, in spite of all precautions, some deformity and
shortening may result, without, however, interfering with the
usefulness of the limb.
_Treatment._--The displacement in complete fractures of the clavicle
is readily reduced by supporting the elbow, bracing back the
shoulders, and levering out the tip of the affected shoulder. In a few
cases the interposition of some fibres of the subclavius muscle
between the fragments has prevented perfect reduction.
In the greenstick variety the bone may be bent back into its normal
position, but no great force should be employed, as, in spite of
imperfect reduction, the clavicle usually straightens as it grows, and
although some deformity may persist, the function of the limb is not
interfered with.
_Recumbent Position._--There is little doubt that the most perfect
aesthetic results are obtained by treating the patient in the recumbent
position. In girls, therefore, in whom it is desired that the
shoulders should be perfectly symmetrical, the best results are
obtained from placing the patient on a firm mattress, with a narrow,
firm cushion between the shoulder-blades, so that the weight of the
shoulder may carry the acromial fragment laterally and backwards. A
pad is inserted in the axilla, the elbow raised, and the arm placed by
the side on a pillow and steadied with sand-bags. Massage is applied
daily. As this position must be maintained uninterruptedly for two or
three weeks, it proves too irksome for most patients. When both
clavicles are fractured, however, it is, short of operation, the only
available method of treatment.
In ordinary cases the arm should be placed in that position which
gives the best alignment of the fragments and least deformity. A thin
layer of wool is placed in the axilla to separate the skin surfaces. A
sling, supporting the _elbow_, is now applied, maintaining the arm in
position, and a body bandage fixes the arm to the side. Massage and
movement should be commenced at once.
A simple method, which yields satisfactory results, is that suggested
by Wharton Hood. The fracture having been reduced, three strips of
adhesive plaster, each an inch and a half wide, are applied from a
point immediately above the nipple to a point 2 inches below the angle
of the scapula (Fig. 15). The middle strap covers the seat of
fracture, and is applied first: the others, slightly overlapping it,
extend about half an inch on either side. The elbow is supported in a
sling. This plan has the advantage that it permits of movement of the
shoulder being carried out from the first, but the plaster rather
interferes with massage.
_The Handkerchief Method._--In cases of emergency, one of the best
methods applicable to all fractures of the clavicle is to brace back
the shoulders by means of two padded handkerchiefs, folded _en
cravate_, placed well over the tips of the shoulders and tied, or
interlaced, between the scapulae. The forearm is then supported by a
third handkerchief applied as a sling, the base of which is placed
under the elbow, the ends passing over the sound shoulder.
_Operative treatment_ may be called for in compound or comminuted
fractures when the fragments have injured, or are likely to injure,
the subclavian vessels or the cords of the brachial plexus, or when it
is otherwise impossible to reduce the fracture or to retain the
fragments in apposition. It is also indicated in some cases of
fracture of both clavicles.
These various methods of treatment are not equally applicable to all
cases. In our experience, in the circumstances indicated, the
following methods have proved the most satisfactory: (1) As a
temporary means of retention in emergency cases,--for example,
accidents occurring on the football field,--the handkerchief method.
(2) In uncomplicated fractures of average severity in any part of the
bone, the method of sling and body bandage. (3) In cases where, for
aesthetic reasons, the chief consideration is the avoidance of
deformity and the maintenance of the symmetry of the shoulders, as in
girls, the treatment by recumbency. (4) When retentive apparatus
fails, or when the fragments are exerting injurious pressure,
operative treatment.
[Illustration: FIG. 15.--Adhesive Plaster applied for Fracture of
Clavicle.]
In quite a number of cases, there is an excessive amount of pain,
preventing sleep; where this is due to cramp-like contractions of the
muscles and movements of the fragments, it is relieved by more
accurate fixation, as by strips of plaster; otherwise a hypodermic
injection of heroin or morphin is indicated.
DISLOCATION OF THE CLAVICLE
Dislocation of the #acromial end#--sometimes, and perhaps more
correctly, spoken of as dislocation of the scapula--is more frequent
than that at the sternal end, and it usually results from a blow from
behind, or from a fall on the tip of the shoulder, driving down the
scapula, so that the clavicle projects _upwards_ and overrides the
acromion process.
_Downward_ displacement of the acromial end of the clavicle is much
rarer, and may follow a fall on the elbow or a blow over the clavicle.
The end of the bone lies under the acromion process, in contact with
the capsule of the shoulder-joint, and the acromion stands out
prominently.
The _clinical features_ are so well marked that the diagnosis is
unmistakable. The head inclines towards the affected side, and the tip
of the shoulder tends to pass slightly downward, forward, and
medially. The displaced end of the bone can be seen and felt as a
prominence under the skin, or the empty socket can be palpated, while
the muscles attached to the displaced clavicle stand out in relief.
The movements at the shoulder are restricted, particularly in the
direction of abduction above the level of the shoulder. These injuries
are sometimes associated with fracture of the ribs, a complication
which adds materially to the difficulties of treatment.
_Treatment._--Reduction is easily effected by bracing back the
shoulders and replacing the bone in its socket by manipulation; but
retention is invariably difficult, and in many cases impossible; even
when the displacement is permanent, however, the usefulness of the arm
is not necessarily impaired.
Treatment is similar to that for fracture of the clavicle by sling and
body bandage. Another plan is to place a pad over the acromial end of
the clavicle, and fix it in this position by a few turns of elastic
bandage carried over the shoulder and under the elbow. The forearm is
placed in a sling with the elbow well supported, and the arm is bound
to the side by a circular bandage. When the bone cannot be kept in
position and the usefulness of the limb is impaired, the joint
surfaces may be rawed and the bones wired, with a view to obtaining
ankylosis.
#The sternal end# may be dislocated forwards, backwards, or upwards.
_Forward_ dislocation is the most common; the end of the clavicle lies
on the front of the sternum, somewhat below the level of the
sterno-clavicular joint, and its articular surface can be distinctly
palpated (Fig. 16). The inter-articular cartilage sometimes remains
attached to one bone, sometimes to the other; the rhomboid ligament is
usually intact.
In the _backward_ dislocation the end of the clavicle lies behind the
manubrium sterni and the muscles attached to it; there is a marked
hollow in the position of the joint, and the facet on the sternum can
be felt. In a comparatively small number of cases the bone exerts
pressure upon the trachea and oesophagus, producing difficulty in
breathing and swallowing. It has also been known to press upon the
subclavian artery and on other important structures at the root of the
neck.
[Illustration: FIG. 16.--Forward Dislocation of Sternal End of Right
Clavicle. From a fall on a polished floor, in a man aet. 40.]
In rare cases the rhomboid ligament is torn, and the end of the
clavicle passes _upwards_, and rests in the episternal notch behind
the sterno-mastoid muscle.
The bone may be retained in position by keeping the shoulders braced
back by a figure-of-eight bandage, or by padded handkerchiefs, and
making pressure over the displaced end of the bone with a pad. The
forearm is supported by a sling, and the arm fixed to the side.
Massage is employed from the first, and the patient is allowed to move
the arm by the end of a week. Imperfect reduction interferes so little
with the functions of the limb that operative measures are seldom
required except for aesthetic reasons.
Dislocation of #both ends# of the clavicle has occasionally occurred
from a severe crush. The ultimate result has been satisfactory, as one
or other end has always healed in normal position, and the function of
the arm has thus been maintained.
DISLOCATION OF THE SHOULDER
The shoulder is more frequently dislocated than all the other joints
in the body taken together. This is explained by its exposed position,
the wide range of movement of which it is capable, the length of the
lever afforded by the humerus, and the anatomical construction of the
joint--the large, round humeral head imperfectly fitting the small and
shallow glenoid cavity, and the ligaments being comparatively lax and
thin. The capsule of the joint is materially strengthened in its upper
and back parts by the tendons of the supra- and infra-spinatus and
teres minor muscles; while it is weakest below and in front, between
the subscapularis and teres major tendons. It is here that it most
frequently gives way and allows of the escape of the head of the bone.
The determining factor is probably that when the arm is abducted the
neck of the humerus comes in contact with the tip of the acromion, and
further abduction forces the head against the lower, weak portion of
the capsule, which gives way.
The violence is usually transmitted from the hand or elbow, less
frequently from the lateral aspect of the shoulder, the limb being
usually abducted and the muscles relaxed and taken unawares. The head
of the humerus, thus brought to bear on the weakest part of the
capsule, ruptures it and passes out through the rent. Dislocation is
readily produced in an unconscious person--as, for example, in
conducting artificial respiration in a patient suffering from opium
poisoning, the arms being hyper-abducted to exert traction on the
chest.
_Varieties._--Several varieties of dislocation are recognised,
according to the position in which the head of the humerus finally
rests (Fig. 17). The simplest of these is the _sub-glenoid_ variety,
in which the head rests on the long tendon of the triceps, where it
arises from the axillary border of the scapula just below the glenoid
cavity. In almost all dislocations of the shoulder the head of the
bone is at least momentarily in this position, but the sharp edge of
the scapula and the rounded head are ill adapted to one another, and
the position is not long maintained. The subsequent course taken by
the humerus depends upon the nature and direction of the force, the
position of the limb at the moment of injury, and the relative
strength and capacity for effective action of the different groups of
muscles acting upon the bone.
[Illustration: FIG. 17.--Diagram of most common varieties of
Dislocation of the Shoulder.]
In the great majority of cases it passes forward and medially, and
comes to lie against the anterior surface of the neck of the
scapula, under cover of the tendons of origin of the biceps and
coraco-brachialis muscles, constituting the _sub-coracoid
dislocation_. Much less frequently it passes under cover of the
pectoralis minor and against the edge of the clavicle--the
_sub-clavicular_ variety. In rare cases the head passes backward and
lies against the spine on the dorsum of the scapula, beneath the
infra-spinatus muscle--the _sub-spinous_ variety. Other varieties are
so rare that they do not call for mention.
_Clinical Features common to all Varieties._--Dislocation of the
shoulder is commonest in adult males; in advanced life the proportion
of female sufferers increases. It is usually attended with great pain,
and there is often numbness of the limb due to pressure of the head of
the bone upon the large nerve-trunks. There is sometimes considerable
shock. The patient inclines his head towards the injured side, and,
while standing, the forearm is supported by the hand of the opposite
side. The acromion process stands out prominently, the roundness of
the shoulder giving place to a flattening or depression immediately
below it, so that a straight-edge applied to the lateral aspect of the
limb touches both the acromion and the lateral epicondyle. The
vertical circumference of the shoulder is markedly increased; this
test is easily made with a piece of tape or bandage and is compared
with a similar measurement on the normal side--we lay great stress on
this simple measure, as it is a most reliable aid in diagnosis. The
head of the bone can usually be felt in its new position, and the axis
of the humerus is correspondingly altered, the elbow being carried
from the side--forward or backward according to the position of the
head. The empty glenoid may sometimes be palpated from the axilla. In
most cases, although not in all, the patient is unable at one and the
same time to bring his elbow to the side and to place his hand upon
the opposite shoulder (Dugas' symptom). Measurements of the length of
the limb from acromion to lateral epicondyle are rarely of any
diagnostic value.
The #sub-coracoid dislocation# (Fig. 18) is that most frequently met
with. It usually results from hyper-abduction of the arm while the
scapula is fixed, as in a fall on the medial side of the elbow when
the arm is abducted from the side. The surgical neck of the humerus is
then brought to bear upon the under aspect of the acromion, which
forms a fulcrum, and the head of the bone is pressed against the
medial and lower part of the capsule. In some cases muscular action
produces this dislocation; it may also result from force applied
directly to the upper end of the humerus.
[Illustration: FIG. 18.--Sub-coracoid Dislocation of Right Shoulder.]
The head leaves the capsule through the rent made in its lower part,
and, either from a continuation of the force or from contraction of
the muscles inserted into the inter-tubercular (bicipital) groove,
particularly the great pectoral, passes medially under cover of the
biceps and coraco-brachialis till it comes to rest against the
anterior surface of the neck of the scapula, just below the coracoid
process. The anatomical neck of the humerus presses against the
anterior edge of the glenoid, and there is frequently an _indentation
fracture of the head of the humerus_ where the two bones come into
contact (F. M. Caird). The subscapularis is bruised or torn, the
muscles inserted into the great tuberosity are greatly stretched, or
the tuberosity itself may be avulsed, allowing the long tendon of the
biceps to slip laterally, where it may form an impediment to
reduction. The axillary (circumflex) nerve is often bruised or torn,
and the head of the humerus is liable to press injuriously on the
nerves and vessels in the axilla.
The _clinical features_ common to all dislocations are prominent,
although Dugas' symptom is not constant.
[Illustration: FIG. 19.--Sub-coracoid Dislocation of Humerus.
(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]
_Treatment._--The guiding principle in the reduction of these
dislocations is to make the head of the bone retrace the course it
took in leaving the socket. The main obstacles to reduction being
muscular contraction and the entanglement of the head with tendons,
ligaments, or bony points, appropriate means must be taken to
counteract each of these factors.
A general anaesthetic is an invaluable aid to reduction, and should be
given unless there is some reason for withholding it. It is specially
indicated in strong muscular subjects, and in nervous patients who do
not bear pain well, and particularly when the dislocation has existed
for a day or two. In quite recent cases, however, the surgeon may
succeed in replacing the bone by taking advantage of a temporary
faintness, or by engaging the patient's attention with other matters
while he carries out the appropriate manipulations.
When an anaesthetic is employed, the patient should be laid on a
mattress on the floor, or on a narrow, firm table; otherwise he should
be seated on a chair.
_Kocher's method_ is suitable for the great majority of cases of
sub-coracoid dislocation. (1) The elbow is firmly pressed against the
side, and the forearm flexed to a right angle. The surgeon grasps the
wrist and elbow and firmly _rotates the humerus away from the middle
line_ (Fig. 20) till distinct resistance is felt and the deltoid
becomes more prominent. In this way the rent in the lower part of the
capsule is made to gape, and the head of the humerus rolls away from
the middle line till it lies opposite the opening, rotation taking
place about the fixed point formed by the contact of the anatomical
neck of the humerus with the anterior lip of the glenoid cavity (D.
Waterston). (2) _The elbow is next carried forward, upward, and
towards the middle line_ (Fig. 21); the humerus acting as the long arm
of a lever on the fulcrum furnished by the muscles inserted in the
region of the surgical neck, the head, which forms the short arm of
the lever, is carried backward, downward, and laterally, and is thus
directed towards the socket. (3) The humerus is now _rotated towards
the middle line_ by carrying the hand across the chest towards the
opposite shoulder (Fig. 22). The anatomical neck of the humerus is
thus disengaged from the edge of the glenoid, and the head is pulled
into the socket by the tension of the surrounding muscles.
[Illustration: FIG. 20.--Kocher's Method of reducing Sub-coracoid
Dislocation--First Movement; Rotation of Arm away from Middle Line.]
[Illustration: FIG. 21.--Kocher's Method--Second Movement; Elbow
carried forward, upward, and towards the Middle Line.]
[Illustration: FIG. 22.--Kocher's Method--Third Movement; Rotation of
Arm towards Middle Line.]
A method of reduction has been formulated by A. G. Miller, which we
have found to be quite as successful as Kocher's method. The limb is
grasped above the wrist and elbow, the forearm flexed to a right
angle, and the upper arm abducted to the horizontal (Fig. 23). While
an assistant makes counter-extension and fixes the scapula, the
surgeon gradually draws the arm away from the body till the head of
the humerus is felt to pass laterally. The humerus is then rotated
medially by dropping the hand (Fig. 24), and the bone gradually glides
into the socket.
[Illustration: FIG. 23.--Miller's Method of reducing Sub-coracoid
Dislocation--First Movement.]
[Illustration: FIG. 24.--Miller's Method of reducing Sub-coracoid
Dislocation--Second Movement.]
In a certain number of cases reduction can be effected by
_hyper-abduction_ of the shoulder with traction. The patient is laid
upon a firm mattress, and the surgeon, seated behind him while an
assistant fixes the acromion, slowly and steadily extends the arm
until it is raised well above the head. In some cases the head of the
humerus spontaneously slips into its socket; in others it may be
manipulated into position by pressure from the axilla. This method is
restricted to recent cases, as in those of long standing the axillary
vessels are liable to be stretched or torn.
The method of reduction by traction on the arm with the heel in the
axilla is only to be used when other measures have failed, as it
depends for its success on sheer force.
_After-Treatment._--After reduction, the part is gently massaged for
ten or fifteen minutes, a layer of wool is placed in the axilla, the
forearm is supported by a sling, and the arm fixed to the side by a
circular bandage. Massage is carried out from the first, and movement
of the shoulder in every direction except that of abduction may be
commenced on the first or second day. The circular bandage may be
dispensed with at the end of a week, and abduction movements
commenced, and by the end of a month the patient should be advised to
use the arm freely.
The #sub-clavicular dislocation# (Fig. 17) is to be looked upon as an
exaggerated degree of the sub-coracoid rather than as a separate
variety. It is produced by the same mechanism, but the violence is
greater, and the damage to the soft parts more severe. The head passes
farther upwards and towards the middle line under cover of the
pectoralis minor, resting under the clavicle against the serratus
anterior and chest wall. The symptoms are usually so marked that they
leave no doubt as to the diagnosis. The outline of the head of the
humerus in its abnormal position is visible through the skin, and the
shortening of the limb is more marked than in the sub-coracoid
variety. The treatment is the same as for sub-coracoid dislocation.
#Sub-glenoid dislocation# (Fig. 17) is less frequently met with than
the sub-coracoid variety, and almost always results from forcible
abduction of the arm. The head of the humerus passes out through a
small rent in the lower and medial portion of the capsule, and rests
against the anterior edge of the triangular surface immediately below
the glenoid cavity, supported behind by the long head of the triceps,
and in front by the subscapularis muscle. It is readily felt in the
axilla. All the tendons in relation to the upper end of the humerus
are stretched or torn, and the great tuberosity is not infrequently
avulsed. There is sometimes bruising of the axillary nerve.
The projection of the acromion, the flattening of the deltoid, the
increased depth of the axillary fold, and the abduction of the elbow
are well marked; the arm is slightly lengthened, rotated out, and
carried forward. It is reduced by the hyper-abduction method (p. 60).
#Sub-spinous Dislocation.#--Backward dislocation is usually termed
sub-spinous, although in a considerable proportion of cases the head
of the humerus does not pass beyond the root of the acromion process
(_sub-acromial_) (Fig. 17). This dislocation is usually produced by a
fall on the elbow, the arm being at the moment adducted and rotated
medially, so that the head of the humerus is pressed backwards and
laterally against the capsule, which ruptures posteriorly. All the
muscles attached to the upper end of the humerus are liable to be
torn, and the tuberosities are frequently avulsed. The long tendon of
the biceps may slip from its position between the tuberosities, and
prevent reduction or favour re-dislocation, necessitating an open
operation.
In the milder cases the _clinical features_ are not always well
marked, and on account of the swelling this dislocation is apt to be
overlooked. In addition to the ordinary symptoms, the shoulder is
broadened, there is a marked hollow in front in which the coracoid
projects, and the arm is held close to the side with the elbow
directed forward. The head of the bone may be seen and felt in its
abnormal position below the spine of the scapula.
Reduction can usually be effected by making traction on the arm with
medial rotation, and pressing the head forward into position, while
counter-pressure is made upon the acromion.
_Prognosis._--The ultimate prognosis in dislocations of the shoulder
should always be guarded. The axillary nerve may be stretched or torn,
and this may lead to atrophy of the deltoid; or other branches of the
brachial plexus may be injured and the muscles they supply permanently
weakened. In a certain number of cases traumatic neuritis has resulted
in serious disability of the limb. The movements of the shoulder-joint
may be restricted by cicatricial contraction of the torn portion of
the capsule and of the damaged muscles. A marked tendency to recurrent
dislocation may follow if abduction movements are permitted before
repair of the capsule has had time to occur.
#Dislocation of the Shoulder complicated with Fracture of the Upper
End of the Humerus.#--In these injuries the dislocation is almost
always of the sub-coracoid variety, and the most common fractures by
which it is complicated are those of the surgical neck, the anatomical
neck, or the greater tuberosity. The most common cause is a fall
directly on the shoulder, and it seems probable that the head of the
bone is first dislocated, and, the force continuing to act, the upper
end of the humerus is then broken; or the two lesions may be produced
synchronously.
When seen soon after the accident, the existence of the fracture of
the humerus is liable to be overlooked, the condition being mistaken
for dislocation alone, or for a fracture through the neck of the
scapula. On careful examination under an anaesthetic, however, it is
observed that not only is the head of the humerus absent from the
glenoid cavity, but that it does not move with the rest of the bone,
abnormal mobility and crepitus are recognised at the seat of fracture,
and the upper arm is shortened. The extravasation in the axilla is
usually greater than that accompanying a simple dislocation, and the
pain and shock are more severe. A fracture through the neck of the
scapula alone is readily recognised by the ease with which the
deformity is reduced, and the way in which it at once recurs when the
support is withdrawn. In many cases it is only by the aid of a
radiogram that an accurate diagnosis can be made (Fig. 25).
[Illustration: FIG. 25.--Dislocation of Shoulder with Fracture of Neck
of Humerus.
(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]
_Treatment._--Unless the dislocation is reduced at once, the movements
of the arm are certain to be seriously restricted, and painful
pressure effects from excess of callus are liable to ensue. An attempt
should first be made, under anaesthesia, to replace the head in its
socket, by making extension on the arm in the hyper-abducted
(vertical) position, and manipulating the upper fragment from the
axilla.
On no account should the lower fragment be employed as a lever in
attempting reduction. When reduction by manipulation fails, recourse
should be had to an open operation. The upper fragment should be
exposed by an incision over its lateral aspect, and made to return to
the socket by using Arbuthnot Lane's levers or M'Burney's hook, or a
long steel pin may be inserted into the fragment to give the necessary
leverage.
Reduction having been accomplished, the fracture is adjusted in the
usual way, advantage being taken of the open wound, if necessary, to
fix the fragments together by plates. The best position in which to
fix the limb is that of abduction at a right angle. Massage and
movement should be commenced early to prevent stiffness of the joint.
When it is found impossible to reduce the dislocation, it is usually
advisable to remove the upper fragment.
The method of allowing the fracture to unite without reducing the
dislocation, and then attempting reduction, usually results in
re-breaking the bone, or else in failure to replace the head in the
socket, and has nothing to recommend it.
#Old-standing Dislocation of the Shoulder.#--It is impossible to lay
down definite rules as to the date after which it is inadvisable to
attempt reduction by manipulation of an old-standing dislocation of
the shoulder. Experience of a hundred cases in Bruns' clinic led
Finckh to conclude that, provided there are no complications,
reduction can generally be effected within four weeks of the accident;
that within nine weeks the prospect of success is fairly good; but
that beyond that time reduction is exceptional.
The patient is anaesthetised, and all adhesions broken down by free yet
gentle movement of the limb. The appropriate manipulations for the
particular dislocation are then carried out, care being taken that no
undue force is employed, as the humerus is liable to be broken. If
these are not successful, they should be repeated at intervals of two
or three days, as it is frequently found that reduction is
successfully effected on a second or third attempt.
Should manipulative measures fail, it may be advisable to have
recourse to operation if the age of the patient and his general health
warrant it, and if the condition of the limb is interfering with his
occupation or involves serious disability. If operation is deemed
advisable, a few days should be allowed to elapse to permit of the
parts recovering from the effects of the manipulations. The joint is
freely exposed, the capsule divided, the head of the bone freed and
returned to the glenoid cavity. It is sometimes so difficult to
replace the head of the bone that it is necessary to resect it and aim
at the formation of a new joint, an operation which usually yields
satisfactory results.
#Habitual or Recurrent Dislocation.#--Cases are occasionally met with
in which the shoulder-joint shows a marked tendency to be dislocated
from causes altogether insufficient to produce displacement under
ordinary circumstances. This condition is usually met with in young
women, and, in some cases at least, appears to be due to too early and
too free movement of the joint after an ordinary dislocation, so that
the capsule is stretched and remains lax. In some cases it would
appear that the liability to dislocation is due to some structural
defect in the joint, and under these conditions both sides are
sometimes affected, and the accident is not attended with the usual
pain and disability either at the time or after reduction. The
facility and frequency with which dislocation recurs render the limb
comparatively useless, and may seriously incapacitate the patient. We
have had cases under observation in which dislocation resulted from
the hyper-abduction of the arm in swimming, from throwing the arms
above the head in dancing and in gymnastic exercises, and even in
"doing" the hair.
The _treatment_ consists in preventing the patient making the
particular movements which tend to produce the dislocation. These are
chiefly movements of hyper-abduction and overhead movements; we have
found an apparatus consisting of a belt applied around the thorax, and
fixed to another around the upper arm by a band which passes above the
axillary fold of the dress, useful in restraining these movements. If
these measures fail, it may be advisable to have recourse to
operation; this may consist in tightening up the capsule, the results
of which are said to be uncertain, or in detaching a portion of the
deltoid or subscapularis muscle and stitching it beneath the joint to
cover and strengthen the weakened portion of the capsule. It is
suggestive that in performing this operation no rent in the capsule is
discovered.
The condition is also met with in epileptics; and it is generally
found that the head of the bone is deficient, as a result either of
fracture or disease; that the muscles which naturally support the
joint are atrophied or torn; and that the capsule is unduly lax.
#Sprain# of the shoulder-joint is comparatively rare, because of the
wide range of movement of which it is capable. The region of the
shoulder becomes swollen and tender to pressure, the point of maximum
tenderness being over the front of the joint, just below the acromion
process; pain is elicited also when the ligaments or tendons are put
upon the stretch.
#Contusion# of the region of the shoulder, on the other hand, is
exceedingly common. In most cases it is merely the deltoid muscle and
the subcutaneous tissue over it that are bruised, but sometimes a
haematoma forms either in the muscle or in the sub-deltoid bursa. There
is pain on moving the limb, and the patient may be unable to abduct
the arm at the shoulder-joint. Under treatment by massage and
movement, the symptoms usually pass off completely in two or three
weeks. The affections of the _bursa_ are described elsewhere.
In other cases, the cords of the brachial plexus above the clavicle
are stretched, or the axillary nerve is bruised, and these injuries
are liable to be followed by prolonged pain, loss of abduction, and
stiffness in the arm. The deltoid frequently undergoes considerable
atrophy, and there is severe neuralgic pain in the axillary nerve,
especially marked in the region of the insertion of the deltoid.
In addition to maintaining the limb in the abducted position, it is
necessary to keep up the nutrition of the muscles by massage and
electricity.
FRACTURE OF THE SCAPULA
Fractures of the scapula may implicate the body, the surgical neck,
the acromion, or the coracoid process. They are rarely compound.
#Fracture of the Body.#--Considering its exposed position, the body of
the scapula is comparatively seldom fractured, doubtless because of
its mobility, and the support it receives from the elastic ribs and
soft muscular cushions on which it lies. Apart from gun-shot injuries,
it is most frequently broken by a severe blow or crush. The scapula
presents two natural arches--one longitudinal, the other
transverse--and when the bone is crushed or struck, the force produces
fracture by undoing its curves (E. H. Bennett). A main fissure usually
runs transversely across the infra-spinous fossa, and secondary cracks
radiate from it (Fig. 26). In other cases the line of the primary
fracture is longitudinal, passing through the spine and involving both
fossae.
[Illustration: FIG. 26.--Transverse Fracture of Scapula, with fissures
radiating into spinous process and dorsum.]
The _clinical features_ are obscured by swelling of the overlying soft
parts. Crepitus may sometimes be elicited by placing one hand firmly
over the bone, and with the other moving the arm and shoulder. When
the spine is implicated, the fragments may be grasped and made to move
one upon another. The displacement, which usually consists in
overlapping of the fragments--although sometimes they are drawn
apart--is partly due to the action of the serratus anterior and teres
major muscles, and partly depends on the direction of the force.
Movement is restricted and painful. Osseous union usually takes place
rapidly, and although displacement often persists, the function of the
limb is unimpaired.
_Treatment._--As these fractures are usually complicated by other
injuries, especially of the thorax, and are accompanied by severe
shock, it is necessary to confine the patient to bed. It is usually
sufficient to fix the arm and shoulder to the chest wall by a firm
binder, in the position which admits of the most complete apposition
of fragments. This retentive apparatus is employed for about three
weeks, after which the patient is allowed to use his arm. The bandages
are removed daily to admit of massage.
#Fracture of the surgical neck of the scapula#, although a rare
accident, is of importance, as it is liable to be mistaken for
dislocation of the shoulder. The line of fracture runs through the
scapular notch, downwards and laterally to the lower margin of the
glenoid, so that the glenoid and the coracoid process are separated
from the rest of the bone.
The coraco-acromial and coraco-clavicular ligaments are usually torn,
and the detached fragment, along with the head of the humerus, sinks
into the axilla, causing a flattening of the shoulder, and leaving a
depression below the projecting acromion. These signs may be obscured
by the general swelling of the shoulder. The arm may be lengthened
about an inch. By supporting the arm the deformity is at once reduced,
but recurs as soon as the support is withdrawn. Crepitus is usually
detected on carrying out this manipulation; and the coracoid process
is found to move with the arm and not with the scapula. By these
tests, and by the X-rays, this injury is distinguished from a
dislocation.
A partial fracture carrying away the lower part of the _glenoid
cavity_ simulates a sub-glenoid dislocation. This is, however, a rare
injury.
The _treatment_ consists in bracing back the shoulders and supporting
the elbow, and this is most satisfactorily done by a body bandage and
sling for the elbow, as for fracture of the middle third of the
clavicle. Passive movements and massage are employed from the first.
#Fracture of the acromion process# may result from a blow or fall on
the shoulder. It is often overlooked on account of the swelling
resulting from bruising of the soft parts, and the absence of marked
displacement. On palpation, crepitus and an irregularity at the seat
of fracture may sometimes be detected. The shoulder is slightly
flattened, and abduction of the arm is difficult. In rare cases the
fracture passes into the acromio-clavicular joint, and is associated
with dislocation of the clavicle.
In connection with this fracture, reference must be made to a
condition frequently met with, in which the epiphysial portion
of the acromion is found to be separate from the body of the
process--_separate acromion_. This is by some (Symington, Hamilton)
looked upon as a want of union of the epiphysis, but the weight of
evidence seems to prove that it is rather of the nature of an
un-united fracture at this level, even when, as sometimes happens, it
is bilateral (Struthers, Arbuthnot Lane).
Between the fourteenth and twenty-second years a true _separation of
the epiphysis_ may be met with, but it is seldom possible to make a
positive diagnosis of this injury. As is the case in all fractures of
the acromion, bony union seldom takes place.
The _treatment_ is the same as for fracture of the lateral end of the
clavicle.
#Fracture of the coracoid process# is rare. It may result from direct
violence, such as the recoil of a gun, but it is more often an
accompaniment of dislocation of the shoulder or of the lateral end of
the clavicle upward. As the coraco-clavicular ligaments usually remain
intact, there is no displacement; but when these are torn the coracoid
is dragged downwards and laterally by the combined action of the
pectoralis minor, biceps, and coraco-brachialis muscles. Crepitus may
be elicited on moving the fragment. _Separation of the epiphysial
portion_ of the coracoid may occur up to the seventeenth year.
The _treatment_ consists in placing the arm across the front of the
chest, to relax the muscles causing the displacement, and retaining it
in that position by a sling and roller bandage.
FRACTURE OF THE UPPER END OF THE HUMERUS
It is most convenient to study fractures of the upper end of the
humerus in the following order: (1) fracture of the surgical neck; (2)
separation of the epiphysis; (3) fracture of head, anatomical neck, or
tuberosities.
[Illustration: FIG. 27.--Fracture of Surgical Neck of Humerus, united
with Angular Displacement.]
#Fracture of the Surgical Neck.#--The surgical neck of the humerus
extends from the level of the epiphysial junction to the insertion of
the pectoralis major and teres major muscles, and it is within these
limits that most fractures of the upper end of bone occur. This
fracture is most common in adults, and usually follows direct violence
applied to the shoulder, but may result from a fall on the hand or
elbow, or from violent muscular action, as, for example, in throwing a
stone. It is usually transverse, and there is often little or no
displacement, the fragments being retained in position by the long
tendon of the biceps and the long head of the triceps. When the
fracture is oblique, the fragments are often comminuted, and sometimes
impacted. The displacement of the upper fragment seems to depend upon
the attitude of the limb at the moment of fracture. When the upper arm
is approximated to the side, the upper fragment retains its vertical
position, but is slightly rotated laterally by the muscles inserted
into the greater tuberosity, while the lower fragment is drawn upwards
and medially towards the coracoid process by the muscles inserted into
the inter-tubercular groove and the longitudinal muscles of the upper
arm, and can be felt in the axilla. The elbow points laterally and
backwards, and the upper arm is shortened. The shoulder retains its
rotundity, but there is a slight hollow some distance below the
acromion. On grasping the elbow and moving the shaft, it is found that
the head and tuberosities do not move with it, and unnatural mobility
and crepitus at the seat of fracture may be detected. When the upper
arm is abducted at the moment of fracture, the upper fragment is
retained in that position by the lateral rotator and abductor muscles
inserted into it, while the lower fragment passes upwards and
medially.
[Illustration: FIG. 28.--Impacted Fracture of Neck of Humerus, in man
aet. 75.
(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]
Although there is sometimes overlapping and broadening after union,
beyond some limitation of the range of abduction the usefulness of the
limb is seldom impaired.
_Treatment._--Massage, by allaying spasm of the muscles, soon
overcomes the moderate amount of displacement which is usually met
with. Further, the skin surfaces of the axilla having been separated
by a thin layer of cotton wool, a sling is applied to support the
wrist, and the arm is bound to the side by a body bandage.
In comminuted fractures and those with marked displacement, a general
anaesthetic may be required to ensure accurate reduction; and to
maintain the fragments in apposition, and to avoid any limitation of
abduction after union, the limb may be fixed in the position of
abduction at a right angle by means of a Thomas' arm splint with
swivel ring, and extension applied, if necessary, to maintain this
attitude. After a week or ten days the patient is allowed up, wearing
an abduction frame (Fig. 29), or a splint, such as Middeldorpf's,
which consists of a double inclined plane, the base of which is fixed
to the patient's side, while the injured arm rests on the other two
sides of the triangle. Massage and movement are employed daily.
[Illustration: FIG. 29.--Ambulatory Abduction Splint for Fracture of
Humerus.]
Should these measures fail, the fracture may be exposed by an incision
carried along the anterior border of the deltoid, and the ends
mechanically fixed, after which the limb is put up in the abducted
position for three or four weeks. Massage is commenced on the second
or third day. Union is usually complete in about four weeks.
#Separation of Epiphysis.#--The upper epiphysis of the humerus
includes the head, both tuberosities, and the upper fourth of the
inter-tubercular groove. On its under aspect is a cup-like depression
into which the central pyramidal-shaped portion of the diaphysis fits.
This epiphysis unites about the twenty-first year.
[Illustration: FIG. 30.--Radiogram of Separation of Upper Epiphysis of
Humerus.]
Traumatic separation is met with chiefly between the fifth and
fifteenth years, and is most common in boys. It usually results from
forcible traction of the arm upwards and away from the side, as in
lifting a child by the upper arm, or from direct violence, but may be
caused by a fall on the lateral side of the elbow.
The epiphysis, especially in young children, may be separated without
being displaced, or the displacement may be incomplete.
When the epiphysis is completely separated from the shaft, the
clinical features closely resemble those of fracture of the surgical
neck, and the diagnosis is made by a consideration of the age of the
patient, and the muffled character of the crepitus, when it can be
elicited. The upper end of the diaphysis forms a projecting ridge
which may be felt below and in front of the acromion. The diagnosis
can usually be established by the use of the X-rays (Fig. 30).
Dislocation is rare at the age when separation of the epiphysis
occurs.
Reduction is often difficult on account of the periosteum and other
soft tissues getting between the fragments, and on account of the
small size of the upper fragment. Union almost invariably results, but
the growth of the limb may be interfered with and its shape altered,
especially when the injury occurs at an early age and its nature is
overlooked.
_Treatment._--This injury is treated on the same general lines as
fracture of the surgical neck. General anaesthesia is almost always
necessary to secure satisfactory reduction, and retention is most
easily secured if the patient is confined to bed with the upper arm
fixed in the fully abducted position. Operative treatment is called
for in exceptional cases.
#Fractures of the Head, Anatomical Neck, and Tuberosities of
Humerus.#--These fractures are met with as accompaniments of
dislocation of the shoulder, and as results of gun-shot injuries,
blows, or falls.
In sub-coracoid dislocation the _head_ of the humerus may be indented
by coming in contact with the anterior edge of the glenoid cavity (F.
M. Caird).
The _anatomical neck_ may be fractured in an old person by a direct
blow on the shoulder. In a few cases the fracture is entirely
intra-capsular, the head of the bone remaining loose in the cavity of
the joint. As a rule, however, the fracture passes laterally and
implicates the tuberosities. In some cases there is impaction, and in
others comminution of the fragments. The use of the X-rays has shown
that in many cases in which prolonged stiffness has followed a severe
blow of the shoulder, there has been a fracture of the anatomical
neck.
The _tuberosities_ may be implicated in other fractures in this region
and in dislocation of the shoulder; and either of them may be
separated by muscular contraction or by direct violence.
_Clinically_ all these injuries are difficult to diagnose with
accuracy, and, without the use of the X-rays, it is impossible in many
cases to go further than to say that a fracture exists above the level
of the surgical neck. Fracture of the anatomical neck is attended with
little deformity beyond slight flattening of the shoulder and
sometimes slight shortening of the upper arm.
When the _great tuberosity_ is torn off, considerable antero-posterior
broadening of the shoulder may be recognised by grasping the region of
the tuberosities between the fingers and thumb. Crepitus can be
elicited on rotating the humerus. At the same time it will be
recognised that the tuberosity does not move with the shaft. Firm
union, with considerable formation of callus and some broadening of
the shoulder, usually results, but the usefulness of the joint is not
necessarily impaired. There may, however, be prolonged stiffness and
impaired movement from adhesion; or pain and crackling in the joint
may result from arthritic changes like those of arthritis deformans.
_Treatment._--These fractures are treated on the same lines as
fracture of the surgical neck of the humerus.
The combination of fracture of the upper end of the humerus with
dislocation of the shoulder has already been referred to.
FRACTURE OF THE SHAFT OF THE HUMERUS
Fractures occurring in the shaft of the humerus between the surgical
neck and the base of the condyles may, for convenience of description,
be divided into those above, and those below, the level of the deltoid
insertion--the majority being in the latter situation.
Direct violence is the most common cause of these fractures, but they
may occur from a fall on the elbow or hand; and a considerable number
of cases are on record where the bone has been broken by muscular
action--as in throwing a cricket-ball. Twisting forms of violence may
produce spiral fractures.
The fracture is usually transverse in children and in cases in which
it is due to muscular action. In adults, when due to external
violence, it is usually oblique, the fragments overriding one another
and causing shortening of the limb. The displacement depends largely
on the direction of the force and the line of fracture, but to a
certain extent also on the action of muscles attached to the
fragments. Thus, in fractures above the insertion of the deltoid the
upper fragment is usually dragged towards the middle line by the
muscles inserted into the inter-tubercular groove, while the lower is
tilted laterally by the deltoid. When the break is below the deltoid
insertion the displacement of the fragments is reversed. The signs of
fracture--undue mobility, deformity, shortening, and crepitus--are at
once evident, and the patient himself usually recognises that the bone
is broken.
The nerve-trunks in the arm--the median, ulnar, and radial
(musculo-spiral)--are apt to be damaged in these injuries; in
fractures of the lower part of the shaft the radial nerve is specially
liable to be implicated. This may occur at the time of the injury, the
nerve being contused by the force causing the fracture, or pressed
upon by one or other of the fragments, or its fibres may be partly or
completely torn across. When there is evidence of nerve injury, the
practitioner should draw the attention of the patient to it then and
there, and so guard himself against actions for malpraxis should
paralysis of the muscles ensue. Later, the nerve may become involved
in callus, or be damaged by the pressure of ill-fitting splints.
Weakness or paralysis of the extensors of the wrist and hand results,
giving rise to the characteristic "wrist-drop." The actions of the
muscles should always be tested before applying splints, and each time
the apparatus is removed or readjusted, to assure that no undue
pressure is being exerted on the nerves.
Union takes place in from four to six weeks in adults, and in from
three to four weeks in children. Delayed union, or want of union and
the formation of a false joint, is more common in fractures of the
middle of the shaft of the humerus than in any other long bone--a
point to be borne in mind in treatment. Arrest of growth in the bone
from injury to the nutrient artery is also said to have occurred.
_Treatment._--To restore the alignment of the bone, extension is made
on the lower fragment and the ends are manipulated into position. This
may necessitate the use of a general anaesthetic, and care must be
taken that no soft tissue intervenes between the fragments, as is
evidenced radiographically by the persistence of a clear space between
the ends even when they appear to be in apposition.
In _transverse_ fractures the position may be maintained by a simple
ferrule of poroplastic or Gooch-splinting. The elbow is flexed at a
right angle, and the forearm supported in a sling midway between
pronation and supination. For a few days the limb may be bound to the
chest by a broad roller bandage.
[Illustration: FIG. 31.--"Cock-up" Splint, for maintaining
Dorsiflexion at Wrist.]
The splints are removed daily to admit of massage and movement being
carried out, and while the splints are off, the patient is allowed to
exercise the fingers and wrist. If at the end of four or five weeks,
osseous union has not occurred, the reparative process may be hastened
by inducing venous congestion by Bier's method.
In _oblique and spiral_ fractures it is often necessary to control the
shoulder and elbow-joints to prevent re-displacement. This can be done
by means of a plaster of Paris case enclosing the upper part of the
thorax, together with the upper arm, abducted, and the elbow, at right
angles.
[Illustration: FIG. 32.--Gooch Splints for Fracture of Shaft of
Humerus; and Rectangular Splint to secure Elbow.]
It is sometimes necessary to apply continuous extension to the lower
fragment to prevent overriding. For this purpose a Thomas' arm splint
is employed, the extension tapes being attached to its lower end, but
care must be taken that the traction is not sufficient to separate
the fragments and leave a gap between them. The elbow should not be
retained in the extended position for more than three weeks.
In rare cases it is necessary to have recourse to operative treatment.
When there is evidence that the radial nerve has been injured, and no
sign of improvement appears within three or four days of the accident,
operative interference is indicated. An incision is made on the
lateral side of the arm, and the nerve exposed and freed from
pressure, or stitched, as may be necessary; the opportunity should
also be taken of dealing with the fracture. The limb is put up in a
"cock-up" splint, with the hand in the attitude of marked dorsiflexion
(Fig. 31).
Satisfactory results have been obtained without the use of splints, by
relying upon massage to overcome the spasm of muscles, and allowing
the weight of the arm to act as an extending force (J. W. Dowden and
A. Pirie Watson).
In cases of _un-united fracture_, a vertical or semilunar incision is
made over the lateral aspect of the bone, and the muscles separated
from one another till the fracture is exposed, care being taken to
avoid injuring the radial nerve. The fibrous tissue is removed from
the ends of the bone, and the rawed surfaces fixed in apposition; the
wound is then closed, and appropriate retentive apparatus applied. As
soon as the wound has healed, massage and movement are employed.
CHAPTER IV
INJURIES IN THE REGION OF THE ELBOW AND FOREARM
Surgical Anatomy--Examination of injured elbow--FRACTURE OF LOWER END
OF HUMERUS: _Supra-condylar_; _Inter-condylar_; _Separation of
epiphysis_; _Fracture of either condyle alone_; _Fracture of
either epicondyle alone_--FRACTURE OF UPPER END OF ULNA:
_Olecranon_; _Coronoid_--FRACTURE OF UPPER END OF RADIUS: _Head_;
_Neck_; _Separation of epiphysis_--DISLOCATION OF ELBOW: _Both
bones_; _Ulna alone_; _Radius alone_--FRACTURE OF FOREARM: _Both
bones_; _Radius alone_; _Ulna alone_.
The injuries met with in the region of the elbow-joint include the
various fractures of the lower end of the humerus, and upper ends of
the bones of the forearm, including the olecranon; and dislocations
and sprains of the elbow-joint. The differential diagnosis is often
exceedingly difficult on account of the swelling and tension which
rapidly supervene on most of these injuries, the pain caused by
manipulating the parts, and the difficulty of determining whether
movement is taking place _at_ the joint or _near_ it.
#Surgical Anatomy.#--The medial epicondyle of the humerus is more
readily felt through the skin than the lateral. The two epicondyles
are practically on the same level, and a line joining them behind
passes just above the tip of the olecranon when the arm is fully
extended. On flexing the joint, the tip of the olecranon gradually
passes to the distal side of this line, and when the joint is fully
flexed the tip of the olecranon is found to have passed through half a
circle. The head of the radius can be felt to rotate in the dimple on
the back of the elbow just below the lateral epicondyle. The coronoid
process may be detected on making deep pressure in the hollow in front
of the joint. As the line of the radio-humeral joint is horizontal,
while that of the ulno-humeral joint slopes obliquely downwards, the
arm forms with the fully extended and supinated forearm an obtuse
angle, opening laterally--the "carrying angle." This angle is usually
more marked in women, in harmony with the greater width of the female
pelvis. The ulnar nerve lies in the hollow between the olecranon and
the medial condyle, and the median nerve passes over the front of the
joint, with the brachial artery and biceps tendon to its lateral side.
The radial nerve divides into its superficial and deep (posterior
interosseous) branches at the level of the lateral condyle.
In _examining an injured elbow_, the thumb and middle finger are
placed respectively on the two epicondyles, while the index locates
the olecranon and traces its movements on flexion and extension of the
joint. The movements of the head of the radius are best detected by
pressing the thumb of one hand into the depression below the lateral
epicondyle, while movements of pronation and supination are carried
out by the other hand. The uninjured limb should always be examined
for purposes of comparison.
In injuries about the elbow much aid in diagnosis is usually obtained
by the use of the X-rays; but in young children it is sometimes
impossible, even with excellent pictures, to make an accurate
diagnosis by means of radiograms alone. In cases of suspected
fracture, a radiogram should be taken with the back of the limb
resting on the plate, the forearm being extended and supinated. If a
dislocation is suspected and a lateral view is desired, the arm should
be placed on its medial side. In obscure cases it is useful to take
radiograms of the healthy limb in the same position.
FRACTURES OF THE LOWER END OF THE HUMERUS
The following fractures occur at the lower end of the humerus: (1)
supra-condylar fracture; (2) inter-condylar fracture; (3) separation
of epiphyses; (4) fracture of either condyle alone; and (5) fracture
of either epicondyle alone.
All these injuries are common in children, and result from a direct
fall or blow upon the elbow, or from a fall on the outstretched hand,
especially when at the same time the joints are forcibly moved beyond
their physiological limits, more particularly in the direction of
pronation or abduction. While it is generally easy to diagnose the
existence of a fracture, it is often exceedingly difficult to
determine its exact nature. Although the ulnar and median nerves are
liable to be injured in almost any of these fractures, they suffer
much less frequently than might be expected.
Ankylosis, or, more frequently, locking of the joint, is a common
sequel to many of these injuries. This is explained by the difficulty
of effecting complete reduction, and by the wide separation of
periosteum which often occurs, favouring the production of an
excessive amount of new bone, particularly in young subjects.
The #supra-condylar# fracture usually results from a fall on the
outstretched hand with the forearm partly flexed, from a direct blow,
or from a twisting form of violence. The line of fracture is generally
transverse, or but slightly oblique from behind downwards and
forwards, so that the lower fragment is forced backward together with
the bones of the forearm, simulating backward dislocation of the
elbow; the lower end of the upper fragment lies in front (Fig. 33).
[Illustration: FIG. 33.--Radiogram of Supra-condylar Fracture of
Humerus, in a child aet. 7.]
_Clinical Features._--The elbow is flexed at an angle of 120 deg. or 130 deg.,
and the forearm, held semi-pronated, is supported by the other hand.
Around the seat of fracture great swelling rapidly ensues. The
olecranon projects behind, but the mutual relations of the bony points
of the elbow are unaltered. The lower end of the upper fragment may be
felt in front above the level of the joint, as a rough and sharp
projection, and this sometimes pierces the soft parts and renders the
fracture compound. Movement at the joint is possible, but unnatural
mobility may be detected above the level of the joint. Crepitus and
localised tenderness may be elicited. The displacement is readily
reduced by manipulation, but usually returns when the support is
withdrawn. The arm is shortened to the extent of about half an inch.
In rare cases the obliquity of the fracture is downward and backward,
and the lower fragment is displaced forward.
The #inter-condylar# fracture is a combination of the supra-condylar
with a vertical split running through the articular surface, and so
implicating the joint. The condyles are thus separated from one
another, as well as from the shaft, by a T- or Y-shaped cleft. As such
fractures usually result from severe forms of direct violence, they
are often comminuted and compound. In addition to the signs of
supra-condylar fracture, the joint is filled with blood. The condyles
may be felt to move upon one another, and coarse crepitus, which has
been likened to the feeling of a bag of beans, may be elicited if the
fragments are comminuted.
[Illustration: FIG. 34.--Radiogram of T-shaped Fracture of Lower End
of Humerus.]
#Separation of the lower epiphysis# of the humerus is met with in
children of three or four years of age, but it may occur up to the
thirteenth or fourteenth year. The more common lesion, however, is a
combination of separated epiphysis with fracture, and this lesion is
produced by the same forms of violence as cause supra-condylar
fracture. If the periosteum is not torn, there is little or no
displacement, but as a rule the clinical features closely resemble
those of transverse fracture above the condyles, or of dislocation of
the elbow. In separation of the epiphysis there is a peculiar
deformity of the posterior aspect of the joint, consisting of two
projections--one the olecranon, and the other the prominent capitellum
with a scale of cartilage which it carries with it from the lateral
condyle (R. W. Smith and E. H. Bennett). The end of the diaphysis may
be palpated through the skin in front. Muffled crepitus can usually be
elicited, and there is pain on pressing the segments against one
another. Sometimes the separation is _compound_, the diaphysis
protruding through the skin.
Union takes place more rapidly than in fracture, but, owing to the
excessive formation of callus from the torn periosteum in front of the
joint, full flexion is often interfered with. If the displaced
epiphysis is imperfectly reduced, serious interference with the
movements of the elbow is liable to ensue, and may call for operative
treatment.
#Fracture of either Condyle alone.#--The lateral condyle or trochlea
is more frequently separated from the rest of the bone than is the
medial or capitellum. In either, the size of the fragment varies, but
the line of fracture is partly extra-capsular and partly
intra-capsular, so that the joint is always involved. Pain, crepitus,
and the other signs of fracture are present. As the ligaments of the
joint are not as a rule torn, there is little or no immediate
displacement of the fragment. Secondary displacement is liable to
occur, however, during the process of union, producing alterations in
the "carrying angle" of the limb--_cubitus varus_ or _cubitus valgus_.
#Fracture of Epicondyles.#--Fracture of the _lateral epicondyle_ alone
is so rare that it need only be mentioned.
The _medial epicondyle_ may be chipped off by a fall on the edge of a
table or kerbstone, or it may be forcibly avulsed by traction through
the ulnar collateral (internal lateral) ligament, as an accompaniment
of dislocation. It is usually displaced downwards and forwards by the
flexor muscles attached to it, and may thus come to exert pressure on
the ulnar nerve. The fragment may be grasped and made to move on the
shaft, producing crepitus. Fibrous union is the usual result.
Up to the age of seventeen or eighteen the epiphysis of the epicondyle
may be separated.
#Treatment of Fractures in Region of Elbow.#--The administration of a
general anaesthetic is a valuable aid to accurate reduction and
fixation of fractures in this region. Much discussion has taken place
as to the best position in which to treat these fractures. In our
experience the best approximation of the fragments, as shown by the
X-rays, is obtained when the limb is fixed in the position of full
flexion with supination. American surgeons favour the position of
flexion at a right angle. In the region of the elbow there is a risk
of promoting too much callus formation by early and vigorous massage,
with the result that the movements of the joint are restricted by
locking of the bony projections. This is probably due to bone cells
being forced into the surrounding tissues, where they multiply and
form new bone on an exaggerated scale.
The _supra-condylar fracture_ is reduced by first extending the elbow
to free the lower fragment from the triceps, and
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