Surgery, with Special Reference to Podiatry Part 20

Puncture and evacuation, followed by swabbing out with pure phenol or strong iodin, may set up an inflammatory reaction within the sac, which acts similarly to the suppurative process, causing adhesion of the walls, thus preventing a recurrence.

CHAPTER XVI

+FRACTURES, DISLOCATIONS AND SPRAINS+

+FRACTURES+

A fracture may be defined as a broken bone. Fractures are cla.s.sified as follows:

1. As to their degree.

2. As to the direction of the line of fracture.

3. As to their location.

4. As to the etiology.

5. As to their relation to the overlying skin.

6. As to the number of fragments.

7. As to whether they are complicated or not.

+Degree of Fracture.+ A fracture which only involves a portion of the thickness of the bones, so that its continuity has not been entirely lost or a fragment has not been completely detached, is called an _incomplete fracture_. A fracture which involves the entire thickness of the bone, so that it is divided into two or more distinct fragments, is called a _complete fracture_.

+INCOMPLETE FRACTURES+

Among the varieties of incomplete fracture are: greenstick; fissured; depressed.

+Greenstick Fractures+ (really a bending rather than a break of the bone) are mostly seen under the age of fifteen, and the bones of the leg are rarely affected.

+Fissured Fractures+ are those in which there is a split or crack in the bones; they are very rare in the bones of the lower extremity.

+Depressed Fractures+ are fractures in which one or more segments of broken bone are depressed; they are most common in fractures of the skull.

+COMPLETE FRACTURES+

+Complete Fractures+ are divided according to the line and the seat of the breech of bone continuity.

DIRECTIONS OF THE LINES OF FRACTURES

+Transverse+, when the line of fracture does not deviate more than ten to fifteen degrees from that of the transverse axis. This variety is rare in the shaft of the long bones. It is usually found at the lower end of the radius or of the femur, and in the short bones.

+Longitudinal+, when the break is parallel to the long diameter of the bone; very few cases of this variety are seen.

+Oblique+, when the direction of the line of fracture may form any angle with the transverse axis of the bone up to a right angle. When it approaches the latter, it belongs to the group of longitudinal fractures. In the oblique variety, the line of fracture may be single or multiple. This and the spiral form are most frequent in the shafts of the long bones.

+Spiral+, when the break line is spiral. This variety of fracture was formerly considered to be very rare. The more systematic use of the X-ray as part of the routine of diagnosis has shown that spiral fractures are quite frequent in the shafts of the tibia and fibula.

They are usually the result of a rotating or twisting force.

CLa.s.sIFICATION OF FRACTURES

+Comminuted+, when there is extensive splintering of the bone adjoining the fracture or one of the fragments.

+Impacted+, when the fragments are driven into each other. This variety usually occurs in the neck of the femur.

+Compression, or Crushing Fractures+, when the broken bones are compressed or crushed; this variety usually occurs in the tarsal bones. The spongy portion and cortical layer are both crushed. In some cases there is a perfect pulpification of these bones. This condition occurs after falls from a height upon the sole of the foot.

LOCATION OF FRACTURE

+In the Diaphysis of a Bone.+ Breaks in the diaphysis of a bone are spoken of as fractures of the _shaft_, and to be still more exact, it is stated whether of the upper, middle, or lower third.

+At the Ends of Bones.+ Fractures occurring at the ends of bones receive the name of the part which the line of fracture transverses; for example, fractures of the _neck_ of a bone, of a _tuberosity_, of a _process_, of a _condyle_, etc.

There are two forms of fracture that require special mention in connection with their location. These are _epiphyseal separations_ and _articular fractures_.

+Epiphyseal Separations.+ The union of the epiphysis to the diaphysis commences during p.u.b.erty, hence these fractures are less common in childhood than after the ages of eleven or twelve. As a rule, they can only occur before the twentieth year. The periosteum is more resisting and tougher during the early years of life than later on.

+Articular Fracture+ (_joint fractures_). Like epiphyseal separations, recognition and proper treatment of these fractures have a.s.sumed great importance.

Articular fractures may be divided into three cla.s.ses:

1. _Intra-articular._ In these the line of fracture lies entirely within the joint. Such fractures are most frequently found in the elbow and knee joint.

2. _Para articular._ In these the line of fracture extends close to the joint but not into it. An example of this cla.s.s is the _supracondyloid_ fracture of the humerus.

3. _Articular fractures proper._ The majority of joint fractures belong to this cla.s.s. The line of fracture either extends into the joint from without or it extends from the joint outward. As example, the ankle joint; the majority of the typical supramalleolar, malleolar, and spiral fractures of the tibia and fibula.

+Etiology.+ Fractures may be divided into two groups: the _traumatic_ and the _pathologic_ or _spontaneous_. In the traumatic, the fracture is the result of violence acting upon a bone which is either normal or shows slight changes due to the physiologic causes mentioned. A pathologic or spontaneous fracture is one which occurs in a bone, the strength of which has been diminished by some preceding abnormal or pathologic changes. In this variety the degree of force which produced the fracture would not be sufficient to cause a fracture in a healthy bone.

The causes of traumatic fractures may be either predisposing or exciting.

+Predisposing Causes.+ The bones of the human body attain their greatest strength toward middle age. From infancy up to that time the bones are very elastic and yielding. Toward old age an interst.i.tial atrophy occurs. It causes a thinning of the cortex of the shafts and of the trabeculae of the spongy portions of the long and short bones. It is an actual diminution of the bone substance and a corresponding increase of the fat. This is especially seen in the neck of the femur.

When it occurs in old age, it acts as a predisposing cause, but when it occurs prematurely or reaches an extreme degree, it must be considered as pathologic.

EXISTING OR DETERMINING CAUSES OF FRACTURES

+Fractures by External Violence+ are divided both clinically and from a mechanic standpoint into two cla.s.ses: _direct_ and _indirect_. In fractures by direct violence the bone breaks immediately under the point where the force has been applied. In this cla.s.s of fractures there is more damage to the soft tissues and this damage is generally more serious than in indirect fractures. Direct fractures are more likely to occur in exposed bones like the clavicle, os calcis, etc.

An example of fracture by direct violence is found in fractures of the tarsal bones after a fall upon the feet from a height.

Under the head of fractures by indirect violence belong (a) those which occur as the result of a rotary or twisting force (spiral fracture of the tibia or fibula, for example); (b) those which are produced by compression; (for example, a fall upon the feet may cause an impacted fracture of the upper end of the tibia); (c) those which are the result of a tearing force.

Fractures resulting from a tearing force occur when a joint is suddenly moved beyond its normal range of excursion. The firmly attached ligaments being a fixed point, the ends or some process of the bones composing the joint are torn off from the remainder of the bone. Examples of this are fractures of the internal or external malleoli, following forcible eversion or inversion of the foot.

Fractures are also caused by muscular action and by gunshot injuries.