Surgery, with Special Reference to Podiatry Part 21

+Pathologic+ (spontaneous fractures):

1. Fractures resulting from bone fragility of local origin as for example, tumors, osteomyelitis, aneurisms.

2. Fractures resulting from bone fragility due to some general disease, as for example, tabes dorsalis, paresis, rachitis, osteomalacia, and exhausting chronic diseases.

CLa.s.sIFICATION AND RELATION OF FRACTURES TO THE OVERLYING SKIN

Fractures are divided into _compound_, or _open_ and _simple_, or _subcutaneous_, according to whether a communication does or does not exist between the seat of fracture and a wound of the skin.

A compound fracture is one in which the cutaneous wound communicates with the seat of the fracture.

A simple fracture is one in which a wound of the skin is absent, or, if present, no communication exists between it and the seat of the fracture.

The majority of compound fractures are the result of direct violence, and the injuries of the soft parts, are, as a rule, far more extensive and serious than in a simple fracture. A fracture which is simple at first, may become compound as a result of necrosis of the skin lying over it; or as a consequence of the original injury; or of pressure upon it by a displaced fragment; or by penetration of the skin, in efforts to use the limb.

FURTHER CLa.s.sIFICATION OF FRACTURES

+Fracture.+ In the ordinary use of the term "fracture" is understood to indicate a _complete_ or _incomplete_ separation of the bone into two or more fragments, the lines of which are continuous with each other.

+Multiple Fracture.+ The term _multiple fracture_ is applied to the simultaneous fracture of two or more non-adjacent bones, and also to those cases in which two or more fractures of the same bone exist, and the lines are not continuous with each other. Such multiple fractures are usually the result of direct violence.

+Complicated Fracture.+ When a fracture is accompanied by injuries of the viscera, nerves, etc., the term _complicated fracture_ is applied.

Such a fracture may be simple or compound. The term complicated, as ordinarily employed, is limited to those fractures which are accompanied by local, rather than by general complications.

+Symptoms of a Recent Fracture.+ In the examination of a patient who has sustained a recent fracture, procedure should be as follows: the history of the patient and of the accident should be taken; an examination should be made for objective signs, like deformity, abnormal mobility, crepitus, and ecchymosis; subjective symptoms, such as pain and loss of function of the limb should be ascertained; an X-ray picture should be taken and every possible precaution observed to exclude distortion or exaggeration.

+Treatment of Fractures.+ _First Aid._ The treatment of fracture may be said to begin from the moment of its occurrence. Much can be done for the comfort of the patient and correct union of the fracture by intelligent treatment during the first hours.

The proper temporary fixation of the limb, the mode of transportation, and the removal of the clothing, all require special mention.

The use of first aid dressings, those which can be used until more permanent and suitable ones can be applied, varies, of course, with the individual bone affected. In fractures of the tibia, fibula and foot, as well as in those of the lower half of the femur, the use of the blanket splint will be found of great aid. Instead of a blanket, a long pillow or soft cushion can be employed in the same manner.

The "blanket splint" can be readily made by folding a blanket in such a manner that it extends from the middle of the injured thigh to below the foot. Two pieces of narrow, strong board, or better still, two broomsticks are rolled up in the blanket, one at either end. The rolled-up blanket is now turned in so that the board supports with their enveloping turns of blanket, lie upon the posterior surface.

Thus, a trough is formed in which the limb is placed and firmly secured by loops of bandage, one below the foot, the second just above the ankle, the third below the knee, and the fourth near the upper end of the blanket.

In fractures of the leg, after the application of the emergency splint, the patient should be transported in a rec.u.mbent position, the support being as firm as possible, a wide board, shutter or a wooden rail being preferable. If such supports are not at hand, and the patient is to be moved without their use, the persons transporting the invalid should be distributed in the following manner: one supporting the head and shoulders, a second the pelvis, and the third the two limbs.

+Reduction.+ The reduction of a fracture is the effort made by the surgeon to overcome any tendency to displacement, and thus to place the fragments in such close apposition that an accurate and firm union is possible. The best time in general for the reduction of a fracture is as soon as possible after the accident, if the patient's general condition will permit. If there is marked displacement of fragments, so that there is danger of necrosis of the overlying skin or of damage to the adjacent vessels or nerves, an early reduction is imperative.

In all cases in which reduction is very painful or difficult, whether performed shortly after the accident or at a later period, it is best to administer an anesthetic to overcome muscular contraction and to decrease the amount of pain. After reduction of a fracture, retentive apparatus is indicated in order to maintain apposition. In the use of dressings there will be two kinds, those which are temporary and those which are permanent. The former are employed where the swelling of the limb is such that some dressing can be employed which will not cause pressure.

Certain general principles should be followed in the use of splints; for instance, a splint, after being applied, should not interfere with the circulation, allowance always being made for the swelling of the limb, which almost invariably occurs during the first week. The splint, if flat, should be wide enough to obviate the possibility of pressure against the point of fracture; also, it should project a little beyond the limb.

In general, it is best to immobilize the adjacent joints, above and below the seat of fracture, but no dressing should be permitted to remain so long as to produce stiffness of the joints and muscular atrophy.

The skin, even in simple fractures, must be cleansed with green soap, water and alcohol. If blebs or an area of threatening necrosis of the skin exist, they should be freely dusted with powdered boric acid and a few layers of aseptic gauze applied.

The form of retentive apparatus to be employed will vary, of course, with the individual bone requiring treatment.

The most important articles of a fracture equipment are as follows:

1. Plaster of Paris bandages for making molded splints and circular casts.

2. A stock of ba.s.swood, three-sixteenths of an inch thick, for making wooden splints.

3. An a.s.sortment of metal splints or materials for making them.

4. Muslin for bandages and slings.

5. Five yard rolls of ordinary and zinc oxide adhesive plaster, three inches wide.

6. Cotton batting and sheet wadding for padding splints.

7. Strips of tin or thin cypress for strengthening plaster casts.

The selection of a dressing for the immobilization of a fracture depends upon, _first_, the particular bone involved and whether apposition can be maintained with or without extension; _second_, whether great swelling be present or not; _third_, whether the fracture be simple or compound; and _last_, whether ambulatory treatment be preferable to that in the rec.u.mbent position. This latter applies, of course, only to fractures of the lower extremity.

+Operative Treatment of Simple Fractures.+ Operative treatment of a recent simple fracture is indicated in general, when reduction cannot be completely made; when correct apposition cannot be maintained; when there is interposition of bone or soft parts; when the fracture is a spiral one with considerable displacement of the fragments; when fragments are rotated upon each other, and when there are multiple fractures.

The most favorable time to operate in recent simple fractures is at the end of the first or beginning of the second week. At this time the process of callus formation is most active. The blood clots and loose shreds of tissue have begun to be absorbed, so that the fragments are more easily accessible.

+Methods of Fixation of the Fragments.+ In the majority of cases the reposition of the fragments alone is not sufficient to maintain accurate apposition. It is usually necessary to employ some means of mechanical fixation. In all the methods employed, the preparation of the parts is the same as for any aseptic operation. The opportunity for serious complications resulting from septic infection, is greater than in any other cla.s.s of operations. It is for this reason that extraordinary caution must be exercised. The incision should be large enough to expose the seat of the fracture thoroughly.

The materials used to secure fixation are: absorbable sutures, such as chromicized catgut or kangaroo tendon; metal suture of silver or bronze aluminum wire; screws, nails, plates, clamps, etc.

+Injuries in the Vicinity of the Ankle Joint.+ In the examination of a patient who shows evidence of injury in the vicinity of the ankle joint, such as swelling, deformity, loss of function, etc., the following conditions must be thought of, in the order given:

1. Fractures of the lower ends of the tibia and fibula (Pott's Fracture).

2. Dislocation at or near the ankle.

3. Fractures of the tarsal bones.

4. Rupture of the tendon Achillis.

5. Sprains of the ankle.

+Fractures of the Lower Ends of the Tibia and Fibula.+ Commonly given the name of _Pott's Fracture_. They may be the result either of forcible abduction or eversion of the foot, or of inversion or adduction. If the sole or main movement is eversion, the _internal_ malleolus is broken, and if the force continues to act, it also causes the _external_ malleolus to be broken. In the second variety, fracture by inversion, the first effect of the force is to break the fibula at the external malleolus. If the movement continues, the internal malleolus or a greater portion of the tibia is broken off.

+Diagnosis.+ The diagnosis is usually easy to make. The ankle joint is greatly swollen, the depression, normally present in front of and behind the malleoli, being obliterated. The foot is displaced outward, and the internal malleolus is prominent. This deformity will often persist and become a cause of disability after healing of the fracture.

There is also backward displacement of the foot. These displacements may be so marked as, at first glance, to resemble a true dislocation of the ankle.

Abnormal lateral and anteroposterior mobility may be ascertained by grasping the sole of the foot with one hand and moving it inward and outward, or backward and forward, while the other hand steadies the leg. There is great tenderness between the tibia and fibula at the front of the ankle, and over the points of fracture in the malleoli.

If the fibula alone be broken, abnormal mobility and crepitus may be elicited by pressing its tip inward with the index finger of the one hand while a finger of the other hand is placed at the seat of fracture.

In some cases of Pott's fracture the foot will move inward instead of outward. The degree of outward displacement can be measured by the difference in the distance from the front of the ankle to the cleft between the first and second toes, as measured on the sound and injured foot. There is not always complete loss of function. In fractures of the external malleolus alone, the patient may walk quite well.

+Treatment of Fractures of the Leg.+ The treatment of a simple fracture of one or of both bones of the leg depends _first_, upon whether or not swelling is present, and _second_, upon the amount of displacement of fragments and our ability to keep them in apposition after reduction. If the case is seen within a few hours after the injury and but little, if any, swelling be present, the following is a perfectly safe and justifiable method of treatment: