• v . .'-'■■'.::,■ ■■:';■ \ v /-.:,; .; . Class _JZ2/o/ Book „<&& Co Entered according to Act of Congress, in the year 1910, by LEA & FEBIGER, In the Office of the Librarian of Congress. All rights reserved. ©B.A2 5960f> PREFACE TO THE SIXTH EDITION. The additions to this edition largely represent the results of further study of the injuries of the small bones of the carpus and tarsus and include a new subhead, the midcarpal fracture-dislocations, the recognition of which has come mainly through investigations stimulated and aided by x-ray examinations. There is reason to think that the knowledge now gained covers all the typical lesions. Sections have also been added on fractures of the floor of the acetabulum and of the internal epicondyle of the femur and on back- ward dislocation of the lower jaw. Other additions of importance relate to treatment. Reproductions of seventeen skiagrams have been added in the plates and a number of new cuts have been added or substituted. Lewis A. Stimson. 277 Lexington Avenue, N. Y., 1910. CONTENTS. FRACTURES. CHAPTER I. INTRODUCTION. PAGE. Definitions, statistics, influences of sex, age, and season 19 CHAPTER II. PATHOLOGY. A. The bone ; varieties of fracture 22 1. Incomplete fractures 23 (a) Fissures ' • 23 (b) True incomplete, green-stick ; infraction 24 (c) Depressions • • . . . 24 (d) Separation of a splinter or apophysis 24 2. Complete fractures ; subdivided according to 25 (a) Direction and character of the line of fracture 25 (b) The seat of fracture 29 Separation of epiphysis 29 (c) Intra-articular 31 3. Multiple fractures . 31 4. Compound fractures 32 5. Gunshot fractures 33 Displacements 36 B. The soft parts 37 CHAPTER III. ETIOLOGY. Predisposing causes 39 External, normal, interstitial atrophy 39 Inherited liability 40 Determining causes 40 External violence, direct or indirect 40 Muscular action . . , 41 Spontaneous and pathological fractures 45 General diseases 45 Diseases of nerve centres 46 Rachitis, syphilis, rheumatism 47 Cancer and sarcoma 48 Cysts, osteomyelitis 49 Intra-uterine, and during delivery 49 CHAPTER IV. EARLY SYMPTOMS AND DIAGNOSIS. Objective signs 51 Deformity (normal asymmetry) 51 Abnormal mobility 52 Crepitus 53 Roentgen rays 54 Subjective or rational symptoms 55 Loss of function ; pain History 55 VI CONTENTS. CHAPTER V. REPAIR OF FRACTURES AND CLINICAL COURSE. PAGE Anatonio-pathological processes 57 The callus 57 In compound fracture •"•"•* 61 In short and flat bones g2 At the epiphyseal line . 53 Clinical course g4 CHAPTEB VI. COMPLICATIONS AND REMOTE CONSEQUENCES. Early local complications 68 Skin. Bloodvessels 68, 69 Gangrene. Degeneration of muscles 70 Suppuration 71 Early general complications 71 Septicaemia 71 Fat embolism 72 Delirium tremens, tetanus, pneumonia 73 Late local complications 74 Excessive or painful callus 74 Development of a tumor 75 Injury of a nerve 75 Weakness of callus 76 Arrest or exaggeration of growth 77 Stiflhess of the joints 77 Atrophy. Thrombosis and embolism 78 Arteries 79 CHAPTER VII. TREATMENT. Reduction 81 Retention 87 Temporary and removable dressings 89 Wooden splints 89 Metal splints , 90 Volkmann's splint 90 Anterior suspended splints 92 Moulded splints 93 Permanent or final dressings 95 Encasement in plaster 95 Traction, Buck's extension 97 Hodgen's splint, long side splint 99 Combined suspension and traction 100 Vertical suspension. Double inclined plane 101 Direct fixation .... • 103 Massage 105 Ambulatory treatment ■. 106 Management of the joints 107 Compound fractures 109 By indirect violence 110 By direct violence 110 Gunshot fractures 112 Amputation 112 Compound articular fractures .... 113 General treatment 114 CHAPTER VIII. DELAYED UNION, FAILURE OF UNION, FAULTY UNION. Delaved union ; failure of union 115 Pathology 116 Etiology 116 CONTENTS. VII PAGE Delayed union : symptoms 118 Treatment 119 Faulty or vicious union 121 Treatment 122 CHAPTER IX. GENERAL PROGNOSIS 124 CHAPTER X. FRACTURES OF THE SKULL. Mechanism and pathology 128 Exceptional forms 133 Internal table 134 Injuries of brain 135 Pathological and reparative processes 136 Symptoms, diagnosis, and treatment 137 Circumscribed fractures of the vault 138 Fissured fractures with generalized brain injury 140 Internal table 143 Rupture of the middle meningeal artery 143 Perforating fractures of the base 144 Summary 145 CHAPTER XI. FRACTURES OF THE VERTEBRAE. Pathology 148 Heematomyelia 151 Etiology 151 Symptoms and diagnosis 152 Atlas and axis 153 Lower five cervical and first two dorsal 155 Lower dorsal and first two lumbar 157 Lower three lumbar 158 Course and termination 158 Treatment 161 CHAPTER XII. FRACTURES OF THE BONES OF THE FACE. 1. Nose 165 2. Malar bone and zygoma 167 3. Superior maxilla . • • ■ 169 4. Inferior maxilla 171 CHAPTER XIII. FRACTURES OF THE HYOID BONE 180 CHAPTER XIV. FRACTURES OF THE LARYNX AND TRACHEA 182 CHAPTER XV. FRACTURES OF THE STERNUM 184 CHAPTER XV I. FRACTURES OF THE RIBS AND THEIR CARTILAGES 190 The ribs 190 The costal cartilages . 195 vi li COS TEXTS. CHAPTER XVII. FRACTURES OF THE CLAVICLE. PAGE Pathology 199 1. Middle third 200 2. Outer third 201 3. Inner third 202 Multiple fractures. Complications 203 Etiology 205 Symptoms and course 206 Simultaneous fractures of both clavicles 208 Treatment 209 CHAPTER XVIII. FRACTURES OF THE SCAPULA. 1. Of the body of the scapula 215 2. Of the inferior angle 217 3. Of the upper angle 218 4. Of the spine . 218 5. Of the acromion 218 6. Of the coracoid process 220 7. Of the neck 221 8. Of the glenoid cavity 223 CHAPTER XIX. FRACTURES OF THE HUMERUS. 994- 1. Fractures of the upper end of the humerus tzz A. Fractures of the head j~*l B. Fractures of the anatomical neck and fracture through the tuberosities . . tt^ C. Fractures of the tuberosities 2-9 D. Separation of the epiphysis 232 E. Fracture of the surgical neck = ~~ Symptoms 239 Diagnosis 240 Prognosis, treatment 241 2. Fractures of the shaft of the humerus 245 3. Fractures of the lower end of the humerus . 249 A. Fractures above the condyles — supracondyloid 251 B. Fractures of the internal epicondyle 257 C. Fractures of the external epicondyle 258 D. Fractures of the internal condyle 259 E. Fractures of the external condyle 261 F. Intercondyloid, T-shaped or Y-shaped fractures 264 G. Separation of the epiphysis 265 H. Fractures of the articular process 266 Of the capitellum 267 Of the trochlea -269 Diagnosis 269 Treatment 270 CHAPTER XX. FRACTURES OF THE BONES OF THE FOREARM. 1. In the vicinity of the elbow-joint 271 A. Olecranon 277 B. Coronoid process % . . 278 C. Of the head of the radius 280 D. Of the neck of the radius 283 2. Fractures of the shaft 284 A. Fractures of the shafts of both bones • 284 B. Of the shaft of the ulna 290 C. Of the shaft of the radius . _ 292 3. Fractures in the vicinity of the wrist 293 CONTENTS. ix. PAGE A. Fractures of the radius. Colles's fracture 293 Cause «g Symptoms oL,u Treatment 300 B. Fractures at the wrist other than Colles's 302 CHAPTER XXI. FRACTURES OF THE CARPUS AND HAND. 1. Fractures of the carpal bones 30^ 2. Fractures of the metacarpal bones £jU 3. Fractures of the phalanges 312 CHAPTER XXII. FRACTURES OF THE PELVIS. 1. Fractures of the ring of the pelvis 314 Separation of the symphysis pubis 315 Separation in front and behind ... 316 Separation of the sacro-iliac synchondrosis 316 Separation of all three joints 316 Fracture of the pubic portion of the pelvic ring 317 Fracture of the lateral portion 317 Course, diagnosis, treatment 319 2. Radiating fracture and fracture of the floor of the acetabulum 320 3. Transverse fracture of the sacrum 322 4. Fracture of the coccyx 323 5. Fracture of the ilium 324 6. Fracture of the ischium 325 7. Fracture of the pubis 326 8. Fracture of the rim of the acetabulum 326 CHAPTER XXIII. FRACTURES OF THE FEMUR. 1. Fractures at the upper end of the femur 329 A. Fractures of the head of the femur .... 329 B. Fracture of the neck of the femur 329 Causes 333 Pathology 334 (a) Fractures through the neck 334 (6) Separation of the epiphysis 335 (c) Fractures at the base of the neck 337 Repair 342 Symptoms 346 Diagnosis 350 Prognosis 352 Treatment 354 C. Fractures through the trochanter and neck 360 D. Fracture of the great trochanter 361 E. Fracture of the trochanter minor 861 2. Fractures of the shaft of the femur 362 3. Fractures of the lower end of the femur 371 A. Intercondyloid fractures 371 B. Separation of the epiphysis 374 C. Fracture of either condyle : 376 D. Fracture of the internal epicondyle . 37 S CHAPTER XXIY. FRACTURES OF THE PATELLA. Cause 379 Pathology 3^0 Symptoms . ggg x CONTEXTS. PAGE Treatment 385 Non-operative 3gg Operative 390 For relief of disability 393 For refracture 394 CHAPTER XXV. FRACTURES OF THE BONES OF THE LEG. 1. Fractures of the upper end 395 Separation of the epiphysis 397 Avulsion of the spine of the tibia .- 397 Avulsion of the tubercle of the tibia 398 2. Fractures of the shaft 399 3. Fractures at the lower end of the leg 403 A. Comminuted fracture of the tibia 403 B. Supramalleolar fracture 404 C. Separation of the epiphysis of the tibia 405 D. Fractures by e.version and abduction, Pott's 405 E. Fractures of the malleoli by inversion 413 F. Of the posterior portion of articular surface 414 G. Of the anterior portion of the articular surface 416 4. Fractures of the fibula 416 A. Of the upper end 416 B. Of the shaft 417 C. Separation of lower epiphysis 4 17 CHAPTER XXVI. FRACTURES OF THE BONES OF THE FOOT. 1. Of the astragalus 418 Of processus posticus 419 2. Of the calcaneum 419 Of the sustentaculum , 420 By muscular action 421 3. Of the scaphoid 422 4. Of the cuboid 423 5. Fractures of the metatarsal bones 423 6. Fractures of the phalanges 424 DISLOCATIONS. CHAPTER XXVII. GENERALITIES. Definitions - 427 Statistics 429 CHAPTER XXVIII. ETIOLOGY AND MECHANISM. A. Predisposing causes 432 B. Immediate or determining causes * ' 433 Recurrent or habitual dislocations 434 CONTENTS. xi CHAPTER XXIX. PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS ; COMPLICATIONS ; PROCESS OF REPAIR AFTER REDUCTION. PAGE Pathological anatomy 436 Complications 437 Bones 437 Bloodvessels 438 Nerves 440 Viscera 443 Soft parts and integument 443 Repair 444 CHAPTER XXX. PATHOLOGY OF UNREDUCED (ANCIENT) DISLOCATIONS 447 CHAPTER XXXI. SYMPTOMS AND DIAGNOSIS. Objective signs 452 Deformity ♦ 452 Loss of mobility 454 Crepitus 455 Subjective symptoms 455 Pain 455 Loss of function ; history 455 CHAPTER XXXII. COURSE AND PROGNOSIS 457 CHAPTER XXXIII. TREATMENT. Spontaneous reduction 459 Obstacles to reduction 459 Anaesthesia 461 Methods of reduction 462 Old dislocations . 467 After-treatment 469 Habitual dislocation 470 CHAPTER XXXIV. ACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE A DISLOCATION . 471 Integument 472 Emphysema of the cellular tissue 472 Rupture of the muscles 473 Avulsion of a portion of a limb 473 Injuries of the main bloodvessels 473 Injuries to nerves 479 Fracture 481 Inflammation, suppuration, gangrene 482 Persistent oedema 483 Syncope and sudden or early death ; fat embolism 484 CHAPTER XXXV. CONGENITAL DISLOCATIONS. Statistics 4£.^ Etiology 4g 6 radiology (hip) 49{) xil CONTEXTS. PAGE Symptoms and diagnosis 493 Prognosis 495 Treatment 495 CHAPTEE XXXYI. SPONTANEOUS DISLOCATIONS ^q>j By distention 498 Paralytic 499 Voluntary 499 By destruction ; by deformity 499 CHAPTER XXXVII. DISLOCATIONS OF THE LOWER JAW. Backward 501 Backward with fracture 501 Upward 502 Outward 502 Forward 502 Pathology 503 Symptoms 505 Prognosis 505 Treatment 505 Pathological 507 Congenital 507 CHAPTER XXXVIII. DISLOCATIONS OF THE VERTEBRAE AND OF THE OCCIPUT FROM THE ATLAS. Classification and pathology 509 Secondary changes 514 Etiology 515 Symptoms and diagnosis 515 Prognosis , . 517 Treatment . . 518 Dislocations of the occiput 519 Dislocations of the atlas 521 Dislocations of the lower six cervical vertebrae 524 Dislocations of the dorsal vertebrae 530 Dislocations of the lumbar vertebra; 532 CHAPTER XXXIX. DISLOCATIONS OF THE STERNUM. Of the body from the manubrium 534 Of the ensiform process 538 CHAPTER XL. DISLOCATIONS OF THE RIBS AND COSTAL CARTILAGES. Of the head of the rib 539 Of the ribs from the costal cartilages 540 Of the costal cartilages from the sternum , 541 Of one cartilage from another 543 CHAPTER XLI. DISLOCATIONS OF THE CLAVICLE. 1. Of the sternal end 544 Forward 545 Backward 548 Upward _^ . . 550 CONTENTS. xiii PAGE 2. Of the acromial end 552 Supra-acromial . . . 553 Subacromial • 558 Subcoracoid 56] 3. Simultaneous of both ends 561 CHAPTER XLII. DISLOCATIONS OF THE SHOULDER. Anatomy 563 Statistics # 567 Classification 588 Anterior (and downward) dislocations 573 1. Subcoracoid 574 Pathology 576 Symptoms and diagnosis 579 2. Intracoracoid 581 Treatment of anterior dislocations 583 Direct reposition ; traction downward and outward 585 Traction upward 586 Traction with leverage 588 Heel in the axilla 588 Forcible traction 588 Manipulation 589 After-treatment . 593 CHAPTER XLIII. dislocations of the shoulder — Continued. Downward dislocations 595 1. Subglenoid 595 Symptoms ; treatment 598 2. Luxatio erecta 598 3. Subtricipital dislocation 5P9 Posterior dislocations (subacromial, subspinous) ... 600 Symptoms 604 Diagnosis and treatment 605 Upward dislocations (supraglenoid, supracoracoid) 606 CHAPTER XLIV. dislocations of the shoulder — Continued. Associated injuries and complications ' 611 Laceration of muscles 611 Fractures 612 Nerves 615 Vessels 616 Chest. Compound 617 Simultaneous of both shoulders 617 Prognosis and after-treatment 618 Habitual dislocation 620 Treatment of old dislocations 624 Subcutaneous section 625 Arthrotomy 625 Excision of the head of the humerus 626 Fracture of the surgical neck 626 Congenital dislocations 627 Pathological dislocations and subluxations 632 Dislocations due to paralysis 633 CHAPTER XLV. dislocations of the elbow. Anatomy 635 Frequency. Classification 6;>7 xiv CONTENTS. PAGE Frequency. Dislocations of the forearm backward 638 Mechanism 638 Pathology 640 Complications 641 Symptoms 642 Diagnosis 643 Prognosis 644 Treatment 645 Lateral dislocations 648 Incomplete lateral 649 A. Inward 650 B. Outward 652 Complete outward 655 Forward dislocations 659 Divergent dislocations of the radius and ulna 664 A. Antero-posterior 664 B. Transverse 666 CHAPTER XLVI. dislocations or the elbow — Continued. Dislocation of the ulna alone 667 1. Backward 668 2. Inward 671 3. Forward 671 Dislocation of the radius alone 671 1. Backward 672 2. Outward 675 3. Forward ■ 678 4. By elongation, or subluxation in children 681 Dislocation of the head of the radius with fracture of the ulna 686 CHAPTER XLVII. dislocations of the elbow — Continued. Treatment of old dislocations 688 Congenital and pathological dislocations 693 CHAPTER XLVIII. DISLOCATIONS AT THE WRIST. Dislocations of the lower radio-ulnar joint 697 Backward . , 697 Forward 698 Inward and downward 699 Dislocations of the radio-carpal joint 699 Backward 701 Forward 703 Outward 705 Pathological ; subluxation forward 705 Congenital 709 Dislocations of the carpal bones 710 Medio-carpal 710 Midcarpal fracture — dislocation 732 Isolated dislocations of the carpal bones 716 Scaphoid 716 Semilunar 717 Unciform : pisiform 719 Os magnum 719 Trapezoid ; trapezium 720 Os magnum and trapezoid 721 Carpo-metacarpal dislocations ....... 721 CONTENTS. XV CHAPTER XLIX. DISLOCATIONS OF THE THUMB AND FINGERS. PAGE Proximal phalanx of thumb J^6 Anatomy iZ Jl Backward '£' Forward \™ Lateral J31 Metacarpophalangeal of the fingers JoZ Backward \%% Forward 16 { Dislocations of the middle phalanges ?3.j Backward l%° Forward l^ Lateral '£■[ Dislocations of the distal phalanges £34 Backward £^2 Forward 'J** Lateral /3 ° CHAPTER L. DISLOCATIONS OF THE PELVIS AND OF THE COCCYX. Dislocations of the pelvis 737 Dislocations of the coccyx 737 Forward 738 Backward 739 Lateral 739 CHAPTER LI. DISLOCATIONS OF THE HIP. Anatomy 740 Statistics 743 Simultaneous dislocation of both hips 744 Compound dislocations 744 Classification 746 Backward dislocations 750 1. Dorsal dislocations 751 Causes 751 Pathology 752 Symptoms 755 Diagnosis 758 2. Everted dorsal dislocations 758 Pathology 760 Anterior oblique 761 Symptoms 761 Treatment of backward dislocations 762 CHAPTER LII. dislocations of the hip — Continued. Dislocations downward and inward 767 Obturator or thyroid dislocations 707 Cause ,767 Pathology 768 Symptoms 769 Treatment 770 Perineal dislocations 77*J Dislocations upward and forward, and inward and forward (suprapubic) 773 Eliopectineal ; pubic; intrapelvic , 773 LIST OF PLATES PLATE PAGE I. — Recent gunshot fracture of carpus and radius 34 II. — Same as Plate I., after repair 34 III. — Fig. 1. Periosteal bridge ; fracture of forearm. Fig. 2. Periosteal bridge; humerus; two years after injury 37 IV — Same as Plate III., fig. 2; injury recent 37 V. — Fracture of hyoid bone 181 VI. — Fracture of surgical neck of humerus in a child 237 VII.— Fig. 1. Skiagram of normal elbow at age of 5 years. Fig. 2. Skiagram of normal elbow at age of 8 years 254 VIII. — Figs. 1 and 2. Cubitus varus ; front and rear views. Fig. 3. Frontal sections of same 254 IX. —Fig. 1. Fracture of lower end of humerus. Fig. 2. Supracon- dyloid fracture by extension 254 X. — Fig. 1. Supracondyloid fracture of humerus by extension. Fig. 2. Supracondyloid fracture of humerus by flexion 254 XT. — Figs. 1 and 2. Supracondyloid fracture 254 XII. — Fig. 1. Old supracondyloid fracture of humerus ; cubitus varus. Fig. 2. Cubitus varus, three years after a low partial supra- condyloid fracture 254 XIII. — Fracture of internal condyle of humerus, in an adult 260 XIV. — Fig. 1. Fracture of internal epicondyle of humerus. Fig. 2. Fracture of external condyle of humerus 260 XV. — Fracture of external condyle, 18 years 260 XVI. — Fig. 1. Angular displacement by flexion. Fig. 2. Diacondyloid fracture 260 XVII. — Fig. 1. Fracture of olecranon; dislocation forward of radius and ulna. Fig. 2. Fracture of forearm ; angular displacement 274 XVin.— Fig. 1. Fracture of head of radius. Fig. 2. Fracture of neck 282 XIX.— Fig. 1. Fracture of humerus by small bullet. Fig:. 2. Fracture of forearm 286 XX. — Fig. 1. Fracture of radius ; marked angular displacement. Fig. 2. Recent Colles's fracture in a boy 12 years old 292 XXI. — Fig. 1. Recent Colles's fracture; male," 22 years old. Fii>-. 2. Old Colles's fracture.., ! 296 XXII. — Fig. 1. Recent Colles's fracture, comminuted ; male, 45 years old. Fig. 2. Recent Colles's fracture, comminuted; male, 40 years old (Plate XXV., fig. 2.) 296 XXIIL— Fig. 1. Recent Colles's fracture; male, 26 years old. Fig. 2. Same as Fig. 1, side view 296 XXIV.— Fig. 1. Same as Plate XXI II., after reduction. Fig. 2. Recent Colles's fracture; male, 56 years old 296 XXV.— Fig. 1. Recent Colles's fracture; male, 22 years old. Fig. 2. Recent Colles's fracture; male, 40 years old 296 xix Xx LIST OF PLATES. VLATE PAGE XXVI.— Colles's fracture 296 XXVII. — Fig. 1. Colles's fracture at 12 years; arrest of growth. Fig. 2. Separation of radial epiphysis ; boy 15 years old 296 XXVIII. — Fig. 1. Normal wrist; adult male. Fig. 2. Normal wrist; adult female, fracture of third metacarpal 296 XXIX. — Fracture of scaphoid, and possibly of radius 306 XXX. — Frature of scaphoid with dislocation of proximal fragment. 306 XXXI. — Fracture of scaphoid with dislocation of proximal fragment. 306 XXXII. — Fig. 1. Fracture of carpal scaphoid. Fig. 2. Separation of lower epiphysis of femur 306 XXXIII.— Figs. 1 and 2. Fracture of first metacarpal 310 XXXIV. — Fracture of acetabulum and displacement of femur inward 322 XXXV. — Fig. 1. Fracture of neck of femur. Fig. 2. The same after traction. 355 XXXVI. — Fig. 1. Fracture of patella, five months later ; non-operative treatment. Fig. 2. Fracture of patella, two years after me- diate suture 381 XXXVII. — Fig. 1. Fracture of patella, three years after periosteal suture. Fig. 2. Fracture of patella, three months after periosteal suture. 381 XXXVIII. — Fracture of patella. Ossification of ligamentum patella? 381 XXXIX. — Fracture of upper end of tibia 395 XL. — Separation of low r er tibial epiphysis 406 XLI. — Fig. 1. Pott's fracture by eversion in a youth. Fig. 2. Fracture of the posterior portion of the low r er end of tibia 406 XLI1. — Fig. 1. Pott's fracture by abduction. Fig. 2. Pott's fracture, two months old; backward displacement 406 XLIII. — Fig. 1. Pott's fracture by abduction. Fig. 2. Bimalleolar frac- ture by inversion 414 XLIV. — Fracture by eversion with interposition of astragalus 414 XLV. — Longitudinal fracture of lower end of tibia by a fall upon and inversion of the foot 414 XLYI. — Fig. 1. Bimalleolar fracture by inversion in youth. Fig. 2. Fracture of femur remaining ununited a year after wiring 414 XLVIL— Fig. 1. Long oblique fracture of tibia and external malleolus. Fig. 2. Fracture of cuboid 417 XLVIII. — Figs. 1 and 2. Fracture of os calcis. (Cabot) 421 XLIX. — Fig. 1. Fracture of os calcis. (Cabot.) Fig. 2. Fracture of upper posterior angle of os calcis 471 L. — Fig. 1. Congenital dislocation of the hip. Fig. 2. Dislocation of semilunar bone 493 LI. — Congenital dislocation of hip 493 LII. — Old dislocation of shoulder 576 LIIL— Congenital dislocation of the shoulder 629 LIV. — Fig. 1. Dislocation backward of elbow. Fig. 2. Dislocation of head of radius 678 LV. — Figs. 1 and 2. Midcarpal fracture dislocation 713 LVI. — Midcarpal fracture dislocation 713 LVII. — Midcarpal fracture dislocation, profile view 713 LVIII. — Midcarpal fracture dislocation 713 LIX. — Midcarpal fracture dislocation, after removal of proximal frag- ment of scaphoid 713 LX. — Midcarpal fracture dislocation 713 LXI. — Fig. I . Old dislocation backward of os magnum, side view r . Fig. 2. Old dislocation backward of os magnum, antero-posterior 719 LXII. — Fresh dorsal dislocation of the thumb 728 LXIII. — Fig. 1. Anterior dislocation of the knee. Fig. 2. Posterior dislocation of the knee 798 LXIV. — Incomplete outw T ard dislocation of the knee 806 LXV. — Subastragaloid dislocation 843 FRACTURES. A TREATISE ON FRACTURES AND DISLOCATIONS, CHAPTEK I. INTRODUCTION. By Fracture, in the surgical sense of the term, is meant the breaking of a bone or cartilage. The liability to fracture of the different bones of the body varies greatly, in consequence of their differences in size, shape, and degree of exposure to external violence or extreme muscular action. Hospital records covering periods varying in length from five to eighty-seven years have been tabulated by different writers, with the object of deter- mining the relative degree of this liability ; but it is evident that such statistics cannot contain all the needed facts, for the reason that patients with fractures which do not necessitate confinement to the bed do not so generally seek hospital care as those with fractures which do. Com- bined hospital and dispensary statistics are more nearly correct, but even they differ considerably from one another in their percentages, possibly because of differences in the occupations and mode of life of the communities which furnished them. I have compiled the follow- ing table from the records of the House of Relief (" Hudson Street Hospital "), of which I am the attending surgeon, including both the In- and the Out-patient services. The hospital is the only one in New York City below Canal Street, a region largely given over to trade, transportation, and manufacturing, with frequent construction of large buildings, and in which there is only a laboring resident population. Hudson Street Hospital, New York: Statistics of Fractures Treated in Hospital and Dispensary, 1894-1905. Cases. Cases. For cent. Cranium 772 Head 772 5.50 Malar bone 29 ^ Nasal bones 672 j Superior maxilla ... 46 I Face and Neck . . . 1281 8.79 Interior maxilla .... 502 Zygoma 29 j Hyoid 3 J 19 20 FRACTURES. Cases. Cases. Spine 66 "1 Pelvis 75 | Coccyx 3 \ Sternum 13 j Kibs 1675 J " Upper extremity " . . 132 ] Clavicle ... ^ ... 662 Scapula 66 Humerus, shaft and neck 411 lower end 209 internal epicondyle . 6 Kadius and ulna . . . 283 Radius, shaft 363 Colles's 1212 Ulna, shaft 318 olecranon 118 Carpus 15 Metacarpus 1063 Phalanges 1990 J Femur 540 ' Patella 183 Tibia, or tibia and fibula 943 Abduction and adduction fractures at ankle . 1089 Fibula 233 [ External malleolus . . 33 Internal malleolus ... 31 Tarsus 151 Metatarsus 326 Toes 334 Total 14,566 Trunk 1832 Per cent 12.5^ Upper extremity . . 6818 46.80 Lower extremity . . 3863 26.54 During the same period 1527 dislocations were treated. Sex. Fractures are more numerous in men than in women, in the proportion of about three to one, because of the greater exposure of men to the accidents which cause them. Mainly, for the same reason, the proportion varies greatly at different ages ; in infancy the difference is slight ; in middle life fractures are ten times as frequent in men as in women ; between the ages of fifty and seventy years the difference again becomes slight, and after the age of seventy years fractures are more common in women than in men, a reversal of conditions due to a dispro- portionate increase in the number of fractures of the neck of the femur. Age. Gurlt l tabulated 1383 cases (hospital and dispensary) with ref- erence to the ages of the patients, and found in the first decade, 265 ; in the second, 193 ; in the third, 274; in the fourth, 224; in the fifth, 154; in the sixth, 155 ; in the seventh, 72 ; in the eighth, 38, and in the ninth, 8. Combining these with statistics showing the relative number of people living at the different ages, he found the highest proportion of fractures in the period above the age of sixty years. Malgaigne 2 made a similar tabulation, using only hospital cases, and grouping in periods of five years he found that the periods between fifty -five and eighty were practically equal to one another, and gave the highest proportion according to population. 1 (lurk : Handbuch (lev Lehre von den Knoclienbriiclien, 1862. 2 Malgaigne : Traite des Fractures et des Luxations, 1847. INTRODUCTION. 21 Season affects the frequency of fracture only by increasing or dimin- ishing the exposure to the accidents which occasion them. Falls due to ice and snow in winter are more than offset as a cause by the more varied and active occupations of the milder months, and fractures are, therefore, less frequent in winter than in summer. This is shown by the following tabulation of the fractures treated in the Hudson Street Hospital, according to months : Hudson Street Hospital : Fractures in 1896, Wards and Dispensary. January, February, December, Omitting hand \ and toes, J 77 88 119 284 57 227 March, April, May, 130 103 97 330 84 246 June, July, August, 82 148 150 380 104 276 September, October, November, 105 107 116 328 92 236 The maximum is found in the summer months, the minimum in the winter. It is only in fractures of the leg that the winter season heads the list, and yet even in these, as the following table shows, a decided monthly maximum is found in March, a month in which there is but little snow and ice in New York : Fractures of the Leg, of either Bone, and Pott's Fracture. January, 19 March, 29 June, 9 September, 8 February, 20 April, 9 July, 11 October, 6 December, 21 May, 12 August, 25 November, 20 60 50 45 34 Fractures of the femur (shaft and neck) give the following totals : Winter 16, spring 17, summer 8, autumn 12 ; those of the upper ex- tremity (clavicle, humerus, and either or both bones of the forearm) give : Winter 67, spring 63, summer 107, autumn 72. Note. — For other statistics see Malgaigne, Gurlt, and the first edi- tion of this work ; also Wallace, American Journal of the Medical Sciences, 1839 ; Norris, Ibid., 1841 ; Lente, New York Medical Journal, 1851; Lonsdale, Fractures, 1838, and Scannell, Boston Medical and Surgical Journal, Nov. 15, 1906. CHAPTEE II. PATHOLOGY. The Bone — Varieties : Incomplete, Complete, Multiple, Compound, Gunshot. Displacements. The soft parts. (A) THE BONE— VARIETIES OF FRACTURE. The varieties of fracture are numerous and are constituted by differences in the extent of the injury to the bone or to the surrounding soft parts, in the seat, shape, and direction of the fracture, in the rela- tion of the fragments to each other, and in the number of bones involved. These varieties may be grouped in five divisions, marked by important clinical differences and containing many subdivisions, as follows : 1 . Incomplete fractures. (a) Fissures. (b) True incomplete, " green stick ;" bent bone. (c) Depressions. (d) Separation of a splinter or of an apophysis. 2. Complete fractures, subdivided, according to (a) Direction and character of the line of fracture, into transverse, oblique, longitudinal, spiral, toothed or dentate, V-, Y-, or T-shaped, and comminuted ; (6) Seat of the fracture, into fracture of the shaft, of the neck, of the upper, middle, or lower third, intercondyloid, separation of epiphysis ; and (c) If extending into a joint, intra-articular. 3. Multiple fractures, comprising fractures of two or more non- adjacent bones and two or more fractures of the same bone. 4. Compound (or open) fractures. 5. Gunshot fractures. The term simple (or closed) fracture is commonly used, in contradis- tinction to the term compound, to indicate that there is no associated wound of the soft parts which establishes communication between the fracture and the exterior. 1 Some writers make also a class of compli- cated fractures to include cases in which some important injury coexists ; and there are still other terms in use to indicate peculiarities which do not lend themselves easily to the above classification. Such are : Spon- taneous fracture, one produced by the minimum of violence ; pathological fracture, one favored by weakening or partial destruction of the bone by disease ; direct fracture, one occurring at the point where the causative 1 Of late an effort has been made to substitute the use of the term open for compound, and closed for simple, but it does not appear to have gained much momentum or that there is urgent need of the change. The significance of compound is freely and widely under- stood, without, as well as within, the profession ; that of simple is perhaps not so well under- stood and is occasionally liable to misinterpretation. 22 PATHOLOGY. 23 external violence is received ; indirect fracture, one occurring at a dis- tance from that point ; recent and old, or ununited, fracture. Another grouping is according to the mechanism of production : fractures by bending, by torsion, by crushing, by avulsion, by gunshot ; with sub- sidiary terms : fractures by flexion or extension, by abduction or adduc- tion, by eversion or inversion. Fig. 1. 1. Incomplete Fractures. Under this head will be considered fractures in which the continuity of the bone has not been completely lost or a fragment has not been completely detached. (a) Fissures. This variety is characterized by the existence of a split or crack in the bone, one which does not entirely circumscribe a fragment and separate it from the rest of the bone. It is of common occurrence in the bones of the cranium, and very rare in the long bones except when associated with other varieties. It is almost unknown in the short or spongy bones. The examples of isolated fissure of long bones are very rare. Fig. 1, copied by Gurlt from Froriep, represents one extending from the greater tuberosity of the humerus to the lower fourth of the shaft, pro- duced in a boy by a fall upon the elbow. Fissures connected with complete fracture are common ; are sometimes very long, and may extend into a neighboring joint. A very long fissure is sometimes termed a longitudinal fracture. The mechanism by which a long isolated fissure is produced in a long bone is probably the forcible bend- ing of the bone. This is plainly indicated in a case reported by De- brou in 1843, and quoted by Gurlt as a case of infraction. The patient, a man sixty-two years old, fell while walking, and injured his thigh. Ery- sipelas set in and caused his death. At the autopsy a fissure was found under the untorn periosteum, extend- ing six inches downward from the tro- chanter minor, and this fissure could be made to widen by pressure upon the ends of the bone. The diagnosis cannot be made with certainty, except when the bone is ex- posed to direct examination ; but it can be inferred with much proba- bility in some forms of fracture with which it is usually associated, such as V-shaped fractures of the tibia. G iese, 1 reporting a case involving the tibia, calls attention to the discrepancy between the slight objective signs and the extreme sensitiveness and interference with function, '(.Jit'se: Miinchener med. Wochenschrift. 1906, No. 9. Fissure of the humerus. ((iURLT.) Partial fracture of the fibula, a, the head : b, the malleolus. 24 FRACTURES. Except when it extends into a joint the importance of a fissure i* probably slight, and is dominated by that of the associated lesions. In some cases the injury has been promptly or tardily followed by suppura- tion beneath the periosteum or within the bone. (6) True Incomplete, " Green- stick Fracture " ; Infraction; Bent Bone, or Curvature Without Fracture. This variety is characterized by a frac- ture involving only a portion of the thickness of a long bone, and combined with a bending of the bone at the seat of fracture. In its consideration is included also that of the rare cases of curvature with- out recognizable fracture, a variety which has only an academical interest, for it cannot be recognized clinically. Its possibility has been demonstrated experimentally upon young animals and by a single specimen belonging to Prof. Uhde, the ulna of an adult much bent by a machinery accident, and showing no trace of fracture. The injury appears ordinarily as a short transverse fracture, continu- ous with one or more longitudinal ones of variable length ; sometimes there is no transverse line, but only oblique ones running from the angle upward or downward. The appearance can be closely imitated by over-bending a green or tough stick, a fact that has given this form of fracture a name by which it is very commonly known. This fracture is seen most frequently in the bones of the forearm, then in the clavicle, and very rarely in the bones of the arm, leg, and thigh. The great majority of cases occur in those under the age of fifteen years. In the forearm it may be found in only one bone, the other being completely broken. The usual cause is a fall, but I have seen several cases in which the cause was the forcible bending of the forearm over a rigid body, as when the limb is caught between a shaft and its belting. The chief symptoms are deformity, consisting in an angular devia- tion of a portion of the limb or bone, and localized pain on pressure at the angle. The deviation can be more or less completely corrected by the use of force, and the correction may be accompanied by crepitus and followed by abnormal mobility, the fracture having been made complete. The prognosis is favorable as regards correction of the deformity and repair. Ordinarily, the limb can be straightened by the surgeon's hands alone, aided, perhaps, by the pressure of his knee against the angle ; and the surgeon should not be deterred, by the fear of making the fracture complete, from using all the force that is necessary. „ (c) Depressions. I limit the use of this term to those cases in which a portion of the outer layer of a flat bone or the spongy portion of a long bone is driven inward by direct violence, usually a blow with a pointed instrument. The injury is most frequently seen in the vault of the skull, and is there generally termed a fracture of the outer table. It is occasionally seen in the limbs in connection with complete fracture. (d) Separation of a Splinter or of an Apophysis. In this variety are included two classes of fractures which differ widely in their mode of production, but have this in common : that the fragment does not com- prise the entire breadth or thickness of the bone, and that consequently the continuity of the latter is not destroved. In the first class a PATHOLOGY. 25 splinter or fragment of bone is broken off by direet violence, as by a cutting instrument ; in the second class a bony prominence is torn off by the violent contraction of the muscle attached to it or by traction through a ligament. The separation of a splinter or scale of bone by a sword-cut or bullet is not uncommon in the spongy bones or the spongy extremities of long bones, and has also been known to occur, in the shaft of the tibia. It is an injury which should be classed rather among wounds of bones than among fractures. The separation of a splinter by direct violence, unaccompanied by a wound of the soft parts, occurs in the bones of the face, at the crest of the ilium, and at exposed points upon the extremi- ties of the long bones. Avulsion of an apophysis, or of a scale of bone, by muscular action is a far more common accident than the one just described. The lesion consists in the fracture of an apophysis at its base or in the tearing off of a portion of bone to which a muscle or tendon is attached. 2. Complete Fractures. The term complete, when applied to a fracture of a long bone, indi- cates that the bone is divided by a line of fracture crossing from side to side or obliquely across the end. Fig. 3. Fig. 4. Fig. 5. A \ Humerus. Femur. (Tracings from skiagrams. Femur. (a) Subdivision According to the Direction of the Line of Fracture. Such terms in use are transverse, oblique, splintered, spiral, V-shaped, 26 FRACTURES. as T- or Y-shaped, dentate, longitudinal, and comminuted. Apparently a result of physical conditions, fractures by direct or indirect violence which bend a long bone are either practically transverse or markedly oblique, with or without splintering. The line of a transverse fracture does not deviate more than about 15 or 20 degrees from that of the transverse axis; that of an oblique fracture lies near an angle of 50 degrees. A transverse fracture may be, but rarely is, exactly transverse and smooth (Fig. 6) ; clinically such details cannot be recognized unless the fracture is compound, and the diagnosis of the variety is made on the fact that the end of the fragment can be felt through the overlying soft parts to be approximately square and smooth. In the oblique variety the line of fracture may be single (Fig. 9) or multiple (Fig. 8), circumscribing in the latter case Fig. Fig. Transverse fracttire of the femur. (Gurlt.) Fracture of humerus. (V. Bruns.) one or more detached fragments which apparently are formed on the side of the concavity created by the bending of the bone {splintered). This is characteristic of the fractures produced by bending. The line of fracture in either form may be markedly irregular on either or both fragments. When this irregularity is found on both fragments the term toothed or dentate is applied ; when it is found only on one side the absence of a corresponding line on the other is due to the crushing of the bone or to the splitting off of one or more large fragments. Spiral fractures, which are rare, are produced by torsion of the bone, PATHOLOGY. 27 and are found in the femur, humerus, and tibia. In the latter they are better known as V-shaped (Fig. 10), and can be readily recognized Fig. 8. Fig. 9. Oblique fracture by direct pressure. (Kocher.) Spiral fracture by outward rotation of lower end. (Kochek.) by the sharp point of the upper fragment, which can be felt midway between the crest and the internal border of the bone. From the re-entrant angle corresponding to this point a fissure runs down to the ankle-joint. Under the term longitudinal are included very oblique fractures run- ning from one side of the bone to the other, fractures running from one end of the bone to or nearly to the other, and fractures which split lengthwise a long fragment intermediate between two transverse frac- tures. The last-named form is produced only by great crushing violence, and the prognosis is very bad. In the other forms the violence is indirect, apparently a bend or twist of the bone or a blow received at one end ; the ill results which have so commonly followed appear to be due in some to the implication of one or both joints or to a failure to recognize the injury and maintain immobility. The most marked cases are one reported by Kronlein, 1 a fracture of the humerus 1 Kronlein: Deutsche Zeitsoh. f. Chir., 1ST;?, p. 13:2. 28 FRACTURES. from the shoulder to the elbow-joint, in a man twenty-seven years old, by an attempt to raise a heavy ladder, and one by Cloquet, in 1831, a fracture of the femur from the intercondyloid notch to a point just below the trochanter minor, by a fall from FlG - 10* a roof. A comminuted fracture of the shaft of a long bone is one in which, in addition to the complete division of the bone into two fragments, there is also extensive splinter- ing of the portion of bone adjoining the fracture or of one of the fragments (Figs. 11 and 12). In a comminuted fracture of a flat bone the bone or a portion thereof is broken into several rather large fragments, with or without additional small ones ; in this use of the term fractures showing only two or three fragments, and those rather small, are excluded, the line of distinction being of necessity vague and arbitrary. In the short bones and the spongy ends of the long bones comminu- tion is frequently associated with crushing of the spongy tissue, or the end of the diaphyseal fragment may be driven into the expanded, spongy end, crushing it or splitting it ; to this form the term compression fracture is sometimes given, specially at the upper end of the humerus and tibia and in the bodies of the vertebrae. If the two main fragments are rather firmly held to- gether in their new relations the condition is termed impaction or impacted fracture (Fig. 13). If the crush- v-snaped fracture. ing of the spongy tissue has taken place without much splintering of the cortical layer the term fracture with crushing is used (Fig. 14). This crushing of spongy tissue is effected by breaking Fig. 11. Fig. 12. Comminuted fracture of the femur, with splitting of the condyles. Comminuted fracture of the lower end of the radius. Palmar aspect. PATHOLOGY. 29 down the innumerable fine lamellae of bone and forcing out the fat within the meshes, as a handful of snow or a wet sponge is compressed, and the result is equivalent to an actual loss of tissue ; that is, if the main fragments are replaced in their original positions a gap is left between them corresponding to the position and extent of the crushing. This gap is often too large to be filled by new bone, formed during repair ; consequently, a full correction of the displacement is inadvis- able, even when possible, lest failure of union should result, and the surgeon must be content to obtain union with some deformity. Fig. 13. Fig. 14. Intra-articular fracture of the head of the tibia, with impaction and sepa- ration of the upper fragments. Fracture of the calcaneum, with crushing. (b) Varieties Dependent Upon the Seat of the Fracture. — A fracture may occupy any portion of the bone and be known by its name ; for example, fracture of the neck of the femur, of the lower third of the tibia, of the head, of the shaft, of the inner condyle, of the acromion ; intercondyloid fracture, when it passes across the shaft and also down- ward between the condyles ; separation of the epiphysis. Separation of the Epiphysis. 1 This term is limited to separation of epiphyses which have not yet become united by bone with the shaft. This union takes place in the different bones at different ages, but is usually complete in all in the female at the age of twenty-two years, and in the male at twenty-five years. Bruns 2 collected 81 cases, with 101 separations, in which direct examination of the seat of injury was possible ; the points of greatest frequency were the lower end of the femur 28, lower end of the radius 25, and upper end of the humerus 11. Of the 52 cases in which the age was given, 44 were between ten and nineteen years old, 8 between one and nine years. Of 61 in which the line was exactly described, the line in 23 ran exactly along the face of the conjugal cartilage, in 5 it ran through the cartilage, and in 33 partly along the cartilage and partly through the adjoining 1 The first work upon this subject is by G. C. Reichel, " De Epiphysium ab Ossium Diaphysi Diductioue," published at Leipsic in 1794. Manqnat's tbesis, in 1ST?, and Bruns' article, in 1878, wore the first in which any considerable number ot* cases was collected. Later articles will be referred to in connection with the different epiphyses. Quite recently. 1898, a large work upon the subject has been published bv John Poland ' 2 Bruns: Arch. i". klin. Chir., 1878, vol. xxii. p. 343. 30 FRACTURES. " chondroid " tissue on its diaphyseal side. An important feature is the fact that the periosteum of the adjoining portion of the shaft is freely stripped off, preserving its continuity to a large extent with the epiphysis. It has lately been recognized that a partial or complete separation of the epiphysis of the lower end of the humerus is frequent. (See Plates XI. and XII.) The mode of production appears usually to be by cross-strain, the limb being bent beyond the limit of normal motion in the correspond- ing joint or in a direction in which there is normally no motion ; for example, lateral bending at the knee. The displacement may be very slight or so great as wholly to sepa- rate the fractured surfaces from each other. Colles's fracture at the lower end of the radius in the young is occasionally a separation of the epiphysis with slight displacement (see Plate XXVII. , Fig. 2) ; at the upper end of the humerus the displacement is usually equal to Fig. 15. Separation of the epiphysis. Periosteum partly intact. (Thudjcum.) about half the thickness of the bone ; at the elbow it may be complete backward or inward, but is usually incomplete inward. The diagnosis is made in the cases of slight displacement on the history of the injury and tenderness on pressure limited to the line of junction of the epiphysis and shaft; in the others by recognition of the deformity and of the size and shape of the fragment. AVhen the dis- placement is great reduction may be seriously opposed by the interpo- sition of the loosened periosteum. The prognosis is affected by the possibility of arrest of growth due to an uncorrected displacement or to premature ossification of the con- jugal cartilage. A few such cases have been reported. This defi- ciency of growth is, of course, most marked in those who receive their injury at an early age, and secondly in those cases in which the affected epiphysis normally takes the larger part in the growth of the bone in length, namely, the upper end of the humerus and tibia and the lower end of the femur and radius. I have seen two cases in which this injury at the lower end of the radius at the age of fourteen PATHOLOGY. 31 years produced a late deformity exactly resembling that of a very bad Colles's fracture. (See Plate XXVII., Fig. 1.) (c) Intra-articular or articular fractures are those iu which the main line of fracture or a subsidiary one, extends into a joint. The forms vary from a simple fissure extending into the joint from a distant frac- ture with little or no injury to the capsule to a fracture in which the articular end of a bone is broken into several widely displaced pieces with much laceration of the capsule and periarticular tissue. They include also that form in which the fracture lies wholly within the joint, with little or no injury to the joint, as in fracture of the narrow part of the neck of the femur, close to the head, and in fracture of the capi- tellum of the humerus, and some fractures of the carpal scaphoid ; to this form the term intra-articular is often limited. Common examples are fractures of either condyle of the femur or humerus, intracondyloid fractures of the same bones, fractures of the patella and olecranon. The special importance of the variety arises partly from the implication of the joint in the inflammatory reaction following the trauma, but mainly from the change in the mechanical conditions produced by the displacement of the fragment, the callus, and the implication of the capsule and periarticular tissues. There is but little recognizable regularity in the effects produced by these different factors, lesions apparently slight sometimes causing complete anchylosis, and extensive displacement of a fragment sometimes causing only slight interference with function. The most marked limitations of motion appear usually to be the consequence of injury to the capsule and adjoining soft parts by which they are shortened or so bound together as to restrict the movements. This factor needs specially to be borne in mind in decid- ing upon the propriety of operation in these cases and upon the method of operation. When a fragment including a portion of bone well out- side the capsule has undergone such displacement, usually by rotation, as to separate its articular portion wholly or in great part from the cor- responding surface of the associate bone an operation is usually required to restore it to its place. If the fragment is smaller and wholly intra- articular, or even if retaining slight capsular connection, it is usually better to remove it, for it is unlikely to maintain its vitality. In the young excessive formation of bone outside of, but near to, the joint as the result of the traumatic irritation of the periosteum may also me- chanically limit the motions of the joint. 3. Multiple Fractures. This term is applied to the simultaneous fracture of two or more non-adjacent bones and two or more fractures of the same bone whose lines are not continuous with one another. The term double is also used when there are only two fractures. This definition is intended to exclude simultaneous fracture of both bones of the leg or forearm and fractures which involve two or more adjacent bones of the skull or pelvis. The term is frequently applied to fracture o{' two or more adjacent ribs, and sometimes to cases of extensive splintering of the flat bones. 32 FRACTURES. Multiple fractures of a single boue are caused by violence, usually great, acting in part directly against the shaft, as the fall of a heavy weight or, as in two of my own cases, by the striking of the thigh against a tree when the patient was thrown from a carriage. The condition may be serious as to life, because of the shock of the injury, and in respect of restoration of form and function, because of the diffi- culty of controlling the position of the intermediate fragment. There is also the chance of overlooking one of the fractures. Multiple fractures of different bones are also usually caused by great violence ; the prognosis is affected much more by the associated injuries and shock than by the multiplicity of ihe fractures. If the patient survives the primary effects of the accident the fractures heal in the ordinary manner. 4. Compound (or Open) Fractures. A compound fracture is one in which communication between the fracture and the external air is established through a wound of the soft parts. The importance of this communication arises through the possibility of infection of the wound from without, with all the risks involved in the consequent suppuration of the bone and the lacerated soft parts. In addition, a large proportion of compound fractures are caused by direct violence, and the consequent laceration of the over- lying soft parts is such as to be a serious addition to the fact of fracture. In other cases the external wound may be merely a puncture made by the broken end of the bone, which, under suitable treatment, heals in a few days, making the fracture thenceforth a simple (closed) one. A fracture that is simple at first may be made compound by the sloughing of the overlying skin in consequence of its injury by the primary violence or of pressure upon it by a displaced fragment, or by the later forcing of the sharp end of a fragment through the skin in the agitation of delirium or in an attempt to use the limb while in ignorance of the character of the injury that has been received. In determining the compound character of a fracture it is sufficient to establish the fact that the wound of the soft parts extends through the enveloping fascia and to the immediate neighborhood of the seat of fracture, for even if the gross lesion should not extend to the broken surface of the bone, yet the minuter lacerations and the extravasated blood create a path for the spread of infection that brings the condition fully within the definition and the special dangers. The prognosis varies so greatly with the extent and character of the injury to the soft parts that statistics which take no account of these variations have but little value. A fracture produced by indirect violence and made compound by a puncture of the skin by the end of a subcutaneous bone, such as the ulna or tibia, may be confidently expected to heal under appropriate treatment as kindly and promptly as a simple fracture ; while one produced by direct violence and accompanied by destruction of the skin and muscles can heal only by granulation, and will probably suppurate, notwithstanding all the care that may be given it j or, the associated damage to the soft parts may PATHOLOGY. 33 be such that the limb would be useless even if the wound should heal. The most virulent and rapidly progressive infections appear with ex- ceptional frequency in compound fractures accompanied by much bruis- ing or laceration of the muscles ; their production is presumably favored by the local reduction of vitality. The shock of the injury is usually much greater than that of simple fracture, and may cause death in a few hours, and the probability of the existence of serious associated lesions is also greater because of the usually greater violence that has produced the fracture. This is shown by the following statistics: During two years, February, 1895, to February, 1897, there were received at the Hudson Street Hospital 70 compound fractures of the limbs, exclusive of those of the hand. Eleven of these patients died within twenty-four hours after the acci- dent, 3 of the 11 having also a fracture of the base of the skull ; 4 more died within three days after the accident, making in all 15 deaths (or 12, if the fractures of the skull are excluded) directly due to the shock of the injury, a mortality of 21 per cent. This is largely in excess of that following simple fractures, although they, too, may be aocompanied by other grave lesions or by severe shock, or may lead to a fatal pneumonia or attack of delirium tremens. I cannot give the final result in the remaining 55 cases of my list, because many of them were transferred to their homes or to other hospitals after they had recovered from the primary effects of their injuries. At least three of them underwent amputation. Mumford, 1 collating 300 cases (excluding those that died within the first twelve hours and those treated by primary amputation) received at the Massachusetts General Hospital during the preceding eight years, found a mortality of 30, or 10 per cent., the causes of death being sepsis, 10; shock, 7; delirium tremens, 6; fat embolism, 3; gangrene, 3; nephritis, 1. The highest mortality was in fractures of the femur — 25 cases with 7 deaths, 28 per cent. The principles of treatment are to transform the fracture into a simple one as promptly as possible, to minimize suppuration and keep it superficial when it is inevitable, and to protect against other infec- tion while the wound is open, meanwhile immobilizing the fragments by suitable splints. Under the protection of strict asepsis (including in that rigid disinfection of the crushed soft parts in fractures by direct violence) the question of the need of amputation may often be post- poned until after the progress of the case shall have clearly shown whether or not the limb can be saved. 5. Gunshot Fractures. The call for separate consideration of this variety of compound frac- tures comes through peculiarities of the lesions and dangers consequent upon the small size and the velocity of the projectile. The subject, consequently, is rather more limited than its title might suggest, and does not include fractures bv large balls or nieces of shell, in which ^ or piece 1 Mumford : Boston Medical and Surgical Journal, May 10, 1S94. 34 FRACTURES. the extensive laceration of the soft parts is even more important than the fracture. The special features are the usually extensive splintering and As- suring of the hone and the bruising of the tissues along the track of the bullet which may prevent prompt healing of the wound. These features are found in varying degrees, corresponding to the velocity of the ball and to its size. A ball whose force is nearly spent may, on striking the shaft of a long bone, do no injury at the point of impact, but may yet cause a curved fissure nearly circumscribing a cortical frag- Fig. 17. Contusion of side of femur by pistol-ball ; " symmetrical " fissure of the opposite side. (Potjlet and Bousqtjet.) Transverse fracture of the clavicle by a spent ball. (Ricard.) ment on the opposite side (Delorme, Fig. 16) ; if its speed is slightly greater, and especially if it strikes the spongy end of the bone, it causes a depression of the surface only ; if the ball is large and its velocity low, and the point struck is near the centre of the shaft, a transverse fracture (Fig. 17) or an oblique one (Plate XIX.) may be produced. At higher velocities the bone is perforated, with more or less splinter- ing and Assuring (Fig. 18), or the entire cylinder for a length of one or two inches is split into small fragments which are driven far into the surrounding tissues (Fig. 19). See also Plate I. With the latter may be associated extensive lacerations of the soft parts on the distal side. In other cases the bone is fissured or split into large fragments on each side. Occasionally the bone may be simply perforated or notched, and then broken by the subsequent use of the limb. I have seen two such cases ; in one the patient was shot by a policeman, and as he ran away the femur broke at the point where it had been perfo- PLATE I Fracture of Radius by Small Bullet of High Velocity entering at the Hand and emerging at the Elbow, PLATE II Same Case as Plate I., after Repair PATHOLOGY rated ; he died of tetanus. In the other, fracture of the leg, the same sequence was observed, but the patient survived, and the exact charac- ter of the injury caused by the bullet remained unknown. In the case shown in Plate I., in which the ball entered between the fingers and emerged above the elbow after extensively splintering the Fig. 18. Fig. 19. Perforating shot wound of tibia. (Ricard.) «, entrance ; b, exit. Fracture ball from small locity of femur by Lobel rifle ; calibre ; high ve- (Chatjvel and NlMIER.) lower half of the radius, the skin of the forearm was torn longitudinally in several places, apparently by the distending effect of the ball. In fractures by a charge of small shot at close range the laceration of the soft parts is the pre- dominant feature. In those of the cranium, chest, and pelvis the associated visceral injuries are the most important ; thus, one of my patients died from the injury done to his brain by a single bird shot, size No. 7, which entered through a very thin part of the frontal bone just below the inner end of the eyebrow. The removal of the bullet, even from the brain, is not essential to recovery, and a search for it may easily be harmful. The great mortality which formerly characterized these injuries has been greatly reduced by antiseptic treatment. In military surgery the gain in saving life and limb has also been increased by the reduction in the size of the bullet and possibly also by its higher velocity. In civil practice, which deals mainly with pistol-shot wounds, the results now obtained are good. A pistol-shot wound is usually surgically clean, and if not officiously treated may be confidently expected to heal kindly ; a piece of the clothing is rarely carried in by the bullet, and in most cases all that is necessary is to clean the surface and the orifice of the wound and apply a dressing. The bullet may be left to heal in unless the wound is large and ragged. Late hemorrhages, due to the slough- ing of bruised vessels, sometimes occur. 36 FRACTURES. Displacements. The relations of the two principal fragments produced by fracture of a bone may be altered in various ways, which Malgaigne classified under six heads. The classification has been generally adopted, with the understanding, however, that a fracture usually presents a combi- nation of two or more of them, and that there is an additional group of cases in which the peculiarities of the displacement defy classification. The six classes group displacements according to 1. The transverse axis of the bone, transverse or lateral displacement. 2. The long axis of the bone, angular displacement. 3. The circumference of the bone, rotatory displacement. 4. The length of the bone, overriding. 5. Penetration of one fragment by the other, impaction or crushing. 6. Direct longitudinal separation. 1. Transverse or lateral displacement may take place forward, back- ward, or toward either side, and may be partial or complete. Pure transverse displacement is rare ; it is usually associated with over- riding or angular displacement, or both (Plate III., fig. 1). 2. Angular displacement may vary in degree from a slight deviation to a right angle, or even more, and may be associated with so com- plete and distant separation of the broken surfaces that the fragments form a T (Fig. 20). It may be produced by the fracturing violence, the action of gravity, or the contraction of the muscles. 3. In rotatory displacement one fragment, usually the lower, turns about its long axis, while the other fragment remains in position. 4. Overriding is most common after oblique fracture of the shaft, and is produced by various causes, such as a continuation for a moment after the fracture of the force that has produced it, the tonicity of the muscles, or the swelling of the limb due to inflammatory reaction and extravasation of blood beneath the deep fascia, which, by increasing the transverse diameters, shortens the longitudinal one. Fig. 20. Fracture of the clavicle. 5. Displacement by penetration or crushing has been already men- tioned as the impacted variety of fracture. Penetration rarely takes place without a change in the direction of the axes of the fragments, because of differences in the resistance or of the direction of the fracture. The callus found after consolidation of the fracture may give the ap- pearance of a much deeper penetration than has actually taken place ; thus, in Fig. 23 the triangular mass of spongy tissue on the side is PLATE 111 Fig. 1.— Fracture of Forearm, Six Weeks Old, showini along Periosteal Bridge. Ossification Fig. 2.— Humerus Two Years after Fracture Periosteal Bridge. Growth of Bone along PLATE IV Same as Plate III., Fig. 2. Injury recent. PATHOLOGY. 37 not the penetrated epiphysis, but is mainly composed of callus formed by the stripped-up periosteum. v 6. Direct longitudinal separation is seen most frequently after fracture of the patella, and is then due partly to the retraction of the quadri- ceps and partly to the distention of the joint by blood and exudate. Fig. 21. Ftg. 22. Fig. 2- Rotatory displacement after frac- ture of the neck of the femur. Fracture of the lower end of the radius. Angular displace- Fracture of both bones of the ment of the lower fragment leg, with overriding. backward. (R. W. Smith.) Among the irregular displacements, those which do not fall entirely within the above classification, may be mentioned rotation of one frag- ment about its transverse axis, as in some fractures of the neck of the humerus, crossing of the fragments in the form of an X, and the inter- position of a bone between two fractured ones, or of the end of the shaft between its separated condyles. (B) THE SOFT PARTS. The periosteum may be simply loosened from the surface of bone adjoining the fracture, or it may be torn across throughout the whole or only a portion of its extent at or near the line of fracture. The first form (excluding fractures of the flat bones') is found only in frac- tures with slight displacement, and especially in the young, in whom the periosteum is thick and resistant. Such fractures are known as subperiosteal. They may be recognized or inferred from the youth of 38 FEACTUBES. the patient and the slight displacement and mobility of the fragments. Their prognosis is exceptionally good. Complete rupture of the periosteum all around the bone is probably infrequent and to be found only in fractures with great displacement. Examination of fresh specimens and of the position and shape of the callus in those that have united indicates that in most cases the conti- nuity of the periosteum is preserved on one side, the continuous portion being stripped off one of the fragments for some distance and forming a " periosteal bridge" (Oilier), which unites the two fragments and takes an important part in the subsequent repair. (Plate III. and Fig. 24. " Periosteal bridge," diagrammatic. The muscles may escape injury or may be extensively torn. The neighboring connective tissue is torn and infiltrated with blood from its own vessels or from those of the broken bone. Injury to important vessels and nerves is rare ; it w T ill be described under Complications, Chapter VI. The skin may be torn by the original violence or by the sharp end of a fragment, or it may be so bruised by the original violence or so pressed upon by a displaced fragment that it subsequently sloughs. These lesions of the skin may communicate with the seat of fracture (compound fracture), or may be at a distance therefrom and without influence upon its course, except so far as they may interfere with the application of splints. Discoloration of the skin due to extravasated blood beneath almost invariably appears after a day or two, and may be widespread. Large blebs filled with dark, blood-stained serum fre- quently appear upon the limb near the fracture by the second or third day. CHAPTER III. ETIOLOGY. Predisposing Causes — Determining Causes— Spontaneous and Pathological Fractures — Intra-uterine Fractures and Fractures During Delivery. The causes of fracture may be grouped under two heads: A. The predisposing causes; B. The immediate or determining causes. The Predisposing Causes are of three kinds : (1) the external, (2) the normal or physiological, and (3) the pathological. Most of the latter, which consist in a local or, more rarely, a general diminution of the strength or an actual de- struction of the bone by a local or general disease, will be considered under the head of Spontaneous or Pathological Fractures. The external predisposing causes are those incidental to various occu- pations and modes of life which involve greater exposure to deter- mining causes ; they account for the great excess of fractures in males over those in females between youth and old age, and for their rarity in young children. The normal or physiological causes are those which have their origin in the position and functions of the different bones. The bones of the skull and chest are broken when the violence against which they are designed to protect the enclosed viscera is too great for their power of resistance ; the use of the arms in many occupations exposes them to fracturing violence, and they and the lower limbs are broken in falls all the more easily because of the contraction of the muscles by which they are stiffened to protect the body against the shock. In like manner the normal curves in single or associated bones — e. g., the clavicle and spinal column — which supply an elasticity that is protective of the viscera increase their liability to fracture. Interstitial atrophy of the bones, which is so common a senile change, is undoubtedly the cause of the greater relative frequency of fractures in the old ; and its agency becomes all the more apparent when the usual withdrawal of the aged from the occupations which most expose to fracture is taken into account. This atrophy consists in thinning of the cortex of the shafts and of the trabecular of the spongy portions and of the short bones, not in a relative increase of the lime salts in the bone tissue itself, as was long supposed. It is an actual diminution of the bone substance and a corresponding increase of the fat and other soft parts contained in it. In the old, and when not extreme, it may be classed as a normal predisposition to fracture, but when it appears prematurely or readies an extreme degree it must be deemed patholog- ical and classed witli other similar atrophies whose nature and eauses are not well understood. 39 40 FRACTURES. The inherited or early developed liability to fracture which has been observed in certain individuals and families who were in other respects normal is probably the result of a similar scantiness of the bone tissue. Of this inherited liability Gurlt gives three examples, extending in one over four generations, in the others over three. One of the patients suffered fourteen fractures, and another thirteen, before either reached the age of thirteen years. All united promptly. He gives also three cases of a congenital but not inherited liability to fracture in families. One girl suffered thirty-one fractures of the thigh, leg, and arm between the ages of three and fourteen years ; her sister had nine before she was six years old. Not infrequently individuals have developed in early or middle life a noticeable fragility of the bones without any other change that would indicate a general deterioration or disease. Thus, Biggs 1 reports a case of twenty-two fractures, all but one of the arm or thigh, between the ages of twenty and thirty years in a man who had suffered none before or after. Immediate or Determining Causes of Fractures. These are of two kinds: (1) External violence, and (2) muscular action, the latter exerted by muscles connected more or less directly with the bone that is broken. 1. Fractures by External Violence. The division of these into two classes, of which one is called fractures by direct, the other fractures by indirect, violence is based upon clinical differences often of ex- treme importance, and not simply upon mechanical differences in the mode of transmission and in the effect of the applied force. This relieves us, therefore, from the necessity of examining the latter ques- tions with their many obscure factors and complex relations, and makes the definitions simple. A fracture by direct violence is one in which the bone is broken immediately under the point upon the surface where the fracturing force is exerted ; and a fracture by indirect violence is one in which the fracture takes place at a distance from that point. The most important clinical difference between the two varieties de- pends upon the injury to the overlying soft parts in the one case and the absence of such injury in the other. The skin is not always broken in fractures by direct violence, even when the vulnerant force has been great and the injury to the soft parts under the skin extensive, but it may have been so injured, even if it shows no marks of violence, that it will slough. On the other hand, the blow may break the skin at the point where it is received and pro- duce fracture indirectly at a greater or less distance, the bone yielding at its point of least resistance and not at that where the force is directly exerted. The fracturing force may be applied directly or indirectly to the bone, to crush or break it, or obliquely to its long axis, or as torsion, or as avulsion. Examples of the first are furnished by falls upon the feet with fracture of the calcaneum, gunshot wounds, and crushing of the lower end of the radius in a fall upon the hand ; of the second by most 1 Biggs: Univ. of Penn. Bulletin, 1903, Ko. 12. ETIOLOGY. 41 fractures of the shafts of long bones ; of the third by some fractures of the leg when the foot is fixed and the body turned forcibly about it ; and of the fourth by some fractures of the lower end of the humerus by forced abduction of the forearm, by some of the internal malleolus in eversion of the foot, and by some of the patella in forced flexion of the knee when its normal range of motion has been limited by previous injury. Indirect fractures are by far more common in long bones than in the short spongy ones, because of their proportions and functions. The principle of their production is that of the transmission of a force along a bone or set of bones made rigid by ligamentary attachments or muscular contraction in such manner that it is resolved into forces acting in two or more directions, one of which crosses the long axis of the bone and acts as if it had been applied directly at the point of least resistance in a transverse direction. The effect is greatly modi- fied by the anatomical structure and form of the bone, the attitude of the limb, the contraction of the muscles, and the direction of the blow. Thus, a fall upon the hand may break the bones of the forearm, the humerus, or the clavicle; a fall upon the foot may fracture the calca- neum by direct violence, or the bones of the leg, the thigh, or even the vertebral column or skull by indirect violence. The best example of the fracture of short bones by indirect violence is furnished by the spinal column, the bones of which, considered as a group, constitute a long bone with several curves, the forcible exag- geration of which produces fracture. 2. Fractures by Muscular Action. Under this head are included only those fractures in which the rupturing force is exerted by the muscles alone, without the aid of any external violence. It is, of course, evident that, if an individual breaks his skull or a limb by running or striking against a solid object, the force that causes the fracture is developed by the action of his muscles; but the mechanism is the same as if he had fallen from a height, or as if his body was at rest and the object with which he has come into contact was in motion. And in many other cases the distinction is somewhat arbitrary and rather clinical than mechanical, for often in fracture by external vio- lence resistance to movement of the bone in the direction impelled by the external force is supplied by the muscles, and without that resist- ance fracture would not occur. The conditions are practically the same as if, the distal end of the limb being held stationary, the muscles were sharply contracted in an attempt to move it. Thus, a man holds his arm outstretched while another seeks to lower it by striking the fore- arm, and the humerus breaks below the insertion of the deltoid ; or a man pushes with his foot, the knee being partly flexed, his foot slips and the patella is broken by the tearing away of its lower portion in the sudden flexion of the knee, the upper part being held stationary bv the tense quadriceps. Strictly speaking, only those eases are considered to be fractures by muscular action in which the action is exerted directly by the muscles upon the bones to which they are attached (mediately or immediately), either as direct traction, as in fracture o\' the patella 42 FRACTURES. or of the olecranon, or obliquely, or in torsion against resistance, or by sudden muscular arrest of the rapidly moving limb, as in throwing, or in striking or kicking at an object and missing it. Some authors have expressed the opinion that no bone can be broken by simple muscular contraction unless it has previously undergone some change that has diminished its strength; but this opinion must be looked upon as an attempt to explain away by an unfounded, or at least an unproved, assumption a difficulty which does not really exist. It is no more logical to claim that such a change has preceded every fracture by muscular action than it would be to make the same claim for fractures by external violence ; it can rest only upon the assump- tion that the power of resistance of a normal bone is superior to any force that a muscle or group of muscles can exert upon it, even under extreme and unusual circumstances; whereas, on the contrary, nature's precautions and adaptations are calculated upon the basis of the prob- able, not of the exceptional. Such a position may be taken with pro- priety concerning all fractures produced by slight causes in the old, the diseased, the cachectic, or in those who have suffered pain at the point of fracture for some time previous to the accident ; but it is entirely unsupported by proof in the rarer, but still sufficiently numer- ous, cases of the fracture of the shaft of a long bone produced by a violent effort in a healthy athletic man, and in the common ones of fracture of the patella. The effect of muscular action is manifested in all the degrees of varying importance between its relatively unimportant additions to the effects of external violence and those cases in which it is the sole agent of the fracture of a healthy bone. The intermediate degrees are presented by those fractures, usually of weakened bones, in which moderate muscular action has acted either alone or combined with slight external violence. In the first case, when the power of the muscle is exerted in the same direction as the external violence, it increases the fracturing force by just so much; and, by prolonging its effect after the fracture has been made, it also increases the displace- ment of the fragments and the laceration of the soft parts. The prin- cipal interest of the intermediate cases is connected with the cause of the exceptional fragility of the bone, and is considered in the following section — Spontaneous and Pathological Fractures. The commonest examples of fracture by muscular action alone are furnished by the patella ; other apophyses and tuberosities to which powerful muscles are attached— the olecranon, greater tuberosity of the humerus, coracoid, acromion — furnish them much more rarely. Of the long bones the humerus is the one most frequently broken in this manner; out of 85 cases of fracture of the limbs by muscular action collected by Gurlt, 1 57 were fractures of the humerus, 15 of the thigh, 8 of the leg, and 5 of the forearm. Ashurst 2 collected 81 cases of fracture of the humerus : 24 by torsion, 57 by a blow. The mech- anism seems in most cases to be the same as in indirect fracture ; in some the fracture takes place at the insertion of the muscle, and in 1 Gurlt : Loc. cit., vol. i. p. 232. 2 Ashhurst: Univ. of Penn. Med. Bull., Feb. 1906. ETIOLOGY. 4:3 others the elements are too complex and too conjectural to be explained theoretically. In a comparatively small number of cases the fracture has been caused by reflex spasms in limbs that had long been paralyzed or by the convulsions of epilepsy or tetanus, but usually the cause is a violent voluntary muscular effort to avoid a fall, to throw a stone, or to lift a heavy object. The following cases taken from Gurlt illustrate the different forms and the methods by which they may be produced. It must be remembered that fractures produced during convulsions need to be closely examined in order not to overlook the possible addition of external violence by a fall from the bed or by a blow. In a negro boy, twelve or thirteen years of age, affected with teta- nus, both thigh bones were broken " at the neck," possibly just below the trochanter, by the contraction of the muscles, and the fragments forced through the skin on the outer side of the limb. An athletic man, thirty-four years old, accustomed to lift heavy weights, broke his humerus with an audible snap, just below the inser- tion of the deltoid, by the effort made, on a wager, to throw a stone weighing about two ounces the distance of a hundred yards. Recovery in six weeks. Gurlt gives also 11 cases (Ashhurst, loc. cit., 24) in which the humerus was broken during that trial of strength in which two men place their elbows upon a table, clasp hands with the forearms parallel and vertical, and strive to force each other's hand backward. Fractures of the femur may occur at any point of the shaft, and in the recorded cases have been the result of an attempt to kick, to avoid a fall, or to rise from the ground on one foot, or of cramps, excited in one case by drawing on a tight boot and in another by turning in bed. A man, thirty-six to thirty-eight years old, of middle size and great muscular power, broke his thigh at the junction of its upper and middle thirds by kicking at and missing his servant. Van Oven described before the Royal Medical and Surgical Society a fracture of the thigh sustained by himself. He was fifty-six years old, healthy and strong, and free from taint of cancer, scrofula, syph- ilis, etc. He was awakened by a sharp, cramp-like pain above the knee, and as he felt the part with his hand, and noticed that the muscle was tense, he heard a snap, followed by relaxation of the muscle, crepi- tus, "and diminution of the pain. Examination showed a transverse fracture of the femur three inches above the knee. Complete recovery in four months. A cavalryman, twenty-nine years old, while trying to rise from a sitting posture on the ground without the aid of his hands, broke his right thigh at its middle. Gurlt' s eight cases of fracture of the leg comprise four of both bones, one of the tibia, and three of the fibula alone, the latter being fractures at the upper end of the bone by the contraction of the biceps. A small, rather corpulent woman, forty-five years old, slipped on the left foot while descending some steps, made a violent effort with the right leg to avoid a fall, felt at once a severe pain in the latter, and fell in a sitting posture. An immediate examination showed a fracture of both bones at the middle of the leg. 44 FRACTURES. A woman, fifty-two years old, mistook a door leading into the cellar for one opening into a closet, and. recognizing the mistake as she put her right foot forward, drew herself instinctively backward, and felt at the same moment something snap in her left leg, upon which the weight of her body rested. She fell and rolled down the steps. A fracture of the left fibula just below its head was found. Fracture of either or both bones of the forearm has been caused by the wringing of wet clothes and in shovelling. A healthy girl, eighteen years old, while wringing clothes, felt a sudden sharp pain on the inner side of the forearm above the wrist. Three days afterward a fracture of the ulna, two and one-half inches above the wrist, was recognized. A woman, thirty years old, broke the radius in its lower third with severe pain while wringing two heavy towels. Fractures of the clavicle have been caused by the effort of raising a heavy object, shovelling, and striking backward or with a whip. Fractures of one or more ribs are not infrequently caused by violent coughing, especially in the consumptive. The sternum has been broken in four recorded cases by the violent straining and bending backward of the body during the expulsive efforts of parturition, and there are several cases of fracture of the cervical vertebrae by muscular action alone, and of the scapula. Hilton reports the case of a man who had broken a rib by muscular action while trying to mount a spirited horse. A primipara, twenty-four years old, taken in labor, sought to hasten delivery by forcible expulsive efforts, bending backward and resting on her elbows and heels ; she felt a sudden sharp pain and a snap in the middle of the breast, and said at once that something had broken there. She died of peritonitis, and at the autopsy a transverse fracture of the sternum was found, one and one-half lines above the junction of its body and the manubrium. A soldier dived into a river, and, not reappearing, was sought for and brought out. His body showed no trace of external violence, but there was paralysis of all the limbs, loss of sensation, pain at the pos- terior and lower parts of the neck, priapism, frequent desire to urinate. He said that as he dived he saw the water was too shallow, and in the effort to avoid striking against the bottom he jerked his head sharply backward and at once lost consciousness. He died the same night, and the autopsy showed a transverse fracture of the body of the fifth cer- vical vertebra a little below its centre. A number of similar cases have been reported. A servant engaged in preparing a lamp raised his arm quickly to arrest the action of an escaping spring and felt something give way in it. The arm fell powerless by his side, and the greater portion of the acromion was found to have been broken off. I have seen two fractures of the coracoid process by forcible con- traction of the muscles of the arm. ETIOLOGY. 45 Spontaneous and Pathological Fractures. The term spontaneous is used to indicate that the violence, external or muscular, which has produced the fracture is much less than that commonly observed in that form ; and the term pathological to indi- cate a preceding abnormal change in the fractured bone by which its strength has been diminished. It has become common to use the terms interchangeably, because the slight violence indicated by the first is efficient to fracture only when the change indicated by the second is present. It is noteworthy that the pain accompanying or following the frac- ture is often very slight • fractures of ribs, and even some of the limbs, have passed unrecognized until the autopsy. The pathological condi- tion known as general atrophy or rarefaction of the bone, or osteopo- rosis, and which has been referred to as senile atrophy, may appear prematurely or may have its origin in other causes than senility, such as paralysis, locomotor ataxia, diabetes, pregnancy, and osteomalacia. It is worthy of note that in not a small proportion of cases union takes place promptly. In most of the cases which furnish autopsies the bones are found softened and reduced to a shell by absorption from within, and in some of the cases suppuration has taken place at the fracture. It has been noted by Bouchard and by Verneuil and Verchere that spontaneous fracture occasionally happens in the diabetic, and that the urine shows the presence not only of sugar but also of phosphoric acid in quantities that suggest its origin in a decalcification of the bones. These observations have been confirmed by Isch-Wall (quoted by Ricard), who also found the phosphoric acid present in some patients affected with cancer. In nine cases of spontaneous fracture in the diabetic reported by Verchere union was greatly delayed. The following cases represent different varieties : A woman, seventy-two years old, had both thighs broken by kneel- ing in church, and the humerus by the efforts of bystanders to lift her up. Another broke her clavicle by putting her arm about the nurse's neck and trying to turn herself in bed (Gurlt). A woman, forty-five years old, the mother of two children, suffered a great deal of pain in her bones after the birth of her second child, and became so helpless that she could not get into or out of bed with- out aid. She broke each thigh below the trochanter by stumbling against the bedpost in one case and by turning in bed in the other. Both united with marked angular displacement, and at the autopsy the bones of the thigh and pelvis were found to be so light that they floated in water and could be crushed by pressure with the finger. The cor- tical layer of the femur was as thin as an egg-shell, the medullary canal enlarged, traversed here and there by delicate plates of bone, and filled with a grumous, semifluid mixture of blood and marrow (Gurlt). A man, sixty years old, broke his femur in the middle third by stumbling, without falling. He died a fortnight later, and 1 found an enormous calculus in eaeli kidney. Saviard saw in 1690 a woman, about thirty years old. who had suf- 4(3 FRACTURES. fered for four months with severe pains throughout the body, increased by movements, and without fever. Three months later she had become bedridden, and her bones had become so friable that most of them were broken, and she could not be moved without causing a new fracture. She lived ten months in this condition, and the autopsy showed frac- tures of almost every bone in her body. The structure of the bones was so delicate that they could not be pressed between the fingers with- out breaking into small pieces ; the marrow was red, the muscles pale, the joints and cartilages unchanged. In a case under my care the tibia appeared to have been weakened by an osteitis set up by a blow and a wound of the soft parts. The wound healed in three weeks ; a fortnight later the patient returned with a compound fracture of the leg at the scar, caused by stepping down a distance of two feet. The bone could be plainly seen and was rarefied. Prompt recovery. A similar friability is also found in some cases of old unreduced dislocation, due, it is supposed, to lack of use. The condition was shown by direct examination in a case of subcoracoid dislocation of six weeks' standing, in which Guerin l tore oif the forearm in an attempt to reduce. The ends of the bones were rarefied and soft, and the mus- cles softened and brown. The autopsy showed no change in the other portions of the body. It seems probable, however, that in most cases in which fracture has occurred during an attempt to reduce a dislocation, and in which un- usual fragility has been alleged in explanation, the force exerted upon the bone has been greater than the surgeon supposed, because of the leverage employed, especially in rotation of the limb. Disease of the Nerve-centres. In 1842 Davey called attention to the facility with which fracture sometimes occurred in lunatics, especially in those w r ho were also paralytic, and the observation has been abun- dantly confirmed, Brims having collected more than sixty reported cases. 2 Weir Mitchell 3 was the first to call attention to the frequency of fractures in those affected with locomotor ataxia, and suggested that the cause might lie in an impairment of the nutrition, and consequently of the strength, of the bone dependent upon the disease of the cord. Shortly afterward Charcot 4 published a remarkable case of multiple fractures and dislocations in an ataxic woman, and Bruns 5 followed with a paper upon the subject, based upon thirty cases reported within a few years. He finds that the fractures are usually multiple, from two to six in number, and are most common in the lower limb, espe- cially in the femur ; the frequency is equal in the different bones of the upper extremity — clavicle, humerus, and forearm. Repair takes place in the usual time. The accident seems to occur more frequently in the earlier than in 1 Guerin: Bull, de la Soc. de Chir., 1864, vol. v., pp. 121 and 131. 2 See also Baum : Deutsche Zeitschrift fur Chir. Vol. 99, p. 1, for 120 cases. 3 Weir Mitchell: American Journal of the Medical Sciences, July, 1873, p. 113. 4 Charcot: Arch, de Phys., 1874, p. 166. 5 Bruns : Berlin, klin. Wochenschrift, 1882, p. 164. ETIOLOGY, 47 the later stages of the nervous disease, and the predisposing condition is a rarefaction of the bone marked' by great absorption of the compact tissue, increase of fat, and loss of inorganic matter. A very remark- able instance of the earliness of this change is given by Tillmann 1 in the report of three cases of spiral fracture of the shaft of the femur caused by the effort made in drawing off a shoe. The patients showed nothing abnormal at the time, but when examined three and half, five, and eight years later, respectively, locomotor ataxia existed. Rachitis. Friability due to rachitis is found only in childhood, for the disease is one which involves the bones only during their period of growth, and consists essentially in the prolongation and exaggeration of the embryonal or developmental condition of the shaft, in conse- quence of which its strength and the firmness of its union with the epiphyses are diminished. Union after fracture takes place rather more slowly than in normal bone, and sometimes fails entirely. The callus is usually large, but, as it is composed of the same soft embryonal tissue whose excess is the pathological feature of the disease, it is lacking in firmness. Syphilis, Mercurialism, and Rheumatism. Syphilis affects the organ- ism in so many and so varied forms, and causes such serious bone lesions in its later stages, that it is not strange that both physicians and patients have been inclined to attribute to it fractures produced by slight causes whenever the patient was or had been affected by it. And in like manner those who saw in mercury the cause of the bone lesions of syphilis attributed the fractures to the use of that drug. When we remember what multitudes of people have contracted syphilis, how numerous those in whom it has caused grave lesions of the bones, and on the other hand how few are the cases, excluding sep- aration of the epiphyses in the new-born, in which it can even be sus- pected as a predisposing cause of fracture, it is evident that it can have but little influence in this direction ; and an examination of the alleged cases shows very frequently a coexisting constitutional weakness or a cachexia not always to be attributed to the specific disease which creates a close resemblance between these cases and those in which the friability of the bone is due to a premature or exaggerated senile atrophy. Yet it seems strange that the development of a gumma in the shaft of a long bone, with the consequent destruction of tissue, does not more often lead to fracture. Gurlt's fifteen syphilitic cases include five in which the fracture was preceded by severe pain, more or less prolonged, in the broken bone, and these might be deemed demonstrative of the influence of syphilis did we not possess other similar cases in which the syphilitic complica- tion does not exist. Malgaigne, indeed, speaks of local inflammation of the bone as a frequent and too much neglected predisposing cause of fracture, adding : " I give this name, conjectu rally, to an affection which manifests itself by dull pains attributed by the patient to some contusion or to rheumatism, rarely sufficient to cause a general reaction, and attracting but little attention until some slight cause produces frac- 1 Tillmann: Berlin, klin. Wochenschrift, 1896, No. 35. '-'Malgaigne: Loe. cit., p. 22. 48 FRACTURES. ture at the point it occupies." There is a striking similarity between the cases he cites and Gurlt's syphilitic cases. There seems to be no reason to suppose that mercury has any direct action upon the bones rendering them more liable to fracture, and the most that can be claimed is that its excessive, unskilful use will cause a deterioration of the health, which may result in an atrophy of the bones similar to that found in old age. Cancer and Sarcoma. There are two ways, apparently, in which the development of a malignant tumor may lead to fracture : either the tumor may occupy the bone itself, primarily or secondarily, and destroy it to such an extent that the slightest force is sufficient to fracture it, or the presence of the tumor elsewhere may induce a cachexia which results in atrophy of the bones. The following cases are quoted in illustration : Louis * was called to see a nun, sixty years old, whose arm had been broken by the efforts of a coachman to help her into a carriage. Union did not take place, and six months later, while seated in a chair, she broke her femur by letting her hand fall upon it. Louis, seeking the cause of this fragility, then learned that the patient had an ulcerated cancer of the breast. A woman, 2 forty years old, who had a cancer of the breast for some time, with well-marked cachexia, broke her right femur in the lower third by rising from a chair. She was taken to the hospital, and there the other femur was broken by the interne as he was preparing to apply a bandage to the first. She died the same night, and at the autopsy cancerous masses were found in the spongy tissue and in the medullary canal at the points of fracture and elsewhere, also in the vertebra? and cranial bones. I have now under treatment a woman thirty-one years old who broke her left femur in the upper third by stumbling, without falling. For two years she has had a carcinoma of the left breast, unulcerated but involving the skin. Two months later there was a large mass at the seat of fracture, and on moving the limb crackling (apparently the breaking of small pieces of bone) could be plainly felt. Now, a month later, there seems to be fairly firm union. In thirty-two cases collected by Gurlt in which the position of the primary tumor is noted, it occupied the mammary gland twenty-six times (once in a man); and of the entire thirty-eight cases thirty-five were women. As a rule, too, the affection was of long standing; in many of the cases the tumor had returned after removal, and in nine it had ulcerated. The humerus and femur were almost exclusively affected, but very unequally — twenty-six fractures of the femur and seven of the humerus. Severe localized pain in the bone preceded the fracture in a number of cases. .Reunion took place in one-fourth of the cases, and in at least three of these there was cancerous degeneration of the bone at the seat of fracture. In most of the remaining twenty-eight cases death, due to 1 Malgaigne : Loc. cit., vol. i. p. 14 2 Cruveilhier : Anat. Path., Livraison xx, PL 1, Fig. 4. ETIOLOGY. V.) the progress of the disease, followed so soon after the fracture that the bones had not time to unite, even if they were capable of doing so. Hydatid and Other Cysts. There are a few instances on record in which the unsuspected development of a hydatid cyst within a bone has resulted in its fracture by slight violence at the point occupied by the cyst ; and others in which a similar result has been produced by the occurrence of a cystic degeneration of unspecified character within the bone. These causes act by direct absorption of the cortical layer of the bone, and their action is purely local. Osteomyelitis favors fracture by partial destruction of the bone, but as this effect is accompanied by a rapid and often very bulky new- formation which makes good the loss, fractures are but infrequently observed except in the course of operations undertaken for the cure of the disease which require much cutting away of the new bone. I have seen several such ; their importance is slight, for there is usually but little displacement, and repair takes place within the usual time. Intra-uterine Fractures and Fractures During Delivery. Fracture of a limb of the child during its delivery through the natural passages of the mother is not very infrequent and is usually the result of manual or instrumental interference. Such fractures belong to the class of fractures by external violence, and present no features of special interest ; but there are others in which the fracture is caused by the expulsive efforts of the mother alone. An arm or a leg is engaged between the body of the child and the rigid parts of the mother, and the humerus or the femur is broken, sometimes with an audible snap, as the child is forced through the passage. Fractures within the uterus have been caused in a few cases by a bullet or sharp instrument that has at the same time perforated the abdominal wall of the mother. The possibility of the occurrence of fracture within the uterus as the result of external violence without perforation of the abdomen of the mother, or, in some cases, of unknown causes, has been proved by the birth of children presenting fractures of different bones in various stages of repair. It is not always easy to say, when a child is born with a fracture, whether it was caused during delivery or at an earlier period, or whether it was due to external violence or to the contractions of the uterus. And, further, it is not always possible to say whether an apparent fracture is actually one or only a malformation, a defect of ossification or of development, or a separation of the epiphysis due to syphilis. Gurlt collected eight cases in which the causal relation between an injury received by the mother during pregnancy and the fracture observed in the child seemed to him to be clearly demon- strated, and twenty-five others in which more or less doubt existed as to the cause of the fracture or the character of the lesion. The injury in the first eight cases was either a fall from a height or a violent blow upon the abdomen ; and the bones broken were those of the thigh, leg, arm, and forearm, and the clavicle. 4 50 . FRACTURES. The other group includes some in which an undoubted fracture existed, but with no history of external violence, and some in which the coexistence of malformations threw some doubt upon the character of the supposed fracture, and others in which the fractures were so numerous and so symmetrical that they must have depended upon some general cause, syphilis or rachitis, acting possibly upon the epiphyseal cartilages. CHAPTEE IV. EARLY SYMPTOMS AND DIAGNOSIS. The symptoms produced by a fracture are divided into two groups : the objective or positive, those which can be directly observed by the surgeon, and the subjective or rational, those for his knowledge of which he has to depend more or less completely upon the statements of the patient. The former include deformity of the limb or part, abnormal mobility at the point of fracture, and crepitus. The second group includes loss of function, pain, and history of the case and of the patient. Objective Signs. Deformity. This term is here employed in its widest sense, to include changes in the relations of the fragments of the bones to each other and the modifications in the appearance of the limb or part of the body produced by those changes, by the effusion of blood, and by the later inflammatory processes. The changes in the relations of the fragments to each other have been described in detail under Displacements. Many of them are so marked that they are recognizable by simple inspection of the part, while others are brought to light only by careful palpation and by meas- urements compared with those of the opposite limb. These measure- ments are used in practice only to recognize displacements by which a limb is shortened or the diameters of an articular extremity modified. In a few places practically normal relations exist which may take the place of comparison with the opposite limb : such are those of the great trochanter of the femur to a line drawn from the tuberosity of the ischium to the anterior superior spine of the ilium, and those of the styloid process of the radius to that of the ulna, both of which may be used with confidence in cases of fracture of the neck of the femur or of the lower extremity of the radius respectively. The chief difficulty in employing mensuration is that of finding well-defined points upon the skeleton between which the measurements can be made. Those employed in fractures are bony prominences or edges sufficiently near the surface to be clearly felt, but as they are all more or less rounded, absolute accuracy in measuring the distance is impossible. Another cause of uncertainty or of error lies in the normal asym- metry, the difference not due to traumatism or disease, which has been found occasionally to exist, and which sometimes is very notable, as much as an inch and a half in the lower limbs. 52 FRACTURES. Other sources of difficulty and error are found in the swelling of the soft parts, which may prevent the tape from being drawn straight, and in the varying angles between the axis of the limb and the line of measurement. The first is not likely to be great or to be overlooked ; but the latter is a frequent source of error. It is rare that fhe two fixed points between which the measurement is made are both upon the limb or the bone whose length is in question ; one of them is usually upon the trunk, and lies at a certain distance from the centre of motion of the limb. Consequently, any change in the position of the limb changes the distance between the two points that have been chosen. For example, in measuring the length of the lower limb the points taken are the anterior superior spine of the ilium and the tip of the malleolus ; the former lies several inches away from the centre of the hip-joint, and when the limb is in abduction the distance between the chosen points is less than when the limb is parallel to the long axis of the body. If a comparison is to be made between the two limbs, it is essential that their position with reference to the pelvis should be the same, and, therefore, care must be taken that the ankles are equidistant from a line drawn between them at right angles to and from the centre of another connecting the two anterior iliac spines. Similar difficulties and uncertainties exist in transverse and periph- eral measurements. The swelling of the soft parts not only increases the bulk of the limb, but it also obscures the bony prominences and places them at a greater distance below the surface, so that an accurate measurement of the distance between points on the opposite sides of a bone is practically impossible. For this and for rotatory and angular displacements the trained eye, aided by careful and minute considera- tion and palpation of the anatomical landmarks and comparison with the opposite limb, is the best guide. The appearance of the limb will be still further modified by swell- ing due to extravasated blood and inflammatory exudate, and some- times to the shortening of the limb, which increases its transverse diameters. Ecchymosis is a symptom that is rarely absent, although its appear- ance may be delayed for several days. It is most marked and most extensive in the old. The blood which escapes from the broken bone and the adjoining parts makes its way along the muscular planes, and first appears under the surface at some distance from the fracture. Its appearance at certain points creates a strong presumption of fracture — e. g., beneath the malleoli in Pott's fracture — and the same interfer- ence is measurably justified whenever an ecchymosis appears upon a limb that has not been directly contused. Large blebs, the serum of which is often dark, frequently appear upon the leg a day or two after its fracture ; less frequently upon other limbs. The cause of their production is not known. In fractures communicating with joints a characteristic deformity is caused by the filling of the cavity of the joint with blood or an inflam- matory effusion, the situation of which is shown by its limitation within the boundaries of the articular capsule. Abnormal Mobility. Mobility appearing after injury at a point in a EARLY SYMPTOMS AND DIAGNOSIS. 53 bone where it did not previously exist, and permitting the bone to be bent at an angle, or a portion of it to be moved while the other por- tion remains at rest, is pathognomonic of fracture, but it is not always present or recognizable, for the fracture may be incomplete or too near a joint, or one of the fragments may be too small or too deeply placed to be grasped. In fracture of the ribs, sternum, or fibula the elasticity of the bone may deceive if not taken into consideration, or raise a doubt if it is. The manipulations employed for the detection of abnormal mobility vary with the seat of fracture and the kind of mobility which is sought to be produced. In fracture of the shaft of a long bone the surgeon seeks first to produce an angular displacement by passing his hand under the limb at the supposed seat of fracture and gently raising it, or by grasping the two extremities of the bone firmly and moving the lower one slightly from side to side while the upper one is held sta- tionary. Or he may grasp the limb with both hands close to the fracture, and produce transverse displacement by moving the fragments bodily in opposite directions. In fracture of the shaft of the fibula, radius, or ulna lateral mobility may be detected by grasping the limb with both hands above and below the fracture, and then making press- ure alternately against the bone. In fracture of the upper portion of the shaft of the femur or of the neck of the humerus or of the upper end of the tibia, where a lateral or angular mobility cannot be easily recognized, recourse may be had to slight rotatory movements of the lower portions of the limb, while the upper portion is so held that its bony prominences can be distinctly felt by the fingers. Abnormal mobility is then recognized by the failure of the manipulation to transmit the rotatory movements to the upper fragment. It is essential that the communicated movements should be slight, for otherwise the attachments of the soft parts or the interlocking of the fragments may prevent the success of the manoeuvre, which, moreover, for obvious reasons, must fail in partial or impacted fractures. In fracture of either condyle of the femur or humerus, or in frac- ture of an apophysis, the surgeon must try to grasp the fragment firmly and move it in the direction of the plane of fracture. It is sometimes possible to give a fragment a tipping or see-saw motion ; thus, by pressing the tip of the external malleolus inward, when the fibula has been broken just above the ankle, the upper end of the lower fragment may sometimes be felt to move outward. In this manipulation the sliding of the skin is liable to be mistaken for movement of the bone, and should be guarded against by pressing the fingers toward each other so as to relax the skin between them. Crepitus. This is the sound produced, or the sensation communi- cated to the hand of the surgeon, by the friction of the fragments of a broken bone against each other, [t is as pathognomonic of fracture as is abnormal mobility, and these two signs usually eoexist. The sensation is not the same in all cases; it may be the sharp click of two hard points or edges, or a dull, muffled contact, or the crackling and grating of multiple fragments and broad surfaces. Some ot' its forms 54 FRACTURES. are practically identical with the friction sounds obtained by the move- ment of joints whose surfaces are altered by disease, and although it- is usual to speak of a recognizable difference in the quality of these sen- sations, the one being called hard or rough, the other soft or smooth, the diagnosis in cases of doubt must depend upon circumstances other than this difference. Crepitus is perceived through the hand rather than the ear, although sometimes it is audible to bystanders not in contact with the patient. It is to be sought by the same methods as abnormal mobility, and also in the ribs and flat bones by placing the palm of the hand over the supposed seat of fracture and pressing gently in various directions. Direct auscultation is sometimes employed, especially in fracture of the ribs or sternum. Crepitus cannot always be produced when there is a fracture, for its production is conditioned upon the contact and, in a measure, the character, of the broken surfaces. If the fragments are completely separated, if a piece of muscle or fascia is interposed between them, or if they have become covered with granulations, their movements may not cause crepitus, and it is a common experience that the manipula- tion which produces it at one moment fails to produce it at the next. Auscultatory percussion, the stethoscope being moved from one frag- ment to the other while percussion is made upon the first, will some- times give a marked change in the sound as the line of fracture is crossed ; but it is rarely significant, except in cases in which the diag- nosis can be made by other means. Conditions giving rise to sensations that may be mistaken for crep- itus are : Roughness of neighboring joints, inflammation of the sheaths of tendons or of bursa?, and the crackling of coagulated blood. Roentgen Rays. — In obscure cases, in fractures of the small bones, and to determine details in those in the neighborhood of or directly involving joints, the z-rays may be of use and sometimes of great value. Errors of interpretation are, however, frequent. It must be borne in mind that the skiagram is the reproduction only of a shadow, and that the apparent modeling of the surface of the bone shown in it is the result of differences of opacity and is often misleading. The elements of the shadow are distorted by differences in the relative distances of the various parts from the plate and in the angle of the rays, and because of the absence of perspective these distances are not indicated. There are many elements of error in a skiagram, many possibilities of misinterpretation, which must be controlled by experience in the use of the rays and by digital examination of the part. I have recently seen a case clinically diagnosticated as fracture of the upper third of the femur, but the skiagram of which was thought by all to show a fracture at the base of the neck. The autopsy proved the correctness of the clinical opinion. The skiagraphic error was due to tilting of the upper fragment. An additional difficulty is caused in children by the per- meability of cartilage to the rays, in consequence of which large gaps corresponding to the cartilaginous epiphyses appear at the joints. Ex- cept for well-defined changes in outline of a single bone a skiagram can- not safely be taken as proof of all it seems to show, but needs to be in- terpreted by the aid of clinical findings and of considerable experience EARLY SYMPTOMS AND DIAGNOSIS. 55 in its use. Particularly, I think, do we need to be upon our guard against assuming that dark lines across spongy bone always indicate lines of fracture. Stereoscopic views are, of course, more trustworthy than single ones, but they are not often available. Subjective or Rational Symptoms. Loss of function of the limb or part involved is a common result of fracture, and is due either to mechanical causes, such as the breaking of the lever through which the muscles act, or to the inhibitory effect of pain or the fear of pain. As pain due to other causes may have the same effect, and as the loss after some fractures, even of the main bone of a limb, may be at first slight, the presence or the absence of the symptom is only suggestive, not indicative, of the presence or absence of fracture. In most cases of fracture of a long bone the limb is practically helpless, but from time to time we meet with patients who can move it with some freedom or who can walk with a broken ankle, leg, or even thigh. Pain, spontaneous or on pressure upon, or movement of, the broken bone, is a constant accompaniment of fracture. Spontaneous pain when the part is at rest is usually slight, not distinctly limited to the seat of injury, and not significant ; but localized pain on pressure, on movement of the bone, and on pressing the fragments together is a valuable symptom, and in some cases the most positive one that can be obtained, and sufficient in itself for a diagnosis. It is to be sought for by pressure with the tip of the finger along the line of the bone, by pressing one end of the bone toward the other, or, more rarely, by gentle lateral or rotatory movements communicated to the lower por- tion of the limb while the upper is fixed, or by making the patient contract a muscle attached to the bone while its movement is opposed, as in fracture of the calcaneum or olecranon. It is of great diagnostic importance in absence of the positive signs, and is therefore specially valuable in many fractures near the end of a bone and in those of the metacarpals and metatarsals and ribs, and its absence is often a positive means of excluding fracture. The absence of pain on handling an important fracture, such as one of the leg or thigh, deserves attention as possibly indicative of central nervous disease or of commencing delirium tremens. The history, with reference to diagnosis, includes earlier injuries which may have modified the form of the limb, the nature of the accident, and the manner in which the force was applied, the interference with function, and occasionally the snap heard at the time and the distortion of the limb observed. A knowledge of the manner in which the vio- lence was applied is sometimes of value in determining obscure points, and, in the absence of positive information, indications may be gathered from the position of contusions or of stains made by contact with the ground. The account given by the patient must always be received with distrust, because of his preoccupation by other circumstances at the moment of the accident and of the tendency to substitute inference for observation. Such are the facts upon which the diagnosis is made. They are not 56 FRACTURES. all present in every case, and it is never necessary to seek for them all ; deformity, abnormal mobility, and crepitus are alone absolutely pathognomonic, but in not a few fractures none of these can be recog- nized by manipulations that are not unduly severe, and the diagnosis must be made upon the history and localized pain. It is important that this should be borne in mind, for many a fracture has been over- looked because crepitus could not be got. The character of the injury is sometimes so apparent that it can be recognized at a glance ; in others so obscure that even the most careful and experienced observer may remain in doubt. In most cases the examination should be made systematically and thoroughly, beginning with the history and follow- ing with an investigation of the interference with function, the pain, the deformity, and the abnormal mobility and crepitus in that order. The clothing should be removed from the injured part, and in doubt- ful cases also from the opposite limb. After having noted such changes in appearance as are easily recognizable, the surgeon makes gentle press- ure with his fingers along the limb in search of the point of maximum tenderness and of irregularity of outline if the bone is subcutaneous, and when that has been found he seeks evidence of abnormal mobility at that point by one of the manipulations above mentioned. If the search is successful the diagnosis is made. If not, or if the injury is at a point where abnormal mobility is not recognizable, the surgeon seeks for such deformity as is likely to exist after such a fracture as is suspected, first inquiring whether the region has been previously injured, in order that he may not mistake an old deformity for a fresh one, and the pain of a sprain for that of a fracture. If neither abnormal mobility nor deformity can be recognized he tests for local pain by pressure in the long axis of the bone or by the action of attached muscles, and accepts pain thus aroused as indicative of the presence of a variety of fracture which may not give the signs that are lacking. If doubt still remains as to the existence of a fracture, and if the search for signs is hampered by the pain that the necessary manipula- tions cause, or if, a fracture having been proved, it is necessary to determine its details, he employs an anaesthetic after having made his preparations to utilize the anaesthesia for the reduction of displacements and the application of a dressing, or he resorts to the .T-rays. The compound character of a fracture is easily determined. In fractures by indirect violence the wound in the skin, close to the seat of fracture, is usually small and bleeds much more freely than a simple wound of the skin would ; in fractures by direct violence the tegu- mentary wound is usually large and ragged, and the broken ends of the bones can be seen or felt through it. It is not necessary positively to determine the existence of direct communication between the frac- ture and the external wound; the coexistence of the two is sufficient to make imperative the employment of every precaution against infec- tion that would be called for if such communication were known to exist. If the wound is explored at all, it should be done only as a part of the treatment, and with strict asepsis, not merely as a diagnos- tic measure. CHAPTER V. THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. Anatomo-pathological Processes. The Callus. Bone is one of those tissues whose cicatrices are com- posed of a substance closely resembling, or identical with, the original tissue. The process of repair after fracture is fundamentally the same as that after other forms of injury, and its histological phenomena, like those of repair of other tissues, are those of normal growth and exaggerated nutrition. It begins with the enlargement and multipli- cation of the cells of the periosteum, marrow, Haversian canals, and lacunae; this multiplication produces a mass of granulations which fill the gap between the fragments and are transformed into bone, some- times directly, sometimes after having passed through a cartilaginous stage. This mass of new bone, at first spongy in its structure — that is, composed of irregular lamellae or plates circumscribing relatively large lacunae filled with bloodvessels and medullary elements — becomes firmer and more compact in some portions by increase in thickness of the lamella and consequent reduction in size of the lacunae — the pro- cess known as " condensing osteitis," and observed constantly in the foetus as well as in many pathological conditions — and becomes thinner and weaker in other portions until it finally disappears by the con- verse process, diminution of the lamellae through their absorption by the medullary elements of the lacunae, " rarefying osteitis," another stage of productive or simple osteitis and also found in the normal development of bone and in pathological conditions. The variations depend upon differences in the degree of the injury or in the position of the fragments, which require disproportionate amounts of work to be done by the different parts. The details of the process will appear upon examination of the manner in which it is carried on after simple fracture of the shaft of a long bone, an example which has the advan- tage of illustrating the behavior of all the different elements and of being both more complete and more open to experimental study than fractures of short bones or of the spongy extremities of long ones. When a fracture takes place the cylindrical shell is broken along an irregular line and probably always with the production of splinters of greater or less size. The periosteum is usually torn, but the extent of its rupture has probably been largely overestimated even when there is much displacement of the fragments. Oilier 1 was the first to call especial attention to the preservation of its continuity at some part of the periphery of the bone and to the fact that when a lateral or longi- tudinal displacement has occurred the membrane is stripped partly 1 Oilier: Traite do la Regeneration des Os. 58 FRACTURES. off one fragment, but without having its continuity broken, and thus forms a band uniting the two fragments. To this band he gave the name of " periosteal bridge." Other portions, also, which do not preserve their continuity with the rest, are doubtless stripped off the fragments, as can be seen in compound fractures, and as tliey are structurally continuous with the overlying soft parts they probably come quite accurately into place when the displacement is corrected, and thus form a fairly complete tubular sheath connecting the ends of the fragments and all splinters except those which are entirely loose, guiding and limiting the formation of the new tissue that is to establish the ultimate union. When this sheath is not complete, because of persisting displacement, the existence of the periosteal bridge is of extreme importance, because it maintains the connection between the fragments by means of a tissue whose activity in the pro- duction of bone is marked. The position and form of the callus in specimens of union with displacement indicate clearly the position and agency of the bridge, and Plate III. shows the ossification on the inner surface of the bridge, but not complete throughout the interval between it and the surface of the bone. At the same time blood is poured out from the torn vessels of the bone into the gap between the fragments and from the vessels of the soft parts into the interstices among the muscles. This blood is grad- ually absorbed during the first few days following the receipt of the injury, and at the same time the effects of the traumatism are mani- fested in the inflammatory oedema of the limb and the infiltration of a thick viscid liquid into the soft tissues immediately adjoining the seat of the fracture, the beginning of the firm ovoid mass which can always be felt at this point. The periosteum becomes much thicker, softer, and more vascular ; a thin layer of gelatinous or viscid liquid is found between it and the bone for a distance of a few lines from the edge of the fracture or from the point to which the membrane has been stripped up, and at the more distant limit of this layer the sur- face of the bone promptly become roughened by the formation of patches of new bone. The portions of the periosteum which have been stripped off, those which form complete or incomplete bridges, and the lacerated tissues which form the wall of the cavity in which the ends of the bone lie, granulate and pour out an exudate to mingle with the remaining blood. The marrow T shares in this production of granulations, and the cells of the connective tissue external to the periosteum share for a greater or less distance in the irritation, and by their proliferation bind to- gether all the adjoining parts in one firm, compact mass. The com- pact layer of bone, the cylindrical shell of the shaft, feels the same influence and reacts in the same manner, but much more slowly in consequence of the scantiness of its cellular elements. Its outer and broken surfaces soon show pink points which enlarge and send out granulations to join those already produced by the periosteum and marrow, and thus there is formed between the separated fragments a bond of union which is actually continuous, almost from the beginning, with all their constituent parts. The size and character of this bond vary THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. Fig. 25. with the degree of displacement ; if the fragments remain nearly in their original relations to each other, the bond is short and sym- metrical, the granulations springing from the marrow meet and unite in the centre of the gap, while the thickened periosteum passes from one fragment directly to the other, remaining adherent to them or separated only by a layer of effused blood. If lateral displace- ment occurs and persists, the bond passes obliquely from the outer surface of one fragment to that of the other, and is much more complete at some points of the periphery than at others. Thus, in Fig. 25, which represents the condition on the seventh day, the firmest union is by the cartilaginous band crossing the angle at b and formed apparently by the thick- ening of a periosteal bridge. On the opposite side of the lower fragment the beginning of an incomplete band of similar structure is seen. The formative action thus begun is rapidly carried on, and principally by the periosteum and marrow. When the fragments are kept end to end an ovoid mass of tissue, having the consistency of jelly and a pearly white appear- ance, and continuous above and below with the periosteum, envelops them, the so-called " pro- visional " or " ensheathing " callus. This mass is formed not solely by granulations springing from the under side of the periosteum, but also by the thickening of that membrane and of the connective tissue on the outer side, including that which surrounds the adjoining muscular bundles, and according to Cornil and Coudray, 1 even the cells of the sarcolemma. Composed at first of embryonal elements, it soon becomes cartilaginous in the portions formed by the per- iosteum ; then lime salts are deposited at dif- ferent points within it, and finally it is transformed into bone. The granulations that spring from the marrow ossify without passing through the cartilaginous stage, and the process here apparently begins at the fine lamellae which lie upon the inner side of the compact shell. The new lamellae extend across the canal, soon occluding it entirely, and also out into the interval to meet those coming from the other fragment. Thus is formed the internal or medullary plug. The granulations occupying the annular interval between the cortical layers of the two fragments (when the reduction is complete) apparently come mainly from the periosteum and pass through a cartilaginous stage before becoming bone, as do the others that have the same origin. They unite promptly with those of the medullary ping and ultimately (sometimes after a long delay) with the cortical layer. It was to this part of the callus that Dupuytren gave the name of " definitive callus." The cause of the delay in union with the cortical layer lies in the slow- ness with which the latter forms the granulations necessary to unite with the others, and doubtless to the occasional long persistence o\' a 1 Cornil and Coudray. Revue de Chir., 24th year, No, 7. Tibia of rabbit. Seventh day : a, blood ; b, cartilag- inous callus ; c, muscles. (GURLT.) 60 FRACTURES. necrotic scale of bone on its broken surface, which has to be slowly penetrated and absorbed by the granulations. The cellular elements of the cortex, which have to do the work of enlarging the Haversian canals and forming the granulations, are scanty, and those immediately adjoining the broken surface cannot share in the work because" their blood-supply is cut off by the clotting of the blood in the torn capil- laries. The cells situated a little more deeply have to carry on the work and slowly break through the intermediate necrotic scale before they can meet and unite with the other granulations that have spread into the interval from without and within. This process in the com- pact tissue is the usual rarefying osteitis, characterized by an enlarge- ment of the Haversian canals and a corresponding loss of the bone tissue, a change, in short, which transforms the cortex for a certain distance into spongy tissue like that of the ossifying callus. Ulti- mately the rarefaction ceases and a " productive" or "condensing" osteitis follows, by which the lamella? are thickened and the interme- diate spaces and canals contracted until the former proportions between them are measurably restored. Occasionally the ossification spreads into ligaments and tendons attached to the bone close by the fracture. While the callus is thus forming and ossifying, the irritation in the adjoining soft parts subsides, and they regain their original condition and functions more or less completely. Occasionally the associated injuries of muscles or tendons or the sheaths of the latter lead to per- manent disabling adhesions. After the ossification of the callus has been completed the excess on its exterior and even projecting portions of fragments slowly disap- pear, and in cases in which the reduction of the displacements has been exact this disappearance of the exterior callus may go so far as to leave little or no trace on the surface of its previous existence. In like manner the central plug diminishes and the medullary canal may be restored. Fragments of the cortical layer broken off at the time of the injury may remain attached to the periosteum, preserve their vitality, share in the same processes, and form a part, often an important one, of the callus. There is reason to believe also that even after they have been entirely detached they may form new connections with the soft parts and granulations, and preserve (or renew) their life. Such fragments have been found embedded so deeply in a callus that no other expla- nation than that of complete detachment can well be accepted. How- ship describes and figures one, and Gurlt another and remarkable one (Fig. 26). The possibility of this preservation has also been estab- lished by experiment upon animals. Portions of the shaft have been chiselled off, separated entirely from the soft parts, and replaced in contact with the bone ; examination after the lapse of some weeks showed re-establishment of vascular connection. It is also known that fragments may long remain without vascular connection embedded in a callus as well-tolerated foreign bodies. After the lapse of months, or even years, and from unknown causes, they may cause irritation ; an abscess forms, the bone softens about them, and either they are cast out spontaneously or they remain, provoking an interminable suppuration, until removed. THE REPAIR OE FRACTURES AND THE CLINICAL COURSE. 61 Fig. 26. It occasionally happens that the callus does not ossify, and in some very exceptional cases the bone is entirely absorbed for a considerable distance on each side of the seat of fracture. The causes are not fully understood. The difference in the process consists in an entire or partial absence of productive osteitis and in an excess of the rarefying osteitis. The latter, I am convinced, is favored by the presence of a metallic suture in the bone. When the fracture is compound, and remains so, the details of the reparative process are dif- ferent to this extent: that the callus does not pass through the preliminary cartilaginous stage at any point where suppuration has occurred. The formation of the medullary plug is not affected, the granulations there being transformed directly into bone as they are in simple fractures; the difference is in the external or ensheathing callus. The reason of this difference, as shown by experiment, 1 lies in the destruction of the periosteum by the suppurative process, in the destruction, that is, of the only tissue whose granulations pass through the cartilaginous stage in forming the callus. The process is slower than after a simple frac- ture because the suppuration of the wound delays or prevents the formation of much of the exter- nal callus and throws most of the labor upon the bone itself, which, as has been shown, is the least able to do it. It is easy to watch the process. The ends of the bone are seen lying bare and ,..., , n • i i Fracture of the neck of white in the wound; a mass of pink granulations the femur and of the shaft. forms at the limit of the denudation and ad- Aspiinter 5 inches long and vances slowly across the bared surface ; the nearly 1 inch wide > com ' bi n> ' n ,. . . ,i posed of the cortical layer, roken surface remains for a time quiescent, then has been turned completely granulations spring from it, beginning at the about its long axis and be- points nearest the medullary canal and spreading come united, with its orig- slowly toward the outer edge ; the wound gradu- ^1^^° ally fills up with these granulations, the bone is ments. (Figured by Gurlt covered in, and cicatrization follows. from the Museum of the In less fortunate cases a portion of the bared 2 03 ? 1 CoUege of Surgeons, i t t • on i r i n - r- England, No. 454.) bone dies and is cast oft by the formation of a line of demarcation which can sometimes be seen at the edge of the granulations, but which more commonly is hidden by them. It must not be thought that all the bare white bone seen in such a wound is dead, even after it has remained unchanged in appearance for several weeks. Its surface may, indeed, be dead, but the interior is often alive and able to cast off the dead superficial scale without aid. The granulations which form between the living and the dead parts seem 1 Eigal and Vignal : Comptes-Kendus do 1' Academic des Sciences, L880, vol. xc. \\ 1218. 62 FRACTURES. sometimes to dissolve and absorb the latter if they are small and thin, or, if not, slowly to bear them to the surface and cast them out. The callus thus formed is larger and more irregular than after simple fracture ; it remains tender and sensitive for a long time, and is covered by an adherent scar at the seat of the wound. Fragments formed at the time of the accident and remaining attached to the peri- osteum usually preserve their vitality ; if not, they become detached after a time and are found loose in the wound, or become shut in by the callus and prolong the suppuration indefinitely. In this latter case the constant irritation due to the presence of the foreign body, the exist- ence of sinuses, and the burrowing of the pus interfere with the evolu- tion of the callus. Instead of undergoing a gradual and uniform diminution and condensation, it becomes eburnated at some points and entirely absorbed at others, irregular prominences appear on its surface or follow the lines of attached tendons and fascia?, and its interior is occupied by cavities of various sizes usually suppurating and in com- munication with the exterior. In the spongy bones and the spongy ends of the long bones less of the work of repair is done by the periosteum and more by the bone itself, for the periosteum is so interrupted by attached tendons and ligaments that it is less freely stripped up, and the bone surfaces are broadly in contact and, being spongy, are ready at once to form gran- ulations without preliminary rarefaction. In fractures involving joint-surfaces the absence of periosteum and other soft tissues on the articular surface prevents the formation of an external callus on that side, and union takes place by granulations arising directly from the fractured surfaces and by an external callus at the extra-articular parts of the fracture. The line of the fracture on the articular surface is marked by the absence of cartilage over it, and usually by a groove. The fracture of the cartilage does not heal by the formation of new cartilage ; usually the callus is covered at this point by a firm white layer of fibrous tissue, but sometimes the bone is bare. In exceptional cases the callus is exuberant and grows out beyond the level of the cartilage, forming an irregular mass in place of the usual groove. Fracture of cartilage (costal cartilage, larynx, etc.) is repaired partly by a fibrous, rarely a cartilaginous, band between the fragments, and partly by a bony peripheral callus. (See Chapter XVI.) Exuberance of the callus, both external and intermediate, is a fre- quent cause of diminution of the functions of the joint by destroying the normal relations of the articular surfaces, by filling up normal depressions, and by creating abnormal prominences. These results are usually beyond the control of the surgeon, and the latter are most common in the young, whose power of producing bone is greatest. Occasionally the productive process excited by the fracture extends far beyond the limits of the latter, and not only may the joint itself be obliterated by fusion of the bones which constitute it, but the process may also spread to and produce the same result in neighboring joints as in the case represented in Fig. 27. Bones which lie parallel and close to each other, as those of the fore- THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 63 arm and leg and the ribs, may become united by an exuberant callus when either one or both are broken. This consolidation is most likely to occur when both bones are broken at the same level, and when dis- placement of one or more of the fragments diminishes the normal inter- val between them. The mass of granulations developed about one fracture becomes continuous with that developed about the other, and ossification follows. The presence of an interosseous membrane favors this result, for this tissue has the same tendency to ossify that is shown Fig. 21 Fig. 2£ Bony anchylosis of the foot and ankle after fracture of the leg. (Gurlt.) Absorption of the neck of the femur after fracture. by other white fibrous tissue in the presence of a productive osteitis. The effect of this consolidation is, of course, to prevent independent motion of the two bones, and while of no importance in the leg and of little, if any, in the ribs, it produces a very serious disability in the forearm by abolishing pronation and supination. It occasionally happens, when two bones are broken at the same level, that the calluses grow into contact with each other but do not unite. Their adjoining surfaces are smooth and together form a sort of lateral joint which may allow movement of one upon the other. When the line of fracture follows that of a still existing epiphyseal cartilage, either wholly or in part, and the fragments arc not displaced. union apparently takes place as readily as after simple fracture, but nothing poskive is known of the details oi' the process. The injury does not necessarily interfere with the subsequent growth of the bone : the layer of cartilage may remain unossitied and perform its functions 64 FRACTURES. as before ; but it is known from the results of experiments upon ani- mals, and from cases of inflammatory disease and from some of trau- matic separation without displacement, that the effect of irritation of the epiphyseal cartilage is sometimes to hasten its ossification, and thus arrest the growth of the limb. This last result must certainly be pro- duced when the epiphysis is dislocated by the fracture and is not restored to its place. Finally, failure of union after fracture may be due to arrest of the reparative process in the granulation stage, ossification not taking place and the bond between the fragments remaining fibrous, or to the wide separation of the fragments, or to the interposition of a bundle of muscular tissue, or to the insufficiency of the blood-supply of one of the fragments. This condition, especially as seen after fracture of Fig. 29. Fracture of the olecranon : fibrous union. (Malgaigne.) the shaft of a long bone, is considered in detail in Chapter VIII., Pseudarthrosis. Examples at other points than the shaft are furnished especially by the patella and olecranon (direct longitudinal separation), and by some fractures of the neck of the femur where the cause lies in an excess of the rarefying process, by which the neck is destroyed, or in the cutting off of the blood-supply by complete rupture of the periosteum of the neck which carries vessels to the head. Clinical Course. This varies with the position and character of the fracture and espe- cially with the complications arising from the peculiarties of the fracture and the health and age of the patient. Ordinarily, in simple cases, after the primary reaction of the injury has subsided and an appropriate treatment has been established, the patient goes on to recovery without pain, fever, or other disturbance of his general health, and incommoded only by the disability of the limb and the confinement to which he is subjected. But in the alcoholic this tran- quil course may be promptly interrupted by the onset of a pneumonia or an attack of delirium tremens; and in the old, confined to bed by a broken thigh or leg, the primary shock may be sufficient to cause death in the first few days, or the general health may begin to suffer about the third week, and death follow after a short interval marked by symptoms of hypostatic pneumonia or mild delirium and gradual failing of the strength. And very, very rarely, even in simple cases THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 65 and without the slightest warning, death may come suddenly in the first few days by fat embolism of the lungs, or at a later period by a car- diac pulmonary embolus detached from a thrombus in some large vein. For the first day or two the patient may suffer pain at and near the fracture, augmented by muscular twitchings, and considerable discom- fort from the weight and tension of the swollen limb ; and if the bone is a large one (thigh, leg, arm) and the fright and emotion at the time of the accident extreme, the symptoms of shock may be well marked. The temperature usually shows a rise of from one to two degrees Fahrenheit, " aseptic" fever, which promptly diminishes, and disap- pears within a few days. At the same time the urine may contain a small amount of albumin and free fat and hyaline casts enclosing brown granules. The fat, which is sometimes sufficient to form a dis- tinct layer on the surface after standing, is thought to come from the crushed marrow of the bone, and the variations in its quality and the time of appearance to depend upon its temporary arrest in the pulmo- nary capillaries (fat embolism, q. v.). The brown casts are sometimes very numerous, but more often are wholly lacking. Bernadi 1 has shown that a leucoeytosis, more marked in the young than in adults, appears in a day or two and reaches its maximum in ten or fifteen days. The eosinophils first diminish, then increase rapidly in cases that do well ; their increasing diminution is an unfavor- able sign and suggests grave complications. The limb swells, partly because of extravasated blood and shorten- ing, but mainly by oedema; the swelling reaches its maximum on the second or third day and then slowly subsides. The skin of the involved region shows a yellowish tinge, the result of staining with the coloring matter of the extravasated blood, and ecchymoses appear at points below and sometimes above the fracture. Larger or smaller blebs appear, especially on the legs, by the second or third day, and may interfere with the early application of a fixed dressing. As the swelling subsides a firm ovoid mass becomes recognizable, extending above and below the fracture, and the sensitiveness on pressure diminishes; this mass diminishes in size and increases in firm- ness as time passes, the abnormal mobility diminishes, and finallv, after a length of time which varies greatly in different cases, ceases, and union is then effected, although not so firm as it will ultimately become after ossification shall have been completed. A small, hard mass can still be felt at the seat of fracture which will slowly diminish for months, perhaps for years. Other things being equal, and bone for bone, less time is required to complete repair in children than in adults ; and fractures heal as rapidly in one sex as in the other, and in the old as rapidly as in the middle-aged. As a general rule, too, the larger the bone the longer the time required, and fractures of the shaft require more time than those of the spongy ends, and those with uncorrected displacement more than those in which the normal relations have been maintained or restored. The average for fractures of the shaft of the long bones 'Bernadi: Alcime modificazioni nel sangue del f'ratturati. Pisa, 1907. Abst in Zentralblatt fur Chir. 1908, p. 1421. 5 6(3 FRACTURES. in adults varies from four weeks for the clavicle or forearm to eight or nine weeks for the thigh. But with the union of the fracture the recovery of the patient, espe- cially after fractures of the limbs, is not yet complete. The circula- tion of the part, the skin, the muscles, and the neighboring joints have yet to recover from the disabilities imposed upon them by the primary injury or by the prolonged disuse of the limb. The skin is harsh and dry; the limb swells and shows venous congestion when used, and especially when dependent, presumably because of plugging of the veins and possibly because of rupture of lymphatic channels ; the joints are swollen, stiff, and sensitive. As a rule, all these features disappear under use, and more rapidly in the young than in the old, but occasionally some of them persist for a long time. The course of the case, as thus sketched, may be greatly modified by exceptional severity of the injury, by associated lesions, or by a wound or contusion which makes the fracture compound either immediately or after the lapse of a few T days. In the severe cases, with more splin- tering of the bone and laceration of the soft parts, the pain, swelling, and general and local reaction are greater and more prolonged, but very rarely end in suppuration. The direct implication of a joint in a fracture, or the spread to it of the neighboring reaction, or the presence of a concomitant sprain, as is so often seen at the knee in fractures of the thigh, adds an arthritis which increases the pain and discomfort, and may delay recovery or diminish its completeness. In compound fractures with a small, clean wound it has seemed to me that the local and general reaction is even less than in simple fracture, presumably because the extravasated blood escapes through the wound, with consequently less tension and less absorption of fibrin-ferments to cause fever. Under appropriate treatment such a wound heals in a few days, and the course is thenceforth that of a simple fracture. In compound fractures with bruising of the skin that prevents pri- mary union of the wound, and in those made compound by the slough- ing of the bruised skin, the course may be very different. It is that of a deep, lacerated wound, from whose walls sloughs must be cast off, and in which suppuration is inevitable and serious infection possible. In the milder forms the suppuration is slight and limited to the super- ficial portions of the Avound, and the course is practically that of a simple fracture with only the delay due to tardier union of the bone and cicatrization of the wound. But in the severer forms all the local and general symptoms are more marked, the swelling is greater, the fever higher and persistent. If treatment fails to overcome the infec- tion the pus burrows amid the muscles, neighboring abscesses form, with chills and exacerbation of the fever, and amputation may be indi- cated to save the imperiled life. Or, by counter-openings, drainage, and the free use of antiseptics, the suppuration may be brought under control, and then the patient pursues his weary course toward conva- lescence through the pains and perils of the slow casting off of necrotic fragments of the bone and the tardy formation and ossification of the granulations that must take their place. Such cases are often despair- THE REPAIR OF FRACTURES AND THE CLINICAL COURSE. 07 ingly slow in reaching solid union and closure of the sinuses, and still longer in regaining use of the limb. The callus is large, the cicatrix adherent and sensitive, the adjoining muscles hampered by adhesions. The condensation of the callus is liable to become extreme in portions, because of the prolongation of the irritation, and thereby to cause par- tial necroses which prolong or renew the suppuration in the efforts to cast them out, so that the sinuses may persist intermittently for years with longer or shorter interruptions. CHAPTER VI. COMPLICATIONS AND REMOTE CONSEQUENCES. Early Local Complications : Skin, bloodvessels, gangrene, degeneration of mus- cles, suppuration. Early General Complications : Septicaemia, fat embolism, delirium tremens, tetanus, pneumonia. Late Local Complications : Excess- ive painful callus, tumor, injury of nerve, weak callus, arrest or exaggeration of growth, stiffness of joints, atrophy, thrombosis, and embolism. These may be local or general, and the complications may be the direct and immediate result of the primary violence or the later result of the primary lesions, of infection, or of constitutional conditions. Some are peculiar to fractures, others may arise also in connection with other forms of injury. Early Local Complications. Skin. The sharp point of the upper main fragment may be forced through the overlying muscles and fascia and perforate the skin or become engaged in its deeper layers in such a way that its reduction is difficult, or it may make such pressure upon the unbroken skin that the latter will slough at the point of pressure in the course of a feAV days. The first condition may sometimes be corrected by traction upon the lower segment of the limb, but usually an incision will be neces- sary to effect a complete reduction of the displacement. If perforation has taken place the opening should be at once enlarged, for this does not add to the chance of infection, and greatly simplifies reduction. Pressure upon the unbroken skin must be relieved by reduction, or at least by diminution of the displacement ; and if this is not possible the bone should be exposed by incision and the projecting portion cut away, for such a wound can be so protected that it will heal promptly, while one made by sloughing will surely suppurate, and even if danger- ous infection thereby of the seat of fracture is avoided, yet the wound will be slow to heal, and will leave an adherent and possibly sensitive scar. The sloughing of the skin contused by the primary violence is rare except in connection with compound fracture — that is, violence which is sufficient to kill the skin generally breaks it. Theoretically, it would be well immediately to remove all skin and other tissues that have been thus killed, in order more surely to avoid infection ; but the limits of such destruction cannot be determined with sufficient accu- racy. A fairly accurate estimate of the probability of sloughing and its extent can be made by applying a rubber bandage tightly to the limb for a few minutes, as in producing artificial ischaemia for opera- COMPLICATIONS AND REMOTE CONSEQUENCES. 69 tion, and noting the areas which do not share in the blush following its removal. This test is fairly accurate except for areas of skin on the distal side of long transverse wounds ; such generally remain pale, even if viable. The failure of blood to flow on minute puncture of the skin is also a fairly accurate indication of its death. Bloodvessels. Rupture or serious bruising of the main vessels of a limb is a serious but infrequent complication. Among the more impor- tant vessels that have been thus injured in simple fracture are the mid- dle meningeal and carotid arteries in fractures of the skull, the sub- clavian vein and artery, and the acromial branch of the acromio-thoracic artery in fractures of the clavicle, the brachial and axillary artery in fractures of the humerus, the popliteal artery and vein in those of the lower end of the femur, and the anterior tibial in those of the leg. In compound fractures the same vessels and also those lying at a greater distance from the bone may be injured. The rupture of an artery in a simple fracture may lead to fatal hemorrhage, even if the vessel is a small one, in case the blood can escape into a large natural cavity, as in a unique case of fatal hemor- rhage following rupture of a small branch of an intercostal artery after fracture of a rib ; l but in a limb it leads either to the formation of a traumatic aneurism or to gangrene. The rupture may be immediate or it may occur after a few days by sloughing of the bruised vessel. The symptoms are a rapidly increasing local swelling, which pulsates after it has ceased to increase, and (in. the case of the main artery) absence of the pulse in its distal branches. Gangrene is more directly due to interference with the venous flow by the pressure of the swelling than to loss of arterial supply, and consequently appears in the " moist" form, characterized by swelling, duskiness, and coolness of the limb. The object of early treatment is to check the hemorrhage and favor the venous flow by elevation of the limb, possibly combined with digital pressure upon the main trunk or with snug bandaging from the lower end of the limb to a point well above the injury. If a well- defined aneurism forms it may be treated, after union of the fracture has taken place or is well advanced, by proximal or local ligature of the artery. Possibly, if gangrene threatened, the limb might be saved by a free incision through which the escaped blood could be turned out, thus relieving the pressure on the veins, and by tying the artery. In compound fractures the diagnosis is made by the profuseness and arterial character of the bleeding ; and the treatment is to tie the artery at the point of injury. But it not infrequently happens that after complete rupture of arteries as large even as the femoral the hemor- rhage promptly ceases spontaneously. Bleeding from a torn vein is more persistent and often profuse. Rupture of a large vein cannot be certainly recognized in a simple fracture, and its treatment is controlled by that of the gangrene which it may cause. In compound fractures the vessels may sometimes he seen and tied, but probably the associated lesions will be such that amputation will be indicated. Thrombosis of an artery, and doubtless also of a vein, maybe caused 1 London Medical Times and Gazette, I860, ii.. p. (507. 70 FRACTURES. by the direct violence which causes a fracture. I have seen examples in the arteries of the arm and leg broken by the passage of a wheel, the condition being found on examination of the limb after amputation because of gangrene, and others have been reported. Thrombosis of a vein may be caused by the pressure of a displaced fragment. A case involving the femoral vein and ending in gangrene and amputa- tion is reported in the Deutsche med. Wochenschrift, June 8, 1892, p. 549. Gangrene may be local or general : the former the result of crushing of the skin and other soft parts in direct fracture, the latter the result of injury to or compression of the vessels or of tight bandaging. Local gangrene is manifested by the darkening and hardening of an area of skin surrounded by an inflammatory zone ; the swelling and fever are more marked and persistent, and when the dry patch is split or cut away an abundant thin, pink or dark, and offensive exudate escapes from beneath it and from the adjoining subcutaneous and inter- muscular planes. The infection must be combatted by free removal of the dead and dying tissues, irrigation, and drainage. The danger of general infection is great, and amputation is often required to save life. Gangrene of the limbs is usually of the moist form and begins with coolness and discoloration of the toes or fingers, the latter beginning as a deep-red color, and soon changing to purple and grayish-black. Dark blebs may appear on the surface, or the epidermis may be exten- sively but slightly raised by a thin, dark serum. If taken in time, and if the cause can be removed, as in tight bandaging, the life of the part may be preserved, and I have thought that keeping the limb in hot water (100° to 102° F.) was helpful ; but the vitality of the skin is greater than that of the muscles, so that even if the circulation returns in the former the muscles may yet disintegrate and the limb be lost. I saw this result in a case of fracture of the olecranon which had been treated by the immediate application of a pi aster- of- Paris dressing. The patient entered the hospital on the fifth day, with the uncovered hand black and swollen ; the dressing was removed, and the limb placed in a hot bath. Two days later circulation was re-estab- lished in the skin of the hand and forearm, but a week later incisions had to be made in the forearm, through which the muscles appeared wholly disorganized and diffluent. It must be borne in mind that even a narrow circular constriction, as by a band of adhesive plaster, is sufficient to produce this disastrous result, and is, perhaps, even more likely to do so than an equally tight bandage covering the limb. Consequently the longitudinal strips of plaster used in making traction should not be reinforced by the circular strips which are sometimes applied with the idea of keeping the former more securely in place. Degeneration and contraction of the muscles, the result of arrested blood-supply by bandaging or injury to the arteries, is occasionally seen ; it is a lower grade of the change mentioned in the preceding section. Volkmann, who first described it, gave it the name of " ischemic con- traction." It is most frequently seen in the forearm after fracture of the radius and ulna or supracondylar fracture of the humerus and is COMPLICATIONS AND REMOTE CONSEQUENCES. 71 marked by atrophy and shortening of the muscles, the fingers being permanently flexed. This change is brought about by rapid degenera- tion of the muscular fibres and subsequent reactive increase and con- traction of the connective tissue. It is to be distinguished from similar contractures due to nerve injury or disease by its prompt appearance. In the less severe cases something may be gained by massage, electricity, and persistent efforts to straighten the fingers. Hildebrand, 1 who had noticed signs of involvement of the nerves, obtained partial relief in 3 cases by removing the nerve trunks from among the shrunken mus- cles and lodging them between the fascia and the skin. Kleinschmidt and Hoffa 2 got good results by excising about an inch of the radius and ulna, thus giving the flexor muscles adequate length. Suppuration in simple fractures is very rare, and when it occurs it appears to be due to auto-infection, by germs carried by the blood and possibly brought from some suppurating focus in a distant portion of the body, as a furuncle ; rough handling of the broken limb and neglect of proper care apparently favor its occurrence. It promptly makes the fracture compound by spontaneous or surgical opening, and the course and prognosis are then those of an open infected fracture. Suppuration in compound fractures can generally be prevented or restricted to the superficial layers when the wound is small and its edges not contused, as is ordinarily the case in fractures by indirect violence. The later its appearance, the less likely is it to spread widely among the muscles and endanger life. In compound fracture with bruising and extensive laceration, sup- puration may remain as a local complication, the pus escaping freely to the exterior and the infection not spreading; the graver cases will be considered in the following section. Early General Complications. Septicaemia. This grave complication occurs in compound fractures and in simple ones followed by gangrene of the limb or suppuration at the seat of fracture. The most prompt, rapid, and fatal forms are seen in compound fractures accompanied by much bruising and lacera- tion of the soft parts and in those patients whose vitality has been lowered by alcoholism, disease, or age. A dusky-brown tinge discolors the skin about the wound and spreads rapidly upward, especially on the sides and back of the limb ; the torn muscles become gray and less moist, an offensive odor appears and grows rapidly more marked, and a thin offensive discharge escapes at the surface of the wound and can be pressed out from its recesses. The limb swells far above the fracture, the temperature rises, the patient becomes apathetic and slightly delirious. Occasionally pressure with the fingers upon the discolored skin provokes the slight crackle of emphysema, evidence of decomposition with production of gas, and. if well marked, strongly suggestive of the presence of one of the most rapidly fatal infections known, that of the " vibrion septique " of Pasteur, or the bacillus capsulatus aerogenes (Welch), the germ of acute gangrenous septicaemia. Amputation alone, with vigorous disinfection of the stump ami of 1 Hildebrand : Saninilung klin. Vortrage, 1906. Chir. No. 122, 'Kleinschmidt and Hoffa : Zentralblatt fur Clur., 1907, p, 81, 72 FRACTURES. the subcutaneous tissue throughout the discolored area, can save life, and that only in so small a proportion of the cases that no one can be blamed for declining to resort to it. The peroxide of hydrogen appears to be a valuable antiseptic in these cases ; it can be forced under the skin with a syringe or through incisions which will serve also for drainage. The germ is anaerobic. I have known only two in which the septic vibrio was present to recover ; in a few cases in which the early symptoms indicated its presence I have changed the diagnosis because the patient did not fail so rapidly as I anticipated, and in every such case culture tests have shown its absence. Air which occasionally makes its way through the wound into the adjoining cellular tissue must not be mistaken for the gas of this decomposition. In the less acute cases septic infection follows the establishment of suppuration and is less marked locally and generally. The limb swells and becomes discolored, but the color is a dusky red and its area is limited ; the swelling is more like the common inflammatory bogginess, and incisions into it give exit to pus or inflammatory serum which has not the odor of decomposition. Such processes may be arrested by free incisions, drainage, and antiseptics ; but complete recovery is long delayed by necrosis of the ends of the fragments. Fat Embolism. As has been stated in Chapter III., free fat can fre- quently be found in the urine during the first two or three days after fracture. It is reasonable to suppose that it comes from the lacerated marrow, entering the circulation either directly through the torn and gaping veins of the bone or through the lymphatics. When thus taken up in considerable quantities it may be arrested in the pul- monary capillaries or, after having passed through those, in the capil- laries of the systemic circulation, and occasion serious symptoms or even death. Although the subject has been studied by several, by observation and experiment, since Von Recklinghausen first noted it in 1884 as a cause of death by plugging the pulmonary capillaries, its symptomatology is not at all clear, presumably because it is masked by the functional disturbances created by its interference with the circulation in various organs, notably the brain. There is even reason to think that it has something, perhaps much, to do in some cases with the phenomena classed as shock, with delirium tremens, which is so much more common after fractures than after other injuries, and with the pulmonary oedema and early pneumonias of the alcoholic and aged. The pathological conditions revealed on autopsy are oedema of the lungs and extensive plugging of the pulmonary capillaries, and sometimes even of the arterioles, with free fat, similar but less ex- tensive plugging of the systemic capillaries, often marked by small hemorrhages, and sometimes extensive filling of the renal glomeruli. The local reaction is that of the beginning of infarction, and probably in the cases which survive it is arrested by the prompt forcing of the fat through the capillaries and the re-establishment of the circulation. Since the emboli are not septic the element of infection does not enter into the case, and death is due to the mechanical interference with the nutrition and functions of the parts involved. COMPLICATIONS AND UEMOTE CONSEQUENCES. 73 The symptoms in well-defined cases confirmed by autopsy have begun within twenty-four hours after the injury, rarely after two or three days, and usually with quickening of the respiration that some- times become marked dyspnoea; undiminished resonance of the chest and abundant, coarse rales ; little or no fever ; face at first pale, then cyanotic ; unconsciousness followed, and death within a few hours. In other cases the central nervous symptoms have been the most prominent : unconsciousness, noisy and slow breathing, muscular twitching, and even convulsions, and sometimes paralyses. Most tragical are those cases, fortunately very rare, in which the complica- tion proves rapidly fatal in a young and healthy patient after a simple, comparatively unimportant fracture, such as a Pott's at the ankle, with which the idea of danger to life is not associated. Treatment is apparently almost powerless to help ; the indications are to prevent further crushing of the marrow by immobilization of the limb, to stimulate the heart, and to aid the respiration by inhala- tions of oxygen when dyspnoea is present. Delirium tremens is a not infrequent complication of fracture in hos- pital cases. The course is less severe and the prognosis better than in cases not excited by traumatism. Its occurrence appears to be favored not only by the traumatism, but also by the withdrawal of the customary stimulant which usually follows admission to a hospital, and I have found it advisable, therefore, as routine practice to give alcohol in moderate quantities during the first week to those injured who are habitual, even if not excessive, drinkers. The attack begins with restlessness and sleeplessness, and when fully developed presents the usual symptoms. In addition to alcohol, sedatives are indicated, together with cathartics and a light, nutritious diet. Usually the attack subsides after one good night's rest has been obtained. Tetanus is a rare complication, almost unknown in simple fractures and much more frequent in compound fractures of the hand and fingers than in those of other bones. Excluding those of the hand and fingers, I have seen it only in one fracture of the femur (gunshot) and in two of the forearm (compound). Although the microbic nature of the disease has been established, it is noteworthy that many of the attacks are preceded by a sudden fall in the temperature of the air. One of my cases developed after such a fall, and on the same day two cases occurred in two other hospitals in the city. Pneumonia, developing on the second or third day, is a rather fre- quent and dangerous complication. Reference has been made to its possible origin in fat embolism of the lungs. It begins more fre- quently without a chill than with one, and, in our hospital cases at least, is likely to run a rapid, severe course, with high fever and delirium, often terminating fatally in three or four days. Pneumonia appears also as a late complication in the old and feeble. beginning insidiously, and pursuing an asthenic course, with moderate fever and mild delirium, and ending usually in unconsciousness and death. Prolonged recumbency is thought to favor its occurrence by promoting venous congestion of the lungs, but it appears to me to be rather a relatively unimportant incident in a general failing ol' the 74 FRACTURES. strength which is usually manifest a few days before the signs of con- solidation appear, and to which the death appears to be due quite as much as to the pneumonia. I have learned to look for this change especially in fractures of the neck of the femur in the old and feeble. Late Local Complications. The callus may be excessive, painful, or weak, or may become the seat of a sarcoma. A callus may be unusually large, " exuberant," either because the fragments remain widely displaced during repair, or because ossification extends far beyond the usual limits, or because the presence of a necrotic fragment maintains irritation and delays the termination of the productive process. The first variety is not prop- erly to be termed a complication, for the size of the callus is necessary to firm union. The second is seen especially in the neighborhood of joints, as the result of the persistent displacement of a fragment, or of ossification of muscular attachments, ligaments, or capsule in the old, or of exaggerated productive actiyity of the periosteum in the young. The third is rather common after compound fractures that have sup- purated. Fig. 30. Fig. 31. Intra-articular fracture of the lower end Exuberant callus ; fracture of lower end of the humerus, with exuberant callus, of humerus, especially in front. Enlargement near a joint may mechanically restrict its range of motion, and at other points it may, in like manner, interfere with the action of a muscle or make disabling pressure upon a nerve or inter- fere with the venous circulation in the limb. An exuberant callus may, and usually does, diminish in size, but not sufficiently to remove marked obstacles to function. Such removal can be effected only by surgical measures, the cutting away of the exuberant mass ; local applications made to the surface with the object COMPLICATIONS AND REMOTE CONSEQUENCES. 75 of promoting its aosorption are useless. The same pressure -effects can be produced by persistent displacement of the fragments, and it is not always possible to determine, previous to operation, whether the offending mass is a fragment or the callus. Painfulness of the callus may begin early in the course of repair and persist long after union has become complete, or it may begin after an interval, sometimes a very long one. Many patients com- plain of dull pain in the limb for months, even for years, after the injury, especially after prolonged use and in connection with changes in the weather, but the cases in which the pain is limited to the callus are rare. The late form, that in which the pain begins after an in- terval, is clearly inflammatory, the inflammation being generally a recurrence in an old suppurative focus, manifesting itself by fever, swelling, and tenderness, and relieved by spontaneous or surgical evacuation of the pus. The early continuous form is not inflammatory, but the causes are not always clear. The pain has been attributed to pressure upon a nerve either without or within the callus, to a neuritis set up by in- jury of a nerve at the time of the accident, as is seen also after wounds involving only the soft parts, and to a supposed persistent osteitis or an osteo-neuralgia (Gosselin) the cause of which is equally conjectural. The pain may be continuous or intermittent, and exacerbated at night or by change in the weather. It must be distinguished from pain due to injury of, or pressure upon, a nerve. Counter-irritation on the surface has given relief, and I should think that in the rebellious cases it might be advisable to incise the perios- teum or to cut into or chisel away the bone. The development of a tumor, sarcoma, at the site of a healed frac- ture, within a few weeks or after an interval of several years, has been occasionally observed, and apparently belongs in the same etiological group as that of sarcomata following other injuries of bone or soft tissues. Still rarer is the development of carcinoma after fracture in those who have or have had a carcinoma at another point. Pearce Gould (Lancet, April 25, 1896) refers to one such case, fracture of the humerus in a lady whose breast had been removed for carcinoma five years previously ; he explored very carefully by operation, without finding any sign of tumor; "two months later an extensive growth had appeared at the seat of fracture." Associated Injury of a Nerve. A nerve may be bruised or completely ruptured at the time of the accident, or it may become stretched over the edge of a fragment or by the growing callus, or compressed within a more or less complete canal formed about it by the callus or by cica- tricial tissue developed in the soft parts. Primary rupture of a motor nerve is liable to be overlooked at first, because of the withdrawal o'i the limb from use in consequence of the fracture, but it is not prob- able that the resultant delay diminishes the chance of successfully uniting the divided portions by operation, and on some accounts the operation is more free from risk if not undertaken until after the frac- ture has become united. The diagnosis of rupture cannot always be safely made on immediate paralysis of the muscles supplied by the 76 FRACTURES. nerve. I once operated upon a ease of supposed rupture of the musculo-spiral nerve in connection with fracture of the shaft of the humerus, and found the nerve untorn and apparently uninjured for some distance above and below the fracture. It must also not be hastily assumed that an operation to reunite the nerve has failed ; in two cases (musculo-spiral nerve) I have seen function return after nearly a year had elapsed since the operation. The compression of a nerve by a displaced fragment may abolish its functions or may excite a neuritis manifested by modifications of sensi- bility and sometimes by great pain ; similar effects may be produced by a coincident contusion of the nerve. The most frequent examples are in fractures above the elbow and above and below the knee ; occa- sionally it is seen in fractures of the clavicle, upper end of the humerus, and pelvis. Similar compression may be made by the callus upon a nerve which crosses or passes through it. Of late years a number of such cases have been operated upon, and various gross changes noted in the nerve, which is usually reduced in size for a greater or less distance below and shows a notable enlargement just above the point of pressure. The treatment consists in the removal of the corresponding portion of the bone or callus, and this should be done freely. I have thought it advisable in some cases to interpose a strip of periosteum or other soft tissue between the nerve and the cut surface of the bone in order Fig. 32. Inclusion and compression of the musculo-spiral nerve in a callus. A in 2 shows a bony bridge crossing the nerve, and in 1 shows the surface left by its removal. The dotted area shows the surface left after the cutting away of the sides of the bony gutter. to diminish the probability of the nerve becoming included in adherent and possibly compressing cicatrix. » firm COMPLICATIONS AND REMOTE CONSEQUENCES. 77 Weakness of the callus, which should not be confounded with delay in consolidation, is manifested in two ways : by its yielding under use of the limb after union, as judged by the usual tests, has appeared to be complete, and by a later loss of its strength under the influence of intercurrent local or general causes; the latter is also termed softening or absorption of the callus, and in either case, if fracture occurs, it is termed secondary fracture. The weakness may be due to insuffi- ciency in the amount of the callus, as when a gap has been created between the principal fragments by their displacement or by loss of bone, or in the ossification of the bond uniting the fragments. In either case the bony bridge uniting the fragments is not strong enough to bear the strain of use, and it either breaks completely or yields enough to permit an angular displacement. Softening of the callus under the influence of a general disease — e. g., scurvy, typhoid fever, erysipelas — has been observed in a few cases, sometimes after the lapse of many months. Clarke, quoted in the Traite de Chirurgie, reported a case in which the softening ap- peared to be the result of overwork in school. The callus has been felt to diminish in size, and abnormal mobility to reappear without the intervention of any violence. Secondary, or u iterative," fracture without apparent defect or change in the callus is a not infrequent accident due to premature use of the limb or to slight external violence. Gosselin tells of a man twenty-five years old who broke his femur six times in twenty months ; the fractures occurred in the second week after he began to walk and in consequence of a slight effort, as in dancing, running, and trying to avoid a fall ; each time the patient had left his bed on the forty-fifth day. The symptoms are those of primary fracture, but usually less marked. Arrest of growth of the bone is occasionally observed in the young after fracture at or near the epiphyseal cartilage. (See Separation of the Epiphyses, Chapter II.) Exaggeration of growth of the bone after fracture has been observed in a very few cases, in consequence either of stimulation of the epi- physeal cartilage to greater activity or of exaggerated production of bone at the fracture. Cases have been reported in which a consider- able shortening noted immediately after recovery has disappeared in the course of a year or two. There is usually room in such cases ful- some doubt of the accuracy of the observation. Enlargement of the patella after close reunion by operation has been observed in a number of cases, both in breadth and length. Stiffness of the joints of the injured limb is habitually seen after fracture, and involves not only those of which the broken bone forms part but also those at a distance from it, especially on the distal side. It is most marked in the old and rheumatic and in joints directly in- volved in the fracture or coineidently sprained. It appears promptly after the accident, is most marked when the splints are removed (unless measures have meanwhile been taken to relieve it), and in most eases disappears slowly under use of the limb. If a joint is involved in the fracture, or otherwise injured at the moment oi' the 78 FRACTURES. accident, a traumatic arthritis may follow and the resultant stiffness may be permanent ; and in the old and rheumatic more or less limita- tion of motion may remain even when the joint has not been directly injured. The causes of the stiffness, exclusive of direct injury of the joint, are to be found in injury of the muscles, oedema, and shortening and loss of elasticity in the peri-articular tissues, sometimes because of their implication in the irritative reaction following the injury, and sometimes because of the enforced quiet. This stiffness may be per- manent, in whole or in part, when the periarticular tissues are perma- nently shortened by cicatricial change, or when a muscle moving the joint has undergone marked fibrous cicatricial change or has become abnormally attached to the callus. This is more common in compound fractures that have suppurated than after simple fracture. Stiffness of the knee and ankle after fracture of the thigh, of the elbow after fracture of the arm, and of the wrist and fingers after fracture of the forearm is constant and often very persistent. It is relieved by measures which diminish the oedema and improve the circulation, and these may some- times be employed before consolidation of the fracture is complete : such are massage, passive motion, and position. The fingers stiffen, and sometimes very rebelliously, under immobilization, and especially when kept fully extended. The rule should therefore be, in all injuries of the upper extremities, to leave them free of the dressings whenever that is possible and to instruct the patient to move them frequently ; when they must be confined the position of flexion for the fingers and abduction for the thumb is to be preferred. Persistent active and passive motion of the joints within their ex- isting range, massage and hot and cold douching will usually increase the range and freedom rapidly ; in the young and young adults little time will be lost by simply trusting to the natural use of the limb to restore its functions. Patients should be encouraged to disregard pain following use which does not leave the joint tender the next day. Limitation of motion due to displaced fragments or overgrowth of callus can be relieved, if at all, only by operation. Atrophy of the Muscles. A limb that has long been withdrawn from use because of fracture appears smaller above the seat of the injury, and also below it if the oedema has disappeared. Advantage has been taken of the death of a few patients at this perio 1 to weigli their muscles, and they have been found distinctly, and in some cases notably, smaller than those of the opposite limb, the loss involving all and not merely those of some group supplied by a nerve that might have been injured. In the young and in young adults the loss is soon made good, but in others and in cases of long duration the atrophy may persist for months or even be permanent. Various explanations have been offered, such as lack of use, occlusion in fixed dressings, diversion of nutritive materials to form the callus, and reflex trophic disturbances from injured nerve branches, but none is free from serious objections. Massage, electricity, and systematic exercise are the measures employed to hasten or effect recovery. Thrombosis of the Veins and Embolism. Thrombosis of some of the COMPLICATIONS AND REMOTE CONSEQUENCES 70 larger veins in the neighborhood of a fracture is thought to be rather common and to be the cause of the oedema and venous congestion which are so constant and troublesome after fracture of the lower limb when the patient begins to walk. Occasionally, but very rarely, the process occupies or extends into a vein sufficiently large to furnish an embolus which is carried to the heart or, more commonly, through it into the pulmonary artery, and causes death. Virchow published in 1846 such a case following fracture of the neck of the femur, and Durodie" l collected eight other cases in which the deaths occurred be- tween the sixteenth and fifty-seventh days. One fracture was of the femur, the others of the leg. Wilde 2 reported two cases and collected five others; and Smirnow 8 reported one and collected thirty-seven reported cases. The symptoms are the usual ones of pulmonary embolism : sudden onset, with lividity or pallor, dyspnoea, precordial distress, and death in a few minutes. Arteries. Traumatic aneurysm is a rare complication. H. Meyer 4 collected sixty reported cases and added one of an intercostal artery after fracture of a rib. Thrombosis of an artery, because of coincident bruising, is more common. 1 Durodie : Etude sur les Thromboses et l'Embolie veineuses dans les Contusions et les Fractures, These de Paris, 1874, No. 326. 2 Wilde : Centralb. fur Chir., 1902, p. 1349. 3 Smirnow: Ibid., 1903, p. 825. * Meyer : Inaug. Dissert., Kiel, 1903 ; Centralb. fur Chir., 1903, p. 819. CHAPTER VII. TREATMENT. Reduction. Retention : Removable Dressings, Permanent Dressings, Direct Fix- ation. Massage. Ambulatory Treatment. Management of Joints. Com- pound Fractures. Amputation. Compound Articular Fractures. General Treatment. Generally speaking, the treatment of a fracture should begin when the patient is first seen, but by this it is not meant that every indication should at once be met by appropriate measures ; even the correction of the displacement, the " setting" of the fracture, and the immobilization of the fragments may have to be left undone or in- complete because of conflicting and dominating conditions, such as extreme swelling, muscular spasm, or associated lesions. A delay of even several days is usually, in respect of these indications, of small importance, for the preparatory work in the bone and soft parts goes on notwithstanding it, and when finally the adjustment is made the condition differs but little from that which would have existed had it been made at the first. A much more important indication in most cases is to prevent addi- tional injury while the patient is being taken home or to hospital. The danger at this time is that by incautious handling, disordered movements, or injudicious attempts to use an injured limb a simple fracture may be made compound or additional laceration caused. This risk exists especially after fracture of the leg because a large ex- tent of the surface of the tibia lies immediately beneath the skin and the end of a fragment can easily be forced through it. The surgeon therefore will protect the limb by a temporary splint, when such pro- tection is needed, and the judicious layman will leave the patient undisturbed or will transport him recumbent. If the fracture is one which necessitates confinement to the bed, the bed should be narrow and high, and the mattress firm. A long, broad board may be placed beneath the latter if the spring mattress is soft. Specially constructed " fracture-beds," some of which are very ingen- iously arranged, are convenient, but not at all essential. A water-bed or air-bed is of the greatest value in the treatment of fractures of the spine in minimizing the formation and duration of bed-sores. The points to be considered and the indications to be followed by the surgeon called to treat a fracture vary greatly in different cases accord- ing to the bone or portion of bone involved, the complications that exist or are to be feared, and the age, the health, the habits, and even the social status of the patient. At one end of the long and varied series of problems which present themselves he lias only to 80 TREATMENT. 81 provide the simplest means to protect the patient from additinal in- jury or pain during the few days or weeks that are needed for repair; at the other the highest resources of his art are required to save life or limb or to preserve function. On the one hand, the fracture may be the sole thing to be considered, his attention must be unremittingly given to the position of the fragments and their maintenance in proper relations, and his skill and care will determine the character of the result ; on the other, his best endeavor may be powerless to affect the position of the fragments or modify the result, or the fracture, as in many of the base of the skull, may be a wholly unimportant and negligible incident beside the associated lesion. The indications for treatment arise, therefore, in varying degrees from the fracture itself, the associated lesions, and the immediate or late local or general effects upon the patient. Occasionally they con- flict, and the surgeon must then temporarily disregard some or he must even be content with a defective local result because an attempt to secure a better one would involve risks disproportionate to the advan- tage sought. Those directly concerned with the fracture are to cor- rect displacement of the fragments, if such displacement exists and if its correction is possible and advisable, and to oppose by appropriate means the action of those forces which might reproduce it, such as muscular action, swelling, and gravity. This correction of the dis- placement is termed the "reduction" or " setting" of the fracture. Reduction. Not every fresh fracture is accompanied by a displacement that needs to be corrected ; and of those in which such displacement exists, in not every one is reduction possible or advisable; and sometimes when reduction is both possible and advisable circumstances require that it should be delayed. Fractures without a displacement that needs to be corrected are many and varied, such as most simple fractures of the cranium, of the scapula, of the ribs, the ilium, the shaft of the fibula or ulna alone, and many of the metacarpal and metatarsal bones. Keduction is said to be impossible (although in most cases the better term would be inadvisable) when the opposing conditions are such that they cannot be overcome by the methods ordinarily in use, and when more efficient ones would involve overbalancing disadvantages or risks. The causes of this condition are varied ; among them may be mentioned the interlocking of the irregular ends of the main frag- ments, the interposition of soft parts or small fragments, and the small size and inaccessible position of a fragment, as in some articular frac- tures. When the fracture is of the shaft or subcutaneous end of a long bone the existence and character of the displacement are usually recognizable, but when one of the principal fragments is a part of the articular end of a long bone and is thickly covered by muscle or masked by swelling, not only the character but even the existence o( the displacement may be in doubt and remain so until after repair is far advanced. In such cases an exact diagnosis can be made ami 6 82 FRACTURES. reduction can generally be effected by the aid of an incision which exposes the seat of fracture, but although the probability that such an operation in experienced hands and under proper precautions would be followed by disaster is small, yet the evils of such a result, if it should follow, are usually so in excess of those resulting from the persistence of the displacement that the operation is rarely undertaken while the injury is recent, and then only because of the presence of some controlling condition or danger, such as pressure upon the skin or a main vessel or nerve that cannot otherwise be removed. In cases not thus complicated the w T orst that can follow after fracture of the shaft is failure of union or union with a disabling deformity, and both of these conditions may be relieved by a late operation. Nevertheless, displacements unrelievable by manipulation and likely to involve serious loss of function if not corrected, can occasionally be recog- nized, and in such cases reduction by open operation is called for. They are generally cases in which the limb has been greatly distorted at the time of the accident, so that the sharp end of a fragment has been driven into an adjoining muscle or through the enveloping fascia, or an obliquely broken fragment has been forced around to the opposite side of the other from which it has been broken. The first form is not uncommon in fractures of the lower end of the femur or in the neigh- borhood of thinly covered joints. From the admitted propriety of operative interference in such cases it is a long step to similar inter- ference in all, as has been urged ; and such generalization, if accepted, would, in my judgment, lead to disasters far more serious and numerous than the disadvantages that would follow failure to reduce the displace- ments. Ranzi l reports 4 severe infections in 50 operations and pro- tests against the generalization of reduction by operation, Tuffier, quoted by Bardenheuer, 3 in 22, Korte, 2 in 4. See also Fritz Konig 2 for a thoughtful study of the conditions justifying or forbidding operation, and a valuable paper on the late results after fracture of the femur by Ashhurst and Newell. 3 The reasons advanced by those who favor reduction by operation and mechanical fixation by suture or pins as a general practice are that by this means alone can complete reduction be made and maintained and failure of union certainly prevented. To this the reply may be made that failure of union is rare, and that in most cases it is due to a general cause and not to a local one which can be removed by operation, and that when such local cause exists the fact is usually apparent and is then a proper reason for operating. Further, that even if exact reduc- tion is made by operation the use of sutures or pins to maintain it is not only ineffectual but is also in itself objectionable, because it may cause delay and even failure of union by exaggerating the rarefactive process which precedes repair and delaying or preventing the productive osteitis which alone can complete it. The wire suture breaks or be- comes loose, pins loosen, so that for effective support during repair we 1 Ranzi: Arch, fur klin. Chir., vol. 80, pp. 567 and 843. * Konig : Ibid., vol. 76, p. 725. 3 Ashhurst and Newell : Annals of Surg., Nov. 1908. TREATMENT. 83 must still depend upon the same external means that are used when no operation is done. Irregularities in the union rarely cause any inter- ference with function, and diminish as time passes, especially in the young. Recent observations by Konig 1 have shown most remarkable corrections thus effected, within three or four years after the fracture, of displacements which would have been thought to ensure conspicuous deformity and disability. Finally, the additional injury to the peri- osteum, which is apparently inevitable in the exposure of the bone for drilling, delays union and facilitates later displacement ; and the injury done to the muscles, if the knife has to pass through them to expose the bone, is liable, perhaps likely, to restrict the mobility of the cor- responding joint through cicatricial change in the muscle or its attach- ment to the callus. It seems to me clear that operation should be reserved in fractures of the shaft for those cases in which it is clearly indicated by some marked and otherwise irreducible displacement, and that for the maintenance of reduction thus made reliance should be upon external support without metallic sutures or pins placed in the bone ; at the most, a temporary silk or an absorbable suture may be used. Most German surgeons appear to be against such generalization of oper- ation ; in England Lane, in France Tuffier, and in the United States Huntington, have written in favor of it. In articular fractures the conditions are different : the displacement if uncorrected may seriously compromise the usefulness of the joint, and but little if any relief is to be expected from a late operation. If anything is to be done it must be while the injury is still recent. I have taken this course in a considerable number of cases, and with- out ill result in any, but I am convinced it should be resorted to only after thorough study of the conditions and careful weighing of the probabilities. The risk of such primary interference by operation is, I think, less the more promptly it follows upon the receipt of the injury : if it is done within the first twenty-four hours the condition is practically that of an operation upon previously uninjured tissues, and the same confidence may be felt that primary union will be obtained, but if the third or fourth day has been reached and the tis- sues are swollen and infiltrated with extravasated blood the same con- fidence cannot be felt, and it is, I think, better to wait for the subsi- dence of the swelling and the absorption of the blood. Other conditions which make exact and immediate reduction inad- visable are crushing of the spongy tissue of the bone, extreme sub- fascial swelling of the broken limb, muscular spasm, and coincident injuries or other conditions which prevent the application of a dress- ing efficient to maintain the reduction when effected. Crushing of the spongy tissue is seen mainly in the old, at the upper end of the femur and humerus, at the lower end of the radius, and in the bodies of the vertebra\ The effect of this crushing is the same as the removal of a piece of the bone; if the fragments are restored to their original positions a gap corresponding to the amount of the 1 Konig-: Arch, fur klin. Chir., 1908, vol. S5, p. 187. 84 FRACTURES. crushing is created between them, which, if the position is maintained must be filled by the production of new bone, a task that may be beyond the power of the organism, and failure in which would lead to failure of union, a result much more disabling than the persistence of the deformity. Extreme subfascial swelling of an injured limb shortens it and in- creases its transverse diameter, because the capacity of the fascial sheath is greater the more nearly it approaches the globular form ; consequently forcible elongation of the limb with the object of cor- recting the shortening diminishes the capacity of the fascial sheath and increases its tension and the pressure upon its contents ; this resistance may be sufficient to maintain the shortening against any reasonable effort to overcome it, or to endanger the vitality of the limb by interference with the circulation. It is therefore necessary to await the subsidence of the swelling. Muscular spasm, excited by the trauma or by pain or the fear of pain, acts powerfully at first to fix the fragments in their faulty positions and especially to produce and maintain shortening of the limb. It usually disappears within a day or two, and can be tempo- rarily annulled by anaesthesia or a full dose of opium or by deep injec- tion at the fracture of J-l grain of cocaine in weak solution. Associated injuries or conditions which prevent or delay reduction may be general or local, such as profound shock due to the fracture or to other injuries, damage to the main vessels of the limb threaten- ing gangrene, and extensive wounds of the skin which would prevent the use of dressings to maintain reduction. In the absence of any of these contraindications the sooner the fracture is " set," the sooner the fragments are brought to and fixed in the positions they are expected to keep during repair, the better; for although the preparatory changes in the bone itself require several days, and in places even weeks, for their completion, yet the accessory processes in the soft parts begin immediately, and it is desirable that they should not be interrupted or undone by changes of place and relations. The thickening and infiltration of the parts adjoining the bone which appear so promptly give a steadily increasing fixity to the position of the fragments, and it is desirable that that position should as early as posible be made the permanent and final one, for although it can be changed without much difficulty and to a considerable extent in many fractures even two or three weeks after the receipt of the injury, yet the shift is necessarily accompanied by some loss of security and time. The actual reduction or setting of the fracture is in many cases a procedure guided only by general ideas, not by an exact and detailed knowledge of the peculiarities of the displacement to be overcome or even of the lines of fracture, and the extent to which the effort has been successful can only be surmised, not positively known. Such is notably the case in fracture of the shaft of a long bone thickly covered with muscle, as the femur. By eye, touch, and measurements the surgeon can recognize shortening, angular, rotatory, and perhaps even lateral displacement, and by traction and pressure he can straighten TREATMENT. 85 and lengthen the limb, but he cannot know whether or not the adjust- ment of the fragment is accurate and close. The same is measurably true even of many fractures of bones that are more or less subcuta- neous and palpable ; or if palpation shows some remaining irregularity of outline the best effort may be unavailing to correct it. This, however, does not make the result so much a matter of chance as the statement may seem to indicate ; the main factors of displacement at the different points are known, and the surgeon is safely guided by this knowledge in his choice and use of methods to make and main- tain reduction and of the attitude and support given to the limb while the fracture is healing, and is justified in awaiting the outcome with a confidence that is limited only by knowledge of the fact that in a certain proportion of cases, fortunately small, unknown and unknow- able factors may defeat efforts wisely conceived and faithfully ex- ecuted. The ideal is the complete restoration of form and function, but he must often be content to obtain, or even to seek, much less. These more or less necessary limitations will be mentioned in connec- tion with the results of the individual varieties of fracture. Since the principal causes of displacement after fracture of the shaft of a long bone are the tonic contraction of the attached muscles and the unsupported weight of the lower segment of the limb, reduction is commonly effected by bringing this lower segment into line with the upper one and making steady traction upon it in the direction of its long axis, the different joints being usually held in partial flexion in order that the attached muscles on either side may be correspond- ingly relaxed. Note must be taken, in fractures at certain points, of the known tendency of the upper segment to assume a certain attitude because of the unopposed action of the muscles attached to it, an atti- tude which is often but faintly indicated by the form of the limb if the fragment is short and thickly covered by muscle. Common ex- amples are furnished by fractures of the upper third of the femur and of the surgical neck of the humerus, in both of which the upper fragment may be markedly abducted, flexed, and rotated outward. The surgeon confidently places the lower segment in the corresponding attitude, even if he cannot detect the deviation of the upper one, for he knows that even if it does not exist the upper fragment will follow the movement he gives to the lower one, and the two pieces will be in line when he makes the traction designed to give the limb its proper length. While traction (and, if necessary, rotation of the lower segment) is made the surgeon makes lateral pressure to correct such lateral dis- placement as may remain, and seeks to discover and take advantage of such peculiarities of the line of fracture as may aid him to main- tain the position he gives the fragments. Thus, in a transverse frac- ture or in one with marked irregularities of outline the opposing ends may be so engaged with each other that the lower fragment will be held in place and kept from overriding, notwithstanding the pull of the muscles. If there is only an angular displacement, as in partial, subperiosteal, and some transverse fractures, traction is not needed, and the surgeon has only to correct the deviation by lateral pressure. 86 FRACTURES. In the partial fractures of adolescence this sometimes requires con- siderable force; the knee must be placed against the projecting angle and the ends drawn into line ; but usually it can be accomplished by the hands alone, the thumbs being placed against the angle while the fingers grasp the limb above and below it. A serious obstacle to reduction occasionally arises from the penetra- tion of the overlying muscle and fascia by the sharp end of one of the fragments, usually the upper one. This occurs most frequently in oblique fracture of the lower third of the femur, and can there be treated most effectively by flexing the hip and the knee to a right angle, thus drawing the relaxed quadriceps (which is the muscle com- monly penetrated) downward past the engaged end of the upper frag- ment, and, if necessary, completing the act by traction at the knee. This exemplifies the principles of treatment in all cases : relaxation of the muscle, if it crosses the proximal joint, and also the fascia by moving the limb toward the corresponding side ; drawing the muscle downward by bending the distal joint in the opposite direction ; and then lifting the lower segment of the limb bodily away from the upper fragment. If this or other appropriate manipulations fail, the frag- ment must be exposed by an incision and freed by direct means. If the fragment has perforated the skin also the opening should be at once enlarged and reduction guided and aided through it ; as the exter- nal wound exists, nothing is lost and much may be gained by freely using it for reduction, cleaning, and drainage. Whenever an anaesthetic is given it is prudent to protect the broken limb during its administration by temporary splints or the hands of an assistant in order that the lacerations may not be increased by the unconscious struggles of the patient. In some cases of fracture at the border of, or just within, the ex- panded spongy end of a bone, where the fragments are interlocked or impacted, as in some Colles' fractures at the lower end of the radius or in supracondyloid fracture of the lower end of the humerus in children, it is advisable to increase the irregular displacement as a first step, and forcibly to press the epiphyseal end downward away from the shaft so as to free it, and then, correcting the lateral displacement by pressure, to turn the fragment into line ; and sometimes the small epiphyseal fragment has to be moved forward and backward forcibly so as to break up the fine interlocking. Under similar circumstances the epiphyseal fragment can sometimes be brought into place by so changing the attitude at the corresponding joint as to make tense a portion of the capsule which is attached to it and then by continuing the movement to correct the displacement, or by making direct traction upon it through its ligaments. In some injuries — e. g., separation of the upper epiphysis of the humerus and Pott's fracture at the ankle — the character of the displacement is so constant that a formula of treatment is based upon these facts ; similar formula? have been made for injuries at other points, as the elbow and knee, but the lesions and displacements are there too varied to make TREATMENT. 87 routine treatment safe. At the shoulder the separated epiphysis is in anterior flexion and abd notion although the arm hangs by the side ; on raising and abducting the elbow the movement of the already flexed and abducted epiphysis is promptly arrested at the normal limit by the posterior portion of the capsule, and then the lower portion of the humerus is brought into line with it by continuing its movement in the same direction, and thus the angular displacement is corrected. At the elbow, after fracture of the internal condyle, the small fragment can be drawn down into place by full extension of the joint and abduction of the forearm ; and after supracondyloid fracture of the humerus full flexion of the elbow, by making tense the posterior portion of the cap- sule, enables the surgeon to correct an angular displacement of the lower fragment in which the apex of the angle is directed forward. Retention. The objects of retention are to prevent displacement of the frag- ments by the various agents that are competent to produce it, notably gravity and muscular contraction, to protect the limb from external violence during the progress of repair, and to prevent the pain that would be caused by movement of the fragments. The relative im- portance or urgency of these needs varies greatly in different cases, and this, together with the mechanical conditions, measurably deter- mines the choice of the method of treatment. Thus, in the fracture of a single long bone, such as the femur, where the weight of the limb and the action of the muscles are efficient and always ready to produce displacement, support equivalent to that destroyed by the injury must be supplied by apparatus; while in fractures of only one of two or more parallel bones, as of the fibula or of a rib, or in those of the flat or small spongy bones, or of an apophysis or condyle, only such a dressing is required as will moderate or prevent voluntary or involuntary contraction of attached muscles. The swelling of a limb which so promptly follows its fracture is an element of much importance because its variations affect the adjust- ment and fit of most dressings and because its appearance after the application of a dressing that envelops a limb may so interfere with the circulation as to cause gangrene of the limb or ischemic degeneration and contracture of the muscles. For these reasons it is frequently advisable to delay the application of an enveloping permanent dressing until after the swelling shall have notably subsided, and it should be the rule to make frequent examination of the fingers and toes during the first two or three days after the application of such a dressing, and to leave them uncovered by the dressing for the purpose of such exami- nation. The possibility of dangerous constriction is specially to be borne in mind in dressings which completely and closely encircle a limb and which are inelastic, such as plaster-of- Paris encasement or even a muslin roller-bandage applied directly to the surface without an inter- vening layer of cotton. Such a dressing snugly applied while the 88 FRACTURES. injury is recent will almost always become too tight and will have to be removed in a few hours either because of the pain which it causes or of the threatening strangulation of the tissues. This is true even when the injury is a comparatively slight one. I have seen gangrene of the hand and forearm follow the application of a gypsum dressing for fracture of the olecranon. A roller-bandage may be placed directly upon the limb below the fracture to restrain its swelling, but should not be carried as high as the fracture beneath the splints, except very loosely ; and when splints are used they should be broad enough to prevent circular constriction by the bandage which binds them in place. If plaster of Paris is used it should preferably be in the form of moulded splints, not complete encasement, or at least in a form which will permit the dressing to be loosened. It is a good rule also to remove a permanent dressing after ten or twelve days in order to detect and correct any displacement that may have taken place under it and to tighten or renew it to meet the shrinking of the limb. It is specially important that the possibility of constriction by the dressing should be guarded against whenever the injury is such that it may itself cause gangrene of the limb. A limb whose vitality has thus been put in doubt by the injury should be treated for the first few days with the primary object of favoring the impaired cir- culation and especially of avoiding the creation of any additional ob- stacle to the venous flow, and this not only for the advantage of the patient, but also for the protection of the surgeon against the suspicion or the charge that his dressings may have caused the gangrene. This disastrous result of injury is a fruitful source of suits for malpractice, and the defence that it was due to the injury and not to the treatment is usually viewed with so much suspicion that the surgeon should be watchful from the beginning of the case that the real cause should be clear. It must be remembered that in the great majority of cases the gangrene is of the moist form and due to interference with the venous flow, and that this interference may easily and rapidly be raised to a dangerous degree by circular constriction at even a single point. Cases differ far too widely in severity and local conditions to permit of a general rule of practice applicable to all. Many, in which the tendency to displacement is slight or easily controlled, may be treated in a permanent dressing from the beginning, one which gives the nec- essary support without danger of constriction, and can be left in place (or removed temporarily for inspection) for one, two, or three weeks. Others, more severe, such as most fractures of the femur, also receive a permanent dressing at the beginning because this dressing is mainly applied below the seat of fracture and does not expose to constriction by swelling. Others, such as most fractures of the leg, should rest in a temporary dressing, such as a Volkmann splint, for from five to ten days, unless permanent moulded splints that can be loosened are used. So, too, when the surface of the limb has been so torn or bruised that the wounds cannot be properly treated through an opening made for the purpose in a permanent dressing, and when damage to the TREATMENT. SO deeper parts forbids the use of any constriction or pressure. Under such circumstances the surgeon must be content to make such dressings as the associated injuries require and to leave the limb simply sup- ported upon the bed by pads or in splints loosely applied over the other dressings. Although the use of these temporary dressings may be necessarily prolonged for several weeks, it will be convenient and proper to describe them under that title. The presence of large blebs is sometimes an additional reason for delay, although they usually heal promptly under a protective dress- ing after puncture. If it is desired to leave the limb as undisturbed as possible, it is advisable thoroughly to clean and disinfect the ad- joining skin, cut away all the raised epidermis, cover the exposed sur- face with sterile rubber tissue or silver foil, and apply a gauze dressing. Temporary and Eemovable Dressings. The object of a temporary dressing is mainly to protect the patient against pain and additional injury by movement of the fragments during transport to his home or hospital, or to prevent displacement by the unsupported weight of the lower segment of the limb ; it is rarely efficient to prevent displacement by the action of the muscles when the character of the fracture is such that such displacement is possible. Side Splints. These are usually made of wood, but in case of need many other materials are available, such as card-board, stiff leather, iron, zinc, tin, even bundles of tightly-rolled straw. The wooden splint in its simplest form is a piece of soft wood of a length and breadth corresponding to those of the injured limb and thick enough not to bend under firm pressure. A thick layer of cotton or other soft material should be bound along the side which is to rest against the limb, and should be reinforced at needed points in order to fill depressions of the surface of the limb. Projecting points of bone should be protected by cotton placed around them, not upon them. While an assistant makes traction upon the lower segment of the limb the surgeon places the splints, one on each side, and binds them on with a roller-bandage, taking care that the turns support the limb throughout its entire length, but do not make circular compres- sion. The splints should be long enough to support the hand and foot respectively. A form in common hospital use is the thin bass- wood splint, the necessary rigidity being obtained by binding several together. Gooch's flexible wooden splint, which is made of narrow strips pasted together upon cloth on one side, is designed to adapt itself to the curve of the limb and thus give a more uniform support. It is rarely used. The carved splints sold in packages of assorted sizes have few if any points of superiority over those improvised for the occasion, for they also need to be fitted and padded. Tf it is desired to have a splint that more 4 nearly follows the contour of the limb an excellent one can be made with plaster of Paris (see below) or card-board or leather softened in water, and similar ones can also be used with ad- 90 TREATMENT. vantage over the dressings that are needed for associated wounds of the skin or compound fractures. Splints of wire that can be measurably modelled to the limb are con- venient ; they can be had from the instrument makers. Fig Petit's fracture-box. The fracture-box (Fig. 33) is a form of wooden splint once much used in fractures of the leg, but now almost wholly discarded for the following : Fig. 34. Volkmann's splint for leg. Volkmann's splint (Fig 34) is a shallow gutter and foot-piece, made in several lengths, and fitted with a movable support, by which the foot can be raised from the bed. For use it is thickly padded with cotton, and the leg is bound in it with a roller-bandage. Care must TREA TMENT. 91 Fig. 35. be taken that undue pressure is not made on the skin covering the front of the tibia by the bandage or on the heel or the tendo Achillis ; the latter pressure is best avoided by slinging the foot by means of a broad strip of adhesive plaster extending from the middle of the calf, under the heel and along the sole, to the top of the foot-piece, where it is made fast by a reversed piece attached to it and then to the lower surface of the metal. Gutters of galvanized wire or tin (Fig. 35) are much used for frac- tures of the humerus : they give more protection than short splints because they include the forearm. They can be readily made from sheets of wire gauze by taking a strip of suitable size and cutting it partly through at the angle, and tying together the meshes which over- lap where it is bent. When it is desired to cover the limb with dressings because of the presence of a wound of the skin or to make moderate uniform com- pression, or while waiting to learn the effect of the injury upon the vitality of the skin or the limb, a convenient method of applying them so that they can be readily and painlessly removed for adjustment or in- spection is in the form of the Scultetus bandage, a dressing which was formerly in wide use for retention. The dressings are cut in thick strips one-half longer than the circumference of the limb and three or four inches wide, and then arranged upon a piece of muslin a little longer than the part to be dressed in such a way that each overlaps its adjoining upper one by about an inch. The limb is then placed along the centre of the band- ages and each end of each of the latter, beginning with the lowest, turned over the front of the limb until it is entirely enveloped ; lateral support is given by splints rolled into the sides of the underlying strip of muslin and bound fast, or by other splints, or by placing the limb in a Yolkmann splint or a gutter. The front and sides of the limb can then be readily exposed by turning back the ends of the pieces of dressing. Instead of lateral, anterior or posterior splints may be used, either that they may be combined with suspension or that portions of the limb may be more conveniently exposed and dressed. Because of the importance of equally distributing the pressure, a posterior splint to be used with suspension should be accurately fitted to the limb ; consequently the moulded splints (plaster of Paris, gutta-percha, etc.. see below) are to be preferred. When they are sufficiently rigid the limb can be suspended by two or three bandages passed beneath and attached above to a suitable support. Wire gutter for the arm and forearm. 92 FRACTURES. Late iu the treatment of fracture of the femur one of the forms of hip-splints may be conveniently used. Anterior suspended splints may also be of the moulded kind, with included metal rings or loops for the attachment of the supporting cords, or some modification of Nathan R. Smith's anterior splint specially designed for the treatment of fractures of the femur. This Fig. 36. Suspended moulded splint for fracture of leg or lower part of femur. splint (Fig. 37) is made of two parallel iron rods, joined at the ends, and by two or three intermediate rods, bent slightly at the knee and sharply upward at each end to fit the foot and pelvis. It is placed along the anterior surface of the limb, which is attached to it by a Fig. 37. Nathan R. Smith's anterior splint. roller or by straps, suspended by cords. Its primary idea was, appar- ently, as a substitute for the double-inclined plane ; it has practically been abandoned for fracture of the thigh in its original form and method of use, and its place taken by modifications which combine traction TREATMENT. 93 with suspension. ( Vide infra.) When used, it should be less bent than as shown in Fig. 37, and the leg horizontal. Moulded splints are constructed of any material that can be made temporarily soft enough accurately to take the shape of the part to which it is fitted and which then becomes hard enough to retain the shape thus given to it. The materials most frequently used are plaster of Paris, pasteboard, leather, felt, and gutta-percha. Pasteboard is used by softening one or two strips of suitable size by immersion in hot water, and then moulding them to the limb by binding them on snugly with a roller-bandage. Temporary support must usually be given by other splints until the pasteboard has be- come hard by drying. When it is necessary to bend the pasteboard at a sharp angle cuts should be made in it in suitable directions and places and the overlapping portions stitched together. Leather and felt are prepared in the same manner. A material is made for this purpose of woven tissue soaked in shellac which can be softened by dry heat and hardens more rapidly than the others. Gutta-percha is used in strips one-sixteenth to one-eighth inch thick Fig. 38. Posterior gypsum splint or gutter. and is softened by immersion in hot water. The stickiness of the surface can be mitigated by covering it with muslin. Plaster-of-Paris, or gypsum, splints can be made of the prepared bandages or of some loose-meshed material soaked in plaster cream. If the prepared bandages are used they should be thoroughly wet in the usual way, squeezed out, and then rapidly unrolled back and forth to make a splint of the desired dimensions. From eight to fifteen layers are required to give the needed solidity. Plaster cream is pre- pared by sifting the dry plaster into water and then spreading the plaster thus moistened upon the selected material previously cut to suitable shape and wrung out. in water. The number of layers needed will depend upon the thickness of the material, and care must be taken thoroughly to work the plaster into them. The use of hot water or the addition of salt or zinc oxide to the water will hasten the setting. If the plaster has been long exposed to the air before 94 FRACTURES. use it should be dried in an oven ; otherwise the setting may be long delayed or even fail. Splints thus prepared can be made impervious to water by varnishing them or by pouring melted paraffin upon them. A strip of rubber tissue or oiled-silk carefully packed in at the exposed point will protect satisfactorily for several days from the discharge of a wound. Weight can be reduced, while preserving the strength, by inserting thin strips of metal or wood at places where the splint will not require much modelling to fit the limb. Splints of this kind are specially useful in fractures at the ankle, wrist, elbow, and arm, and not infrequently, such a temporary splint will remain efficient for two or three Aveeks. For fractures of the leg one of the splints should be posterior and broad enough to cover nearly half of the circumference of the limb ; a narrower anterior one may be used Fig. 39. with it, or a lateral one the lower end of which encircles the instep, or a bilateral one crossing below the instep like a stirrup. The posterior splint should pass along the sole and project about an inch beyond the toes so as to take the weight of the bed- clothing. They must be snugly moulded to the limb with a roller bandage, and the de- sired position of the fragments maintained by the hands or a suitable support until the plaster shall have set. If for any reason a posterior splint cannot be used, a strong broad anterior one may be substituted, and if suspension is desired the inclusion within it of a stout wire bent into loops at several points will facilitate it (Fig. 36). A form of bilateral moulded splint which I have found convenient in fractures of the leg as a substitute for the Volkmann splint during the first week, and, because of the ease with which it can be removed, even for the complete encasement in plaster of Paris which usually follows, is the following : Two pieces of muslin are cut to the shape shown in Fig. 39, and of a size to fit the limb, and stitched together along the median line. Then twelve or fifteen pieces of crinoline, or three or four of can- ton-flannel, each a little smaller than a lateral half of the first, are soaked in plaster cream and laid in each half of the first between its two layers, and the whole then bound smoothly to the limb with a roller-bandage. Swelling of the limb is met by loosening the band- age, and inspection is easy by turning down either lateral half, the line of stitching acting as a hinge. The additional trouble entailed in its preparation, as compared with the Volkmann splint and later encase- ment in plaster, is offset by the greater security and ease with which the patient can be moved during the first week, and the ease with which the dressing can be removed and the seat of fracture inspected so long as intercurrent displacement is possible and corrigible. Stocking or bivalve plaster splint. TREATMENT. 95 Permanent or Final Dressings. The dressings included under this title are those designed to main- tain the fragments in the relative positions given them until union is complete or, at least, far advanced. They are expected to give the pro- tection and quiet of the temporary dressings, and in addition to oppose, with as much efficiency as possible, shortening of the limb or angular displacement by muscular contraction or gravity. As has been said, the temporary dressings may sometimes be used equally well for the same purpose, and some of the permanent dressings, especially those making continuous traction, may be used from the beginning. A rule of practice which will save the surgeon an occasional and very disagreeable surprise and disappointment should be to examine about the end of the second week, and again later if the fragments are still movable, every fracture that has been covered by the dressing in order to detect and correct such displacement as may have occurred beneath it. This applies especially to fractures of the shaft of the long bones and to some articular fractures in which displacement is easy. Fig. 40. Encasement of leg in plaster of Paris. . Complete encasement in plaster of Paris (Fig. 40), occasionally advis- able, if carefully watched, even as a primary dressing, is most useful and efficient when applied after the swelling has subsided, and at still later stages in cases in which continuous traction has been used until union has become well advanced. Its mode of application is as fol- lows : The limb is raised by one or two assistants who make steady traction upon it in order to keep it straight and of full length, the sur- geon wraps it in a thin layer of cotton batting, preferably prepared in three-inch rollers, and then applies the plaster roller-bandages, thor- oughly wetted and wrung out in hot water, from below upward. The turns of the-first layer should be drawn just tight enough to keep their place, and the subsequent turns simply rolled over the first without increasing the pressure, taking care to model the dressings accurately to the prominences and depressions of the limb. When the dressing is complete the limb is lowered to rest, and proper support given it until the plaster is hardened. The dressing should extend far enough above and below the fracture to rest against such prominences of the skeleton or muscles as may be present and will act, after the plaster shall have set, to prevent movement of the limb within its ease. When such fixed points do not exist, as at the shoulder and hip, other mean- to prevent shortening must be used, usually some form ot' traction. 96 FRACTURES. The upper and lower ends should be so placed that their edges will not make irritating pressure directly against a diverging surface ; thus, for the forearm it should stop well short of the flexure of the elbow or should pass a short distance up the arm ; at the ankle it should stop short of or pass well forward on the dorsum of the foot ; on the inner side of the thigh it should not reach the perineum. The finger or toes should always be left uncovered and should be repeatedly inspected during the first two or three clays in order to detect any interference with the circulation. In the lack of plaster rollers the dressing can be made of any coarse material cut in suitable strips and soaked in plaster cream. If it is desired to have a small portion of the limb exposed, as for the dressing of a wound, a fenestra can be cut, and its edges protected with adhesive plaster, rubber tissue, or oiled silk. If a larger opening is required the splint must be reinforced by one or two curved iron m the dressing bands incorporated additional turns of a dressing has hardened, opening includes the (Fig. 41). Ochsner recommends very highl protection of the splint or, better, fastened to it by plaster roller after the main portion of the These are termed " fenestrated " or, if the entire circumference, "interrupted" splints a means devised by Croux for the gainst the discharges in compound* fractures. Fig. 41. Fenestrated plaster dressing. It consists of a thick solution of India-rubber in chloroform mixed with small pieces of lambs' wool ; this is poured in between the splint and the limb around the opening. Similar dressings can be made with silicate of soda or potash, starch, dextrin, or glue. The silicate and dextrin are used by thoroughly satu- rating roller-bandages with the material and applying them in the same manner as plaster bandages. They do not dry so rapidly as plaster, but are lighter and cleaner and not so liable to crumble at the edges. Silicate is frequently used for dressings of the hand and forearm. The edges of both silicate and plaster dressings can be advantageously protected against crumbling by covering them with adhesive plaster. TREATMENT. 97 The removal of one of these dressings is a tedious and troublesome task ; it can best be done by cutting lengthwise with a short, stout- bladed knife, aided in the case of plaster by moistening the dressing along the line of the division. The diminished resistance to the knife gives warning of the proximity of the skin, and the deepest layer and the underlying cotton should be cut with strong bandage scissors. The principal difficulty is in turning re-entrant angles, as at the front of the ankle or elbow. After the division has been completed the sides can be forcibly drawn back and the limb lifted out. In cases in which the absence of firm points of support makes a fixed dressing inefficient effectually to oppose the contraction of the muscles, as in most fractures of the thigh and many of the humerus, permanent moderate traction is employed to tire the muscles and obtain and maintain the desired length of the limb. For this purpose the partially unsupported weight of one segment of the limb may be utilized or a weight attached to the lower segment. Traction by Weight and Pulley, or Elastic Traction. This method is employed almost exclusively in the treatment of fractures of the thigh. Methods of treatment by continuous traction have long been in use, but the efficiency and comfort which now make the method so Fig. 42. Adhesive plaster and "spreader" for Buck's extension. popular date from the introduction about the year 1850 by the Ameri- can surgeons Sargent, Josiah Crosby, and Gurdon Buck of the use of adhesive plaster to attach the weight or screw to the limb. Previously the attachment was by bandages about the foot and ankle, and the pain and damage to the skin occasioned thereby were such that efficient traction could not be maintained. "Buck's Extension." (As for a fracture of the thigh.) Two strips of stout adhesive plaster, each four inches wide and long enough to reach from well above the knee to a little beyond the sole, are notched on each side at the junction of the lower and middle thirds for one- third their width, and the sides turned in, as shown in Fig. 42, so as completely to cover the adhesive surface of that portion. The sides of the remaining portion are obliquely notched at several points. A piece of wood, 5X3 inches, with a central hole, is then covered with adhesive plaster folded beyond the ends, as shown in Fig. 42. A third piece of adhesive plaster a yard long ami 2 inches wide is cut in two and the halves fastened together end to end by facing their terminal four or rive inches; it is attached to the hack oi' the calf, and brought along and well beyond the sole o\' the toot ; a roller-bandage 7 98 FRACTURES. is applied to the foot and lower third of the leg, the first two strips of plaster placed one on each side above it so that their folded por- tions extend below the ankle, and the roller carried over them. Unless the fracture is too low the roller and strips of plaster should be car- ried well above the knee. The ends of the plaster on the wooden "spreader" are then attached by pins or clamps to the free ends of the lateral plasters so that the " spreader " lies squarely across the sole a few inches below it. A cord is then passed through the hole in the " spreader " and secured by a knot. A Yolkmann's slicling-rest (Fig. 43) is then placed under the leg, the foot lightly swung from it by carrying the free end of the third Fig. 43. Volkmann's slicling-rest for fractures of the thigh. strip of plaster over its top and sticking it to its lower surface, and the leg secured to it by a roller. This cord is then carried over a pulley at the foot of the bed, and a weight of from ten to twenty pounds attached. Counter-extension is made by raising the foot of the bed about four inches. Coaptation splints about a foot long are bound about the thigh to give lateral support, or a molded plaster gutter is used, covering the posterior half of the thigh from the gluteal fold to the knee. Steinmann 1 makes traction by attaching the weight to two nails driven into the condyles of the femur, one on each side. Wilniis 2 after having 1 Steinmann: Ztlblatt, fur Chir., 1907, p. 938. 2 Wilms : Deutsche Zeitschrift, iiir Chir. Vol. 92, p. 260. TREATMENT. 99 attached twenty-five kilos during the first week and fifteen during the second, in this way found he had lengthened the limb more than an inch. This shows that heavier weights can be used in this way than by ad- hesive plaster, but it does not seem probable that the method will become popular. Wilmis 1 has recently employed this method in five fractures of the leg and three of the forearm. Becker 2 used in two cases a steel drill passed through the upper part of the condyles, from side to side ; he preferred this to nails, as less likely to split the bone or to work loose. Fig. 44. Hodgen's suspended splint. Hodgen's suspended splint (Fig. 44) is a modification which gives more freedom of motion and consequently more comfort to the patient. It consists of two parallel iron bars, slightly bent at the point corre- sponding to the knee and connected at the lower end by a straight bar and at the upper end by a curved one. The leg and thigh are placed between these bars and suspended from them by half a dozen bands, and the ends of the lateral pieces of plaster are attached to the lower cross-bar, care being taken that they do not press against the malleoli, or by the cord of the spreader of Buck's extension. Then the limb is raised from the bed by a cord, as shown in the figure, which should be attached to a support at least four feet (better more) above the bed and so placed that the cord is inclined fifteen to thirty degrees from the vertical, and shall thus tend constantly to draw the leg downward : this furnishes the traction, and by moving the point of support to the i Wilms: Ztlblatt, fur Chir., 1909, p. 79. * Becker : Ztlblatt, fur Chir., 1908, p. 1420. 100 FRACTURES. outer side the position of abduction of the thigh, which is usually desirable, can be readily obtained. Combined Suspension and Traction (Fig. 45). During the last two years I have used a combination of suspension by Hodgen's splint and traction by Buck's extension, which has given much satisfaction ; tlie patients are much more comfortable than with Buck's alone, and the traction is Fig. 45. Combined traction and suspension in fracture of the femur. more efficient and regular than with the Hodgen. Its application is shown in Fig. 45. The Buck's extension is applied in the usual way, and the Hodgen splint adjusted with vertical (not oblique) support. The pulley over which the Buck's cord passes should be at least twelve or eighteen inches distant from the patient's foot so that lateral shifts of his position shall not greatly change the line of traction. This can be easily effected, when necessary, by so binding the rod which carries the pulley to the bed in such a way that the pulley stands well out beyond the foot of the bed. Besides the greater comfort of the patient, this has the advan- tage of readily giving the flexion and abduction needed in high fractures of the femur, and of making coaptation pressure upon the ends of the fragments by means of the supporting bands. TREATMENT. J 01 The same method of traction is sometimes used in fractures of the thigh in connection with a long side splint, either with a weight and pulley or with an elastic cord on the side of the splint (Fig. 4s on pseudarthroses, 1871. For experimental study : Cornil and Coudray, Revue de Chir., 24th year, No. 7. 115 116 FRACTURES. than after simple fracture. According to Von Brims' s statistics delayed union occurs in about 1\ per cent, of fractures of the shaft of the bones of the limbs, and failure of union in about half of 1 per cent. Pathology. Although the anatomical conditions differ greatly in detail they may be conveniently classified in two groups, one, contain- ing most of the cases, in which the fragments are united end to end or laterally and more or less closely by fibrous tissue, and another, very rare, in which a distinct joint has formed between them. The varie- ties of the first form are very numerous, the variations depending upon the relative positions of the fragments, the extent of the preliminary rarefaction, the amount of fibrous tissue, and the presence or absence of a productive osteitis or partial ossification of the bond. In short, the process of repair in an}^ of the widely different forms imposed upon it by the character of the fracture and the displacement may be arrested at any period or may be continued unevenly but still incom- pletely at different points. Thus, the fragments may be in close ap- position and united by a short firm bond with only slight motion between them, or they may overlap in such a way that the surfaces of fracture are not apposed and the union is only by the thickened inter- posed connective tissue ; or the displaced end may be enlarged, with osteophytes extending into the fibrous bond and separate nodules of bone developed within it, needing only a slight additional ossification for complete bony union ; or the effect of the preliminary rarefaction of one or both fragments may not have been corrected by subsequent ossification, and they remain soft and spongy, or atrophied and pointed, and even this process of rarefaction may be so exaggerated as to create as distinct a gap between the fragments as if a piece had been removed or even to transform the entire shaft of the bone into a fibrous cord, or, as in a case of fracture at the lower end of the humerus reported by Machol, 1 to cause the disappearance of the epiphysis. Of the second form, the creation of a joint between the fragments, only a few examples have been recorded. They show, in more or less complete and distorted forms, joints with a fibrous capsule embedding cartilaginous or bony nodules, a cavity containing a synovia-like liquid, and the ends of the fragments rounded, eburnated, usually enlarged, sometimes smooth and polished and sometimes covered with a fibrous or even a cartilaginous lining. Etiology. Certain general conditions have been deemed a cause of delay or failure of union either through a specific poison, as in syphilis, or through a deterioration of the health or a lowering of the vitality induced by them, as pregnancy, lactation, defective nourishment, and acute diseases ; but it is beyond question that the causes are usually local and that the most common one is a faulty relation of the frag- ments to each other, including therein the interposition between them of muscular tissue. Others are defective innervation, disease of the bone, inflammation on the surface, and defective treatment, and in compound fracture the prolongation of suppuration and the existence of parcellary necrosis of the ends of the fragments. But it is also true that delay and even failure may occur when no local or general i Machol: Centralb. fur Chir., 1904, p. 1399. DELAYED, FAILURE, OB FAULTY UNION. 117 cause can be found, when the fragments are in exact apposition, and when the general condition is good. We know that the less the primary displacement, the more exact the reposition, and the more complete the immobilization, the less is the local reaction and the smaller the callus. It is possible, therefore, that the reaction — the hyperemia and the exaggeration of the local nutritive processes — may be too slight or too brief to complete repair, but this only throws the question further back, and we have yet to learn why the reaction is insufficient in one case and sufficient in others which are apparently identical. In a few compound fractures at the lower end of the leg and of the arm in which after a delay of two or three months I have exposed the fragments to remove a sequestrum or for readjustment, I have noticed that while the upper fragment was richly supplied with blood the lower one was pale and the granulations capping it soft and scanty. The appearance suggested that the loss of the blood usually supplied to the lower fragment by the nutrient artery might sometimes leave it too scantily supplied for active reparative work. Injury of the nutrient artery may then be one of the causes of delayed union. In the leg and in the forearm a condition occasionally exists which is not found where there is only a single bone. For example, the fibula unites, but the rarefactive process in the tibia is exaggerated and leaves the fragments separated by quite an interval occupied by granulations, and the ossification which follows is not active enough to extend entirely across it. If the bone were single it seems not unreasonable to sup- pose that the fragments would be brought nearer together and the intermediate granulations stimulated by the pressure caused by the contraction of the muscles, but here the fibula holds the fragments apart. This exaggerated rarefaction can sometimes be directly observed in compound fractures, especially in the spongy tissue near the epiphy- ses. The delay commonly observed after resection for the relief of pseudarthrosis I attribute to the absence of a periosteal bridge and to the stripping back of the periosteum from the cut end of the bone. The defective relations of the fragments consist mainly in a dis- placement by which the fractured surfaces are more or less widely sep- arated and which is maintained perhaps by the interposition of muscle. This interposition, which has occasionally been demonstrated by opera- tion, is thought by some to be by far the most common cause of failure of union, but in the present lack of observations the opinion must be deemed too exclusive. It is probable that when interposition occurs it is by penetration of the sharp point of one fragment into the overlying muscle. Another form of defective relations is constituted by the inter- position of a fragment wholly or partially detached or by the loss, in a compound fracture, of one or more fragments and the consequent erea- tion of a considerable gap. Delay or failure in compound fracture is furthered by necrosis o\' the end of a fragment. If the sequestrum is large it creates a gap ; it' it is small and lodged amid the granulations which arc awaiting ossifi- 118 FRACTURES. cation, it has seemed to me that its action might be similar to that which I have attributed to the metallic suture. I have found several such small imbedded sequestra amid pale granulations in exposing old, long-delayed compound fractures. It seems, too, as if the impulse to a productive, ossifying, process was lost or greatly diminished after the lapse of the time usually sufficient to repair, and it is well known that it can be re-aroused by fresh local violence. Failure by defective innervation, as shown by Bognaud, 1 occurs when the trophic nerves or nerve centers of the limb are injured. Motor or sensory paralysis without injury of the trophic apparatus does not delay union. Bognaud collected six cases of failure of union of fracture of the leg with paraplegia due to injury of the spinal cord at or below the last dorsal vertebra, while in others in which the paral- ysis was incomplete or the spine was injured at a higher point union took place. Local diseases, syphilis, cancer, etc., which by destroying or soften- ing the bone lead to " spontaneous " or " pathological " fracture, act in like manner to prevent repair ; and deep suppuration in compound fracture, which is usually associated with necrosis, is a frequent cause of delay or failure. The presence of an open wound exposing a fracture, even when sup- puration is slight and superficial, I have observed in several cases to be accompanied by marked hyperemia and softening of the bone and by great delay in union of the fracture even when the fragments were in exact apposition. Defective treatment includes the failure to correct the displacements which make union difficult and which might be corrected, to secure immobility and maintain it for a sufficient length of time, and possibly certain errors of commission, such as the excessive use of cold upon the limb. Of these, frequent movement of the fragments upon each other has long been thought to be a potent factor in delaying union, but recent experience in treatment by brief immobilization and frequent massage suggests a revision of the opinion. The return of mobility after union has become apparently complete, and even after the patient has used the limb for some time, is occasion- ally observed. In most of the cases probably the union has only been fibrous, although close and firm, and has slowly yielded under use ; but in others, in which there is no reason to doubt the solidity of the union, the cause has been a local inflammation, such as erysipelas, or an ulcer, an acute febrile disease, or scurvy. Symptoms. The persistence of abnormal mobility after a lapse of a period that is usually largely sufficient for union constitutes " de- layed " union ; the merger into " failure of union " is a matter of opinion rather than of exact definition. If the position of the frag- ments is good and the mobility slight the condition should be deemed merely one of delay for a much longer period than when the local relations are less favorable, and the usual treatment of a fracture should be continued ; the instances are numerous in which union has 1 Bognaud : Sur l'influence de quelques lesions du systeme nerveux sur la formation du cal, These de Paris, 1878. DELAYED, FAILURE, OR FAULTY UNION, 119 finally become complete after the lapse of several months and without exceptional measures. Ou the other hand, failure may be predicated even before the usual time has passed if the position of the fragments is very unfavorable and the mobility still great. The persistence of abnormal mobility is the pathognomonic sign, but it is occasionally difficult or even impossible of recognition either because it is very slight or because the fracture is so close to the articular end of the bone that the mobility is masked by the movements at the joint ; under such circumstances the functional disturbance and pain may be the only symptoms. The abnormal mobility may be slight or very free, and is usually painless until its limits are approached or reached. Functional disturbances vary with the extent of mobility, the limb, and the amount of the associated muscular degeneration ; it ranges from complete disability to interference so slight as scarcely to be noticeable ; in one of my own cases, a compound fracture, the patient preferred amputation of the leg to longer delay, and others have sought in amputation relief from the pain of the mobility. Others, again, are able to use the limb with the aid of a brace, and some even without it. In the shaft of the femur the disability is usually the greatest and is practically complete, but when at its neck the limb may be still quite useful ; I have seen several such cases. Treatment. When delay has occurred and the local conditions are such that union may reasonably be hoped for, the surgeon's first duty is to seek for and combat any general condition that may be at fault, such as syphilitic or malarial poisoning or defective nourishment, using the respective remedies and tonics, and perhaps giving preference among the latter to phosphorus or phosphate of lime. 1 Then he continues the immobilization, aiding it then or a little later by massage ; this still failing, he has choice of a number of mild measures to hasten the proc- ess, such as the application for a few hours, once or twice repeated, of a bandage about the limb above the fracture tight enough to cause venous congestion and swelling (Bier), the painting of the skin with iodine, or the injection of a few drops of tincture of iodine or of a 10 per cent, solution of the chloride of zinc into the periosteum and the fibrous bond at the fracture ; or, in the case of the leg, if the mobility is slight and the fragment in good position, he applies a splint or brace by the aid of which the limb can be used in walking without too much risk of causing displacement, in the hope that the irritation thereby pro- duced at the fracture may stimulate the process. Bier (3Iecdzinisehe Klinik, 1905, No. 1) recommends the hypodermic injection about the fracture of 30 c.cm. of blood drawn from a vein of the patient. Some interesting experiments with the method are reported by Hil- genreiner (Beitrage zur Min. Chir. Vol. 54, p. 581.) Anzilotti (Arch. di Orthopedia, 1908, Pt. 1) obtained union by fifteen injections o1i gelatine. 1 Gauthier: Lyon Medical, June and July, 1897, reports the successful use in two cases of the thyroid extract to cause consolidation after delay of about three months; the remedy was used for between three and four weeks and union was then estab- lished. I have employed it in two cases without recognizable benefit. 120 FRACTURES. If these also fail or if the condition calls for more pronounced meas- ures, he seeks to produce a sharp reaction by forcibly and widely bend- ing the limb at the fracture, under an anaesthetic, so as to tear the bond and measurably produce the conditions of a fresh fracture, or he passes a drill down to the bone, with or without incision, and perforates the ends of the fragments at several points. Bone and ivory pegs have been inserted into holes thus made and withdrawn after a few days or weeks, but apparently Avith no advantage over simple drilling. Electrolysis has also been used with advantage, the needle being passed into the bond between the fragments. Finally, the surgeon may freely expose the fracture by incision, resect the ends of the fragments, bring them into close and exact apposition, and secure them there by external dressing with or without the aid of a suture or other fastening applied directly to the bone. In the pre- ceding chapter, I have given reasons for thinking that the presence of a permanent metallic suture or pin interferes with the processes by which alone union can be accomplished, and I must repeat my belief that sufficient security can be given by an external dressing, and that the usefulness of a suture is limited to keeping the fragments in position during the application of that dressing. No suture that can properly be used is strong enough to relieve the surgeon from the necessity of great care in handling the limb during the application of the dressing, not because the fragments have a great tendency to slip apart laterally, but because the angular deviations which are certain to take place bring a great breaking strain upon the suture. For this reason I believe that if any suture is used it should be of catgut or silk, and tied loosely so as to permit angular deviation within a mod- erate range. The best security, I believe, lies in making the ends of the bone square and then having an assistant press the lower segment of the limb forcibly against the upper one until the dressing has been completed. I have successfully operated upon at least six cases of failure of union of the femur in this way and without suture. I may add that I have seen as many cases of pseudarthrosis of the leg that had been unsuccessfully sutured with silver wire, and in all of them I have found at the second operation the wire lying loose and sometimes broken. (See also Plate XLVL, fig. 2.) If on resection the end of the bone is found thickened and dense I drill it in several places in order to promote its rarefaction by increas- ing the area of irritation, and under such circumstances the use for two or three weeks of a silk or other removable suture might further the same aim and thereby be advantageous. In the humerus and in the bones of the forearm I have used both absorbable and temporary silk ligatures. A pin of bone or the thigh bone of a fowl has sometimes been in- serted into the medullary canal to hold the fragments together; if asepsis is preserved it may heal in, but it usually needs to be removed. Bardenheuer quotes Lane as having seen sarcoma develop after implan- tation of a piece of bone. According to Von Brims out of 440 resections for pseudarthrosis 203 failed. DELAYED, FAILURE, OR FAULTY UNION. 121 When failure of union has been due to loss of bone the gap lias sometimes been filled and union obtained by pieces of fresh or decalci- fied bone over which the soft parts are closed by primary healing. Absolute asepsis is necessary to success. Apparently the pieces act only mechanically by furnishing a framework within and around which the granulations grow and by filling the space which if left to be filled by the slowly forming granulations would collect the exudates and thus favor the spread of chance infection. It has also been proposed to fill the gap with powdered calcined bone on the theory that it would equally well fill the space and serve as a framework, and would also supply the lime salts needed for the formation of bone. The plan commends itself by its simplicity and cleanliness, for the powder can be perfectly ster- ilized by fire, and I have thought it might also be useful in delayed compound and even simple fractures, the powder being poured in among the granulations or introduced through a hypodermic needle mixed with water. When loss of substance has occurred in one of two parallel bones, as in the leg or forearm, it is usually advisable, if the gap is not too large, to excise a corresponding piece from the other bone so that the frag- ments of the first can be brought into contact. When the gap has been larger in the tibia a solid limb has been obtained by dividing the fibula and uniting its lower segment with the upper segment of the tibia. In time the bone enlarges sufficiently to make the limb strong and useful. Faulty or Vicious Union ; Union with Deformity. The use of these terms is restricted to cases in which the deformity or persistent displacement differs notably from the result usually obtained after that form of fracture ; the term is not applied when the irregularity is slight or common. Thus it is not applied to moderate shortening by overriding in oblique fractures, to the shortening and out- ward rotation commonly seen after fracture of the neck of the femur, or to the deformity of the wrist so frequently seen after Colles's fracture. In short, its use implies a condition that might and should have been avoided. Any of the possible displacements after fracture may remain uncor- rected and produce this condition, but the most common are marked angular displacement or rotation after fracture of the shaft and trans- verse displacement with overriding. Excessive size of the callus is sometimes included in this group and so is the inclusion in the callus of muscle, tendon, or nerve. The ill results are not limited to the change in the appearance of the limb, which is often marked and offensive, but include also an interference with function, which may amount to complete disability by shortening of the limb, by the devia- tion of its lower segment, or by restricting the movements of a neigh- boring joint either directly or indirectly by implication of its muscles. Thus angular displacement, with or without overriding, after fracture of the thigh near the middle may produce a shortening of several inches; angular displacement after fracture of the leg may so raise the heel or toes or invert or evert the foot as to make it difficult or impos- 122 FRACTURES. sible to place the sole squarely on the ground in walking ; transverse displacement backward or forward close above the elboAV may limit flexion or extension respectively, more, I think, by cicatricial implica- tion of the muscle than by contact with the bones of the forearm. Treatment. The method of treatment varies with the solidity of union, and therefore to some extent with the length of time, that has elapsed. As persistent displacement is often a cause of delay of union and of early weakness of the callus, it is possible to correct the posi- tion by the hands alone at a much later period than under better con- ditions ; that is, an angular displacement can thus be corrected by forcibly straightening the limb with the hands or with the knee pressed against the projecting angle. But little improvement in overriding is to be expected from such means because the cicatricial condition of the soft parts which maintains it cannot often thus be modified. A few cases have been reported in which continuous traction has been quite efficient. Gradual straightening has occasionally been effected by a lateral brace with transverse elastic pressure at the angle. Refracture by specially devised osteoclasts has been much employed in the past for the correction of angular deformity, but has largely given place of late to open operation. Some of the instruments are very powerful and accurate in the application of the force. Union after early refracture may be confidently expected to require less time than after primary fracture. A serious obstacle to success may exist in the permanent retraction of the soft parts on the concave side when the deformity has long existed. The condition then resembles that of a bent bow, and as the length of the soft parts determines that of the limb the latter cannot be increased, and the bone can be straightened after breaking it only by forcing the ends of the fragments past each other, overriding. Osteotomy meets the indications in the same manner as osteoclasis, but more widely and precisely, for it not only insures division at the chosen point, but it also permits the correction of lateral displacement and the removal of a V-shaped or longer piece if the condition is that mentioned at the close of the preceding paragraph. With strict attention to asepsis recovery is likely to be as uneventful as after osteoclasis, but it will be notably slower if bone is excised. Unless anatomical reasons to the contrary exist the incision should be made longitudinally at or near the most projecting part of the bone, and should be long enough to permit free exposure arid easy access to it ; the management of the bone will be determined by the relations of the fragments and by the end in view, but in case of excision every effort should be made to maintain the continuity of the periosteum on one side and to restore it by suture on the other at the end of the operation. In articular fracture with displacement, such as Pott's fracture above mentioned, the bone can sometimes be restored to place by open operation with considerable improvement in function. I have im- proved the condition in a number of Pott's fractures in this way ; and in one of accidental refracture of the outer condyle of the humerus DELAYED, E ALLURE, OR FAULTY UNION. 123 in which the primary fracture (two years previous) had resulted in considerable limitation of motion, I exposed the fracture by incision because of non-reducible displacement of the fragment, and was able so to place it that the range of motion was subsequently increased. Possibly a like advantage could be gained by a deliberate osteotomy and shifting of the fragments. An excessive portion of callus or a projecting fragment which causes pain or ulceration of the skin by pressure can be removed by the chisel or rongeur. CHAPTER IX. GENERAL PROGNOSIS. The prognosis after fracture involves consideration of the effects of the injury in respect of the prolongation of life, the preservation of the limb, its usefulness if preserved, and the time required for recovery. The factors in the prognosis have been considered in detail in the pre- ceding chapters and will only be grouped here for a more convenient general review. The prognosis varies with the age and condition of the patient, the position and character of the fracture, and the complications present or possible. The Patient. Sex does not affect the prognosis. Age has a con- siderable influence ; the younger the patient the better the prognosis, because in the young fractures unite more easily and promptly than in the adult, and advancing years increase the probability of dimin- ished vitality and of the presence of constitutional dyscrasise. In the old the prognosis is worse in respect of life because of their diminished ability to withstand the shock and to bear prolonged confinement to bed and pain, and worst in respect of function because of the greater difficulty with which the affected soft parts and joints regain their original conditions. The reduction of vitality by degeneration or dis- ease of various organs may have a similar effect. Chronic alcoholism exposes to an outbreak of delirium tremens and, as does also advanced age, to the so-called hypostatic pneumonias. Sudden death by fat or pulmonary embolism is possible, but very rare, at any age and with almost any form of fracture. The Fracture. In compound fracture the prognosis is worse in every respect than in simple fracture, and worse when by direct violence than by indirect violence because of the usually greater extent and severity of the associated lesions of the soft parts. The fracture of the shaft of a long bone generally heals with some shortening, the chief exceptions being the incomplete and subperiosteal fractures of the young and transverse fractures in which lateral and angular displacements can be reduced or prevented. Fractures of the short or spongy bones heal promptly, but the dis- placement, with or without crushing, cannot usually be fully corrected. Fracture of the spongy end of a long bone usually heals more quickly than fracture of the shaft, but occasionally delay, or even failure of union, is occasioned by exaggeration of the preliminary rarefactive process. Fracture of a flat bone is rather frequently followed by exaggerated formation of callus. Fracture of one of two parallel and connected bones (leg, forearm) is more easily managed and has a better prognosis than fracture of both 124 GENERAL PROGNOSIS. 125 or of a single bone, because the unbroken one acts as a splint ; an exception to this is found when the fracture is accompanied by a loss of substance which creates a gap between the fragments. Articular fractures and fractures near the joints are especially liable to be followed by limitation of motion in the joint; at the knee and elbow, and to a less extent the shoulder and hip, this is the rule. No general statement of value can be made as to the time required to reach the final result after fracture or as to the completeness of resto- ration of function, and the statistics that have been collected are prac- tically valueless because they do not completely discriminate between the different forms and ages of the patients. Each fracture or at least each class of fracture must be judged by itself, and in many a given case there can be no great certainty that it will not vary widely from the average. As I write this paragraph, I have just visited a patient who broke the outer portion of the head of the tibia seven months ago ; I predicted great loss of motion and was gratified when at the end of about four months a range of 45° had been obtained, and yet within the last two months that range has been increased to 90° under natural use of the limb. I think it can properly be said that an uncompli- cated fracture of the shaft of the long bone of the arm, forearm, or leg will, in the great majority of cases, heal without any diminution of the earning capacity of the patient after six months, and that almost all the remainder will have reached the same condition in a year. In fractures of the shaft of the femur more time is required, and the number of those who will remain more or less disabled is greater. As middle life is passed, the ability of the patient to adapt himself to changed conditions is less, the joints are more likely to be stiffened, and pain in the limb after fatigue or when the weather is cold and damp is more common. The latest statistics I have seen are those of Loew l and Ramsperger, 2 collected from the records of Aid Societies. Loew's were of 167 simple fractures of the leg; only one was perma- nently disabled, the others regained their earning capacity in an average of 101 days, 70 per cent, in 91 days each. Ramsperger's, of 145 fractures of the leg, given in more detail, show complete earning capacity, after simple fracture of the shaft of both bones healed without deformity, restored in most during the first six months, in a few not until the third or fourth year ; in those that healed with deformity (36 per cent.) the restoration was complete in 29 per cent., in the remainder the loss was generally less than 25 per cent. Of the compound fractures of the shaft complete restora- tion followed in 32 per cent., the loss in the remainder was usually less than 25 per cent. Of the simple fractures of the malleoli there was recovery without deformity in 61 per cent., with deformity in 39 per cent. ; of the former, restoration was complete in 75 per cent., of the latter, in 23 per cent. Two-thirds of all resumed work during the first six months, one-third during the second six months. After compound fracture there was always some loss. 1 Loew: Deutsche, Zeitschrift f. Chir. vol.xliv. Abstr. in Centralb. f. Chir., L897, p. 855. * 2 Ramsperger : Korresp. des Wiirtenib. iir/.t. Landesvereins. Abstr. in Centralb., L897j p. 735. See also Morian : Arch, klin. Chir., vol. St. ii. p. PS. 126 FRACTURES. After fractures of the fibula restoratiou was always complete, but sometimes much delayed. Sauer * iu 111 cases of fracture of one or both bones of the leg or of one or both malleoli (Pott's), found complete restoration of earning capacity in 75 per cent, after 16.4 months. The percentage varied from nearly 100 in patients under twenty years of age to about 33 per cent, in those over fifty years. All these statistics are taken from the records of relief associations, the patients receiving aid according to the degree and continuation of the disability. The more unfavorable estimates of results in respect of earning capacity, notably those of Lane, are entirely out of accord with my own experience and observation. I recently sent letters to all the patients who had been treated in the New York Hospital for fracture of the lower limb during the previous year and received answers from twenty-six as follows : Neck of femur, 3 ; limb nearly useless. Shaft of the femur, 4; limb as useful as before the injury. Leg, 10; in 7 as good as ever, in 3 good, but with some pain. Pott's fracture, 9 ; in 6 as good as ever, in 2 fairly good, in 1 bad. A painstaking and valuable study of the late results after fracture of the thigh, based on a hospital service of three years was made by Ashhurst and Newell. 2 Of 1 9 elderly and 2 young patients with fracture of the neck of the femur 13 had entirely useful limbs, 6 walked with a decided limp (some using a cane or crutch) and 2 were incapacitated. Of 31 fractures of the shaft 19 had a perfect functional result, 10 a limp but no disability, and 2 (subtrochanteric fracture with 2 inches shortening) marked impairment. Nine fractures of the condyles gave 4 perfect functional results, 3 with limp but no disability, and 2 inca- pacitated. 1 Sauer : Beitrage zur klin. Chir., vol. 46, p. 184. 2 Ashhurst and Newell : Annals of Surgery, 1908, vol. 48, p. 748. CHAPTER X. FRACTURES OF THE SKULL. The function of the cranium is so largely limited to mechanical protection of the brain and its annexa from external violence, its frac- ture in a great majority of cases involves after recovery so slight an interference with this function, and treatment can do so little to dimin- ish this interference, that the importance of the injury lies almost wholly in the associated injury of the brain and in the later inflam- matory or degenerative processes therein to which that injury or that of the overlying soft parts may give rise, and its consideration falls in the majority of cases rather under the rubric of injury of the brain than under that of fractures. It is unfortunate that these injuries should be so universally classed as fractures, for this leads to an undue fixing of the attention upon the lesion of the bone to the exclu- sion or minimizing of that of the brain and to undeserved reproach for occasional failure to recognize the presence of fracture. It should be remembered that the violence which causes fatal injury of the brain together with fracture of the skull may, under slightly changed con- ditions, cause the former without the latter, and that in a large propor- tion of fatal cases the fracture is merely an incident without any direct relation to the fatal result or only with that of having made the causa- tive lesion possible. On the other hand, there is a class of fractures in which the lesions are entirely local and limited to the bone and the overlying soft parts, or in which, if the contents of the cranium are at all injured, the injury is limited to the immediate neighborhood of the fracture. In these the fracture is the essential lesion, and the treatment is almost wholly directed to it. Between these two forms — generalized contusion of the brain and its envelopes, with or without fracture, and circumscribed fracture with or without localized injury of the brain or meninges — there are others in which the character of the fracture and its mode of production are exaggerations of those of the second group, and the effect upon the contents of the cranium those of the first group. In the first group the fracture is usually fissured and almost always occupies or extends to the base of the skull, and hemorrhages covering a large area though limited in amount of extravasated blood are found upon the surface of the brain and sometimes within it and the medulla, indicating contusion ; in the second the type is a compound circum- scribed depressed fracture, possibly with a rent in the underlying dura ; in the intermediate class there are the comminution of the second (but more extensive and associated with fissure) and the hemorrhages and the contusion of the first. In the production of the first the causative violence acts broadly upon the skull, modifying its shape through its elasticity and perhaps splitting it by exceeding the limits of that elas- 127 128 FRACTURES. ticity, and bruising its contents by that modification of the shape and by the jar, as in a fall; in the second, as in a blow of a hammer, the force is consumed in breaking the bone at the point of impact, there is no general change in the shape of the skull, no diffused effect upon the brain as a whole. Because of the mode of production fractures of the second group are usually compound. In the intermediate group the violence is greater than in the others, it breaks a larger area of bone and is not exhausted in producing the fracture. This difference in the mode of production and in the effects of the violence dominates the whole subject and determines the treatment and the prognosis. All this appears plainly in study of the mechanism, pathology, and cause of the injury in the various forms. Mechanism and Pathology. In studying the mechanism of fracture certain anatomical features of the cranium must be borne in mind. Of the vault and base of which it is composed in unequal parts, the former is globular, thick, and elastic ; the latter is flattened, irregular, thick in places, thin in others, and perforated at many points for the passage of nerves and vessels. From the occipital condyles, by which it rests upon the spinal column, pass outward, backward, and forward various thick portions or ridges constituting a strong framework to connect them with the vault ; the basilar process and body of the sphenoid, the occipital crest, and the petrous portions of the temporal bones ; further forward are the thicker portions of the greater and lesser wings of the sphenoid and the frontal crest. To a certain extent these ridges direct lines of fracture of the base to the thinner intermediate segments, but Fig. 52. Sword cut ; fissured fracture. (Konig.) all can be crossed by them. The vault, which varies greatly in thick- ness at different points and in different individuals, has a thick outer and a thin inner table of dense bone separated by the spongy diploe. The physical characteristic of the vault which most concerns us is its FRACTURES OF THE SKULL. 129 elasticity, which is sufficient to permit a considerable change of shape without fracture — that is, a diameter of the skull can be shortened and those at right angles to it lengthened by compressing it in a vise, or a portion of its surface can be momentarily flattened by a blow. The effect of violence acting upon the skull varies with its character and the size and shape of the vulnerant body, and appears in all the gradations between a slight crush or cut of the outer table or of the entire thickness of the bone, through circumscribed depressed areas to single or multiple fissures running completely around. A cutting instrument, as a chisel or sword, cuts partly or entirely through the bone and by its wedge-action may produce long fissures running from each end of the cut if the weapon is heavy and the blow powerful (Fig. 52), or, if the instrument changes its direction, it may break off a piece of the bone and raise it above the level. A moderate blow with a pointed or edged weapon may simply break the outer table, where the bone is thick, and depress it by crushing the underlying diploe, or, if the bone is thin, it may make a small rounded hole in it without splintering or Assuring of the side. If the instru- ment is not sharp or edged the bone is bent inward and the effect varies with the force of the blow and the prolongation of its action. In the slightest form the elasticity of the skull takes up and distributes the force without recognizable injury to the bone. If the force is a little greater the inner table, which is overbent in the movement, splits away from the diploe and is broken (frac- ture of the inner table alone), the unbroken portion springing back to its original position and leaving the fragment more or less removed and changed in position. The same effect has been produced in the outer table by a blow from within, as by a bullet that has traversed the skull from the opposite side. If the force is still greater the bone is broken entirely through to an extent and in directions that vary widely, and the circumscribed por- tion remains more or less depressed. If the lines of fracture do not en- tirely circumscribe the affected area the elasticity of the unbroken portion brings back the depressed piece toward or to its place (Fig. 54), sometimes imprisoning in the fissure a few hairs or a portion oi' the head covering. If the circle of fracture is complete the enclosed portion remains depressed, either bodily or, more commonly, with sloping sides (Fig. 55). From the edge of the opening, small fissures or circumscribed lines of fracture frequently run. The inner table i> always more extensively broken than the outer one, and the two are largely separated from each other by planes of fractures through the diploe (Fig. 56). These fractures are almost always compound because of the character of the causative violence, the skin yielding Fig. 53. i Mechanism of fracture of the internal table by bendinsr of the bone. 130 FRACTURES. under it as the bone does. They are part of the so-called " compound comminuted depressed fractures of the skull." All of the injuries thus far described belong in what are termed the second group in the opening paragraph of this chapter, those in which Fig. 54. Circumscribed fracture with inclusion of hair. (Konig.) the dominant feature is the fracture and in which injury to the brain is usually absent or strictly localized. This feature is of so great prac- tical importance that I wish it might be indicated in the classifying Fig Circumscribed depressed fracture. (Konig.) nomenclature, to the exclusion, or at least the great subordination, of " depression," which has long held the attention of the surgeon, to the hopeless confounding of radically different cases and the useless or FRACTURES OF THE SKULL. 131 harmful generalization of therapeutic measures the value of which is strictly limited. I have long sought such a name that would be dis- tinctive and short; possibly " circumscribed fracture of the vault" would serve the purpose, although it is far from meeting all the indi- cations. The vast majority of fractures of this class involve the vault, but they occasionally occur at the base, the vulnerant body reaching it through the mouth or orbit, and in a very few cases even the condyle of the lower jaw has been driven through the roof of its socket, or the ethmoid driven in by a blow on the nose. The prognosis is worse in these basal cases because important parts of the brain are usually injured, efficient treatment is impracticable, and infection is more likely to occur. Fig. 56. Fig. 57. Circumscribed depressed fracture, inner side healed. (Konig.) Fracture of internal table. (Bergmann.) The other group of fractures, those produced by a force acting broadly upon the cranium to modify its shape as a whole, include almost all fractures of the base, and all so-called " indirect fractures " and " fractures by contrecoup" which have had so large a part in the discussion of this subject. In these, I repeat, the important lesion is that produced in the brain ; the fracture is an incident, it usually has no influence upon the progress of the case and gives rise to no thera- peutic indications. Similar brain lesions can be produced without fracture, and these cases belong among injuries of the brain rather than among fractures. This makes a detailed account of the mam forms, their relative frequency, and their more or less hypothetical 132 FRACTURES. relations to different forms of violence unnecessary in a work of the scope of this one. The mode of production of these fractures has been the subject of close observation, experiment, and study by many, among whom I shall mention only Aran, Felizet, Messemer, and Von Wahl. Another, Duret, 1 deserves to be remembered, perhaps above all others, for his remarkable investigations and his theory of mechanism by which the changes of shape of the cranium produce the often distant lesions of the brain and meninges, a theory which, even if carried in its details somewhat further than it can readily be followed, and possibly even incorrect, has yet been most valuable in fixing the attention upon the intracranial lesions and clearing away a large amount of nebulous theories concerning distant effects and their hypothetical causes. The theory of these fractures as now apprehended is based in part upon the shortening of the diameter in the direction of the violence and the consequent lengthening of those at right angles to it, and in part upon the overbending of the bone under a like strain. In a globular body of uniform elasticity the shortening of one diameter under pressure is necessarily accompanied by the enlargement of the mass in the line of the equator and in the corresponding separation of the meridians. If the limit of cohesion is passed, separation (frac- ture) necessarily takes place between two or more meridians, and the line of fracture runs approximately from pole to pole — that is, from the point struck to one diametrically opposite — along a meridian. To these Messemer gave the name of " bursting fracture." Thus, in the skull, a blow received in the centre of the frontal bone and directed backward would shorten the antero-posterior diameter and enlarge the skull in the central transverse plane at right angles to the line of force, and, if strong enough, produce one or more fissured fractures running from before backward along the summit or side of the cranium. If the blow were received upon the side the lines of fracture would be transverse through the vault or base or both. Under other circumstances not fully understood, but probably de- pendent upon lack of uniformity in or differing degrees of elasticity, the yielding along the line of impact is not so fully or so promptly met by expansion in the other plane, and the bone breaks at the point of maxi- mum curvature at the periphery of the depressed area and along what may be termed a parallel of latitude, at right angles to the line of force, producing what Von Wahl names a "bending fracture." Thus, a force acting from before backward upon the centre of the frontal bone would produce this form of fracture along a line crossing the cranium from side to side. The lines of fracture produced in these two ways are modified by lack of uniformity in the shape and structure of the cranium and by the degree of the fracturing force; the majority of those involving the base and limited to a single zone occupy the middle fossa, and in those not limited to a single zone the violence appears to have been greater, and the portion of the vault which has received the blow shows ex- 1 Duret : Etudes Experiruentales et Cliuiques sur les Trauniatisrues Cerebraux, Paris, 1878. FRACTURES OF THE SKULL. 133 tensive splintering (Von Bergmann). The direction of fissures lim- ited to the middle fossa is in the great majority of cases transverse, following one of two paths, either in the anterior part of the petrous portion of the temporal bone, parallel to its long axis and opening into the middle ear, or further forward in the great wing of the sphenoid. The cause is a blow upon the vertex or the side of the skull, and the fracture ends in the foramen lacerum anterius or in the sphenoidal fissure. If the force is greater the fracture may extend across the sella turcica into the opposite middle fossa, or obliquely through the sphenoid into the opposite anterior fossa, or into the anterior fossa of the same side. Fractures of the posterior fossa, caused by a blow on the occiput, are rarely limited to it, but cross the petrous portion to the middle fossa, but never cross the occipital ridge ; and those of the anterior fossa usually pass through the upper margin of the orbit and run back to the optic or sphenoidal foramen, extending sometimes across the middle into the posterior fossa, sometimes also across the cribriform plate to the other orbit (Konig). In crushing fracture of the bones of the face longitudinal fracture of the base along the body of the sphe- noid appears to be frequent. That most of the fractures produced in this manner occupy the base with but little or no extension to the vault is to be explained by the less resistance of the base due to its relative thinness and its irregu- larity of shape and also, possibly, in part to the impinging force or the resistance of the body exerted upon the base by the spinal column through the occipital condyles. When the vault is more extensively involved the line of fracture may cross it completely in any direction either as a long fissure with little change of place or with a separation so free that the two halves of the skull can be freely moved upon each other. The internal table shows no splintering. The short isolated fissures distant from the point struck, which are seen not infrequently in the base and occasionally, but very rarely, in the vault, are produced in a variety of ways and will be considered in the following paragraph among the exceptional forms. Most of the extensive fissures of the vault belong in what was spoken of in the opening paragraph of this chapter as the group of fractures intermediate between the two main groups, those in which the causative violence is great and produces extensive crushing fracture at the point struck, with radiating fissures and generalized lesion of the brain. They are sometimes, but not always, compound. Exceptional forms of fracture, the mode of production of some of which is very obscure, are found at many points. The small isolated fissures at a distance from, or even directly opposite, the point struck, to which the name " fracture by contrecoup" was given, belong almost all among the "bursting "or "bending" fractures, those of the base (when the blow has been received upon the vertex) being due to the resistance of the spinal column acting through the occipital condyles. The cases in which the fracture is directly opposite the point struck are so few and so doubtful that their existence has been denied, yet Perrin produced experimentally a fracture of the frontal bone by throwing a skull upon its occiput, and therefore the possibility must 134 FRACTURES, be admitted. Inclusion in this group of fractures at such a point pro- duced by a second blow directly upon it, as when a fracture of the occiput is caused by a fall upon the back of the head following a blow upon the forehead, is, of course, unjustifiable. A special group of nine cases collected by Yon Bergmann l in which the orbital plate was broken is of great interest. In four cases the primary violence was by a glancing bullet, in the others a bullet penetrating the temporal (3), the occipital (1), and the parietal (1). In some only one orbital plate was broken, in others both ; the fracture was either a straight fissure or circular ; in President Lincoln's case 2 (perforation of the occipital by a bullet) both plates were broken and the fragments " pushed up toward the brain ;" in two the fragments were depressed a few millimetres into the orbit. In an allied case a perforating bullet wound of the right parietal was accompanied by a fissure extending from the sella turcica through the great wing of the sphenoid. The explanation offered by Longmore 3 and Von Bergmann is by moment- ary excessive intracranial pressure produced by the penetration of the ball or the bending inward of the vault. Fracture of the posterior clinoid processes is occasionally observed, evidently produced by traction upon them by the attached tentorium during elongation of the antero-posterior diameter of the skull. The so-called " ring fractures " about the foramen magnum caused by a fall upon the feet or buttocks are due to the impact of the skull, through the occipital condyles, upon the upper end of the spinal col- umn, just as, to use Felizet's comparison, the head of a hammer is driven firmly down upon its handle by striking the other end of the latter against the ground. Exceptional isolated fractures of the base by direct violence have been referred to, such as those produced by the passage of a bullet, a stick, or a knife through the orbit or the mouth, fracture of the ethmoid by a blow upon the nose, or fracture of the temporal by the pressure of the condyle of the inferior maxilla in a blow upon the chin. Fracture of the anterior Avail of the auditory canal by the same cause deserves mention because of the bleeding from the ear which it occasions and which may be mistaken for that following fracture of the petrous portion of the temporal bone. These fractures owe their impor- tance to the associated injuries of the contents of the cranium, espe- cially of the carotid artery and cavernous sinus in wounds through the orbit, and to the possibility of the spread of infection from the outside to the interior. Fractures of the Internal Table. These are apparently extremely rare. In the Medical and Surgical History of the War of the Rebellion twenty cases observed during the war are recorded and brief notes are given of twenty-nine cases reported during the preceding two hundred years. Von Bergmann describes three additional specimens. In the great majority of the reported cases the cause was a blow by a glancing bullet which exposed the bone but left the outer table uninjured or only grooved or contused ; among the other causes are blows with small 1 Von Bergmann : Deutsche Chirurgie, Lief. 30, p. 211. 2 Surg. Hist. War of the Rebellion, vol. i. p. 305. 3 Lancet, 1865, vol. ii. p. 649. FRACTURES OF THE SKULL. 135 round objects, such as a hammer, a cricket-ball, a beer glass ; in only one case was the cause a fall upon the head. The alleged greater brittleness of the internal table appears to be entirely foreign to this limitation of the effect of the blow, the cause of which is the over- bending of the table as described above. The fracture may be a simple fissure, one side of which is slightly depressed, or circumscribing and detaching a scale of bone, or, more commonly, a comminuted one with a marked central depression (Fig. 56). The dura may be torn or the small fragment may be forced entirely through it. In one case the middle meningeal artery was torn. In some of the cases close examination after death has shown a slight fissure of the outer table and diploe. As almost all the reported cases have ended fatally, usually in consequence of suppuration of the super- ficial wound and extension of the infection to the interior of the cra- nium, it is possible that many other cases not thus complicated have ended in recovery and passed unrecognized ; the inference then would be that the danger to life lay not in the fracture or in the displacement of a fragment but in the coexisting wound and the spread of infection from it. The coincident injuries of the contents of the cranium are rupture of the dura and pia, laceration and contusion of the brain, rupture of arteries, venous sinuses, and cranial nerves, and multiple extravasations of blood from the smaller vessels on the surface of the brain and ven- tricles and less frequently in its substance. The dura is rarely torn except when the fragments are notably driven inward, and then only to a moderate, extent. Direct contusion and laceration of the brain, recognizable macroscopically, is found only under the same circumstances, but there is reason to believe that even in the slighter cases it receives a contusion which makes it peculiarly liable to be secondarily affected by infection proceeding from suppura- tion of the adjoining scalp ; that is, central abscesses and cysts which are probably not the remains of hemorrhages are occasionally observed, the former after suppuration of the scalp, the latter after even simple fracture. The hemorrhages from the vessels of the pia which are constant in the "bursting" and " bending " fractures are attributed by Duret to rupture of the smaller vessels by the sudden forced shifting of the cerebro-spinal liquid under the influence of the blow and the change in the shape of the skull thereby produced, by which certain portions of the space in which it is contained are sharply distended and the connected vessels torn. The effects are seen not only on the surface of the brain or in the subarachnoid space but also within the cortex and in the ventricles, especially the fourth, and it is to these that many of the cerebral symptoms are to be attributed. This also is the expla- nation of the presence of the hemorrhages found at points distant from the one struck. Rupture of the middle meningeal artery is followed by increasing extravasation of blood, usually between the dura and the skull, with quite characteristic symptoms and the possibility of relief by operation. Rupture of the cavernous sinus, and more rarely of the carotid artery 136 FRACTURES, where it lies within it, is seen in some fractures of* the base and espe- cially in those due to the entrance of the vulnerant body through the orbit. Occasionally an arterio-venous aneurysm results. The other sinuses may also be torn when the line of fracture crosses them, but the complication seems rarely to be important. Laceration of a cranial nerve is rare ; the facial most frequently. But interference with function by hemorrhage into the sheath of a nerve is more common. Pathological and Reparative Processes following Fracture. These differ radically according as infection is present or absent, and while this difference does not exactly coincide with that of simple and compound fractures, yet the existence of an open wound in communi- cation with or even near the fracture creates dangers which are almost wholly absent from simple fractures. Kepair of the fracture is effected largely by the diploe, and although the pericranium and dura can each produce bone they usually do so to only a slight extent, and consequently an overgrown callus is rare. Moreover, the osteogenetic action is rarely sufficient to close even a small gap in the bone, so that gaps created by the removal of frag- ments or trephining are habitually closed only by fibrous tissue with at the most a small margin of new bone along the edge of the opening. And yet in a case in which I removed fully two square inches from the frontal bone, broken by a blow with a hammer, I found twenty- five years afterward firm, apparently bony, resistance over the entire area. Depressed fragments heal in the position in which they are left, and large broad depressions in infants will often be diminished by intracranial pressure. Persistent depression in the motor area may maintain a correspond- ing paralysis by its local pressure upon the cortex, but the weight of surgical opinion at the present time is opposed to the belief that it has any marked influence in producing irritation or other functional dis- turbances, such as epilepsy. 1 It has been abundantly shown clinically and by experiment that the brain readily accommodates itself to a marked diminution of the cranial capacity, and that even a sudden diminution must amount to about two cubic inches in the adult skull before it can of itself produce permanent symptoms of general com- pression. In very few fractures is the depression as great as that, and the symptoms which accompany it rarely differ from those of other fractures with little or no depression. That cerebral symptoms have been promptly relieved by the removal of a depressed portion of bone does not prove that the depression was their cause, for similar relief has often been given by the removal of portions that were not depressed or in any way altered, and even by operations on distant parts of the body. The clinical grounds for the belief that the scar following removal of a portion of the skull is able to cause functional disorders are as good as those that a persistent depression can do so. It seems 1 See Von Bergmann, Konig, Hutchinson, in London Hospital Beports, vol. vi. ; Eche- verria, Arch. Gen. de Med., 1878. FRACTURES OF THE SKULL. 137 probable that if the dura is torn, and intrameningeal adhesions thereby produced, the chances of chronic irritation and functional derangement are greater than if such adhesions do not exist. Contusion of the brain and laceration of its vessels and of those of the pia, in. uncomplicated cases in which the patient survives the pri- mary injury, heal kindly, and the cases in which they give rise to a meningitis of any extent or importance are very exceptional. The extravasated blood is absorbed, or occasionally remains as a cyst. Occasionally, but very rarely, suppuration takes place beneath a simple fracture, just as it does in closed injuries in other parts of the body. Generalized contusion of the brain, as seen in the "bursting" and " bending " fractures and in those of the intermediary group, is gen- erally fatal, but not through meningitis. The lesions are more exten- sive than those of most apoplexies and apparently they kill in like manner. Even in fractures of the base with rupture into the middle ear the cases in which an intracranial infection has originated through this communication with the exterior are, in my experience, very rare. It is the cerebral lesion that kills, not the fracture or any secondary result of the fracture. In compound fractures when infection is avoided repair goes on in the same manner ; but if the wound suppurates the infection may spread not only to the bone but also, as in cases of phlegmon without fracture, to the interior of the cranium by lymph channels, connective tissue, and thrombi in the veins, and thus give rise to suppurative meningitis and pyaemia. In short, the progress of a case is determined mainly by the character and extent of the intracranial lesions and the pres- ence or absence of infection, and the fracture, as such, usually has but little influence upon it. Symptoms, Diagnosis, and Treatment. The distinction which has been made between those cases in which the fracture is an important, perhaps the principal, lesion and those in which it is only a comparatively unimportant accompaniment of grave lesions of the brain and its annexa must here be kept constantly in mind. Fortunately, in the former, in which the recognition of the fracture is important because of the therapeutic indications which arise from it, the diagnosis is usually easy ; and in the latter, in which the fracture seldom demands or can receive any direct treatment or affects in any way the prognosis, and in which the practical interest is limited to the intracranial injuries, the fact that the existence of a fracture can only be inferred, and not be demonstrated, does not leave us less able to do all that can be done for the patient. Instead, therefore, of fol- lowing the usual division of the subject — fractures of the vault and fractures of the base — I shall use that of circumscribed fractures of the vault and fissured fractures with generalized brain injury i with separate consideration of the rarer forms which lie outside of this grouping. Furthermore, as diagnostic and therapeutic measures in many eases run closely together or even coincide, I shall at the same time consider the treatment. 138 FRACTURES. Circumscribed Fractures of the Vault. As these fractures are produced by a blow from a relatively small body or from one having an edge or corner, the fracture is often com- pound and the diagnosis is made' by direct inspection and palpation of the bone. In most cases there is no difficulty ; the fragments can be seen and felt at the bottom of the wound, and it remains only to deter- mine the extent of the fracture and apply the appropriate treatment. In the doubtful cases the bone has to be carefully examined in search of a fissure, or its condition and the character of the violence con- sidered as bearing upon the probability of a fracture of the internal table. In respect of a fissure the edge of the torn periosteum can easily be mistaken for one by touch, or a cranial suture by the eye. The error in the first case is so easily made, even when one is on his guard against it, that the finger should not be trusted ; in the second the fissure can generally be recognized by its bleeding, when fresh or when rubbed. The importance of its recognition comes from its possible indication of more extensive fracture beneath and from the frequent advisability of enlarging it for thorough disinfection. When the bone is distinctly broken and depressed, even when the area is small, the depressed portion should be raised. If it proves to be only a fracture and depression of the outer table the operation needs to be carried no further ; the wound is washed and closed. . If the entire thickness of the bone is broken the deeper as well as the super- ficial fragments must be removed. It is rarely necessary to use a trephine for this purpose, for the corner of a chisel or elevator can be engaged under the edge of a fragment and thus raise it, and after one piece has been removed the removal of the deeper ones is easy, for they can be grasped with forceps and withdrawn by careful traction ; the amount of internal table removed is usually greater than that of the outer table. If the dura is torn, and there is no bleeding from the pia, the opening in the dura should be closed with catgut sutures ; if there is free bleeding from the pia the wound should be packed with gauze for a few hours, after which the opening in the dura may be closed. The overlying soft parts, including the pericranium as far as possible, should be closed with sutures, a small gauze drain being inserted and main- tained for a day or two. The scalp should be shaved for some distance about the w T ound and thoroughly disinfected by scrubbing and washing with bichloride before anything is done to the bone. When the gap left by the removal of bone is large and the wound is clean a thin sheet of aluminum, celluloid, rubber tissue, or foil cut to fit it may be inserted in it. The softer materials seem to answer as well as the firmer ones by leading to the formation of a thick and tough cicatrix. Gold foil or rubber tissue has sometimes been placed beneath the torn dura to prevent meningeal adhesions, but either is liable to induce exaggerated cicatricial formation. Freeman has lately recommended the use of the lining membrane of an egg. Brewitt 1 has recently (1906) published a series of remarkable results obtained by replacing the fragments and closing the wound over them. 1 Brewitt : Arch, fur klin. Chir., vol. 79, p. 47. FRACTURES OF THE SKULL. 1 39 Of 38 cases 2 died ; in all the others primary healing took place, and in 28 of them the fragments united solidly on a level with the adjoin- ing bone ; in the others there was some depression of the surface. He also claims, with statistics in support, that patients thus treated are also more free from late ill effects. In small perforations, as by a nail or even by the end of a small stick (the handle of a paint-brush in one of my own cases), the open- ing must be enlarged by the chisel or trephine for the better cleaning of the deeper parts of the wound ; and in pistol-shot fractures this is also necessary, but only for the same purpose and for the removal of the ball, if it is within easy reach, and of small fragments. Bullets can heal in, and without giving rise to late consequences ; and I think the risks of attempts to remove a bullet are greater than those of leav- ing it in place if the orifice of entry is the only communication with the exterior and can be thoroughly cleaned. If the bullet in its pas- sage has opened the ethmoid cells or the frontal sinus infection from that side is probable and the bullet should be removed if possible, but whether it is removable or not the prognosis is thoroughly bad. In any of these cases there may be free hemorrhage from within the cranium and escape of brain tissue, or, very rarely, a flow of cerebro- spinal liquid coming from the subarachnoid space or even from the lateral ventricle. Bleeding from a wounded sinus can be arrested by lateral ligature or suture or by packing. Circumscribed depression without wound of the soft parts may be recog- nized by the finger, which when carried firmly along from the adjoining bone appreciates the change in level, but a very similar sensation is given by the swollen circular margin of a deep contusion ; that is, the finger passes over a firm rim to a soft central area which suggests depression. Error can be avoided by making firm pressure on the hard margin and then passing slowly toward the centre; the margin yields under the pressure and the finger recognizes the level resistance of the bone throughout. In these cases, as in the preceding, general symptoms — cerebral shock or contusion — may be slight, transient, or absent ; the stunning, the partial or complete unconsciousness passes and is perhaps followed by nausea and headache ; if they are more than this they indicate gener- alized lesions that bring the case into the intermediate group, to be subsequently considered. If the depression is immediately over a por- tion of the motor area or a special centre there may be a corresponding paralysis or abolition of function. Very rarely a fluctuating tumor may form under the skin which on puncture proves to contain cerebro- spinal liquid that has escaped through the torn dura. This has been observed only in young children. In the treatment of these simple circumscribed fractures with depres- sion there are two things to be considered : the effect upon the brain and meninges if the depression persists, and the risks involved in relieving it. The reasons have been given above for the belief that persistent depression is not often responsible for the late functional disturbances that have been attributed to it, and that consequently it does not, in the absence of special indications, imperatively require relief. But, 140 FRACTURES. on the other hand, although it is properly urged that the unbroken skin is a safer protection against infection than the strictest asepsis (Konig), yet the danger incurred in making an opening in the vault of the cranium, especially if the dura is not wounded, is so slight that I cannot criticise those who act upon the conviction that it is less than those of persistent displacement even when the disadvantages of the resultant gap are taken into account. This applies only to' small areas of depression and the removal of only a small portion of bone. The special indications referred to, which call for operation, are found in the evidences of localized pressure or of hemorrhage from a branch of the middle meningeal artery. (See below.) The value of a localized symptom (monoplegia, etc.) is much greater in a fresh injury than when it occurs after the lapse of a few days, for in the latter case it may be due to the spread of inflammation from a primary focus at some little distance from the centre which corresponds to the paralysis. Fissured Fractures with Generalized Brain Injury- These, let me repeat, are the " bending " and " bursting " fractures produced by violence acting broadly upon the skull, changing its shape temporarily beyond the limits of its elasticity, and causing contusion of the brain with larger or smaller hemorrhages especially upon its surface. In the great majority the fracture occupies or extends to the base of the skull, and the injury is hence generally spoken of as fracture of the base. The principal injury is the lesion of the brain, and the associated fracture is mainly of importance as indicating that the injury to the brain is probably extensive and grave. The opinion long held that fractures of the base were necessarily fatal has been shown to be exaggerated, 1 but yet the percentage of mortality is high, and similarly produced fractures of the vault have a like gravity. In ten years — 1895-1904 — 319 cases of fracture of the base were treated at the Hudson Street Hospital, with 206 deaths. The chief symptom of the brain injury is unconsciousness, more or less complete, with the history of a blow, irregularity of the pupils, and a moderate rise of temperature. There may also be the signs of compression : slow- ing of the pulse, increase of bloodpressure, and choked disc. The high temperatures which have been spoken of as constant, 105° to 107° F. (Phelps), I have seen only in the few hours before death. Paralytic symptoms and symptoms connected with the circulation and respiration depend upon the portions of the brain and medulla involved in the injury. The differentiation is from other forms of coma, especially the alcoholic, and is often extremely difficult or even impossible, as when alcoholism coincides with trauma. The points of diiference (with many exceptions) are that in alcoholic coma the temperature is not raised, the unconscious- ness is less deep, the pupils are equal and responsive. It must always be remembered that the two conditions may coexist. 1 Graf (Deutsche Zeitschrift fur Chir., vol. lxviii., p. 464) gives statistics of 90 cases of fracture of the base treated at the Charite in Berlin between 1896 and 1902, includ- ing the condition after recovery in 48 of them. There were 34 deaths. The most common late result was diminution of the hearing in 27 of 39 cases examined. In 2 there was persistent facial paralysis. 140 FRACTURES OF THE SKULL. 141 During the past year I have withdrawn by lumbar puncture a few drops of the cerebrospinal liquid in many cases of unconsciousness due to various causes, in the hope of finding that the presence or absence of blood in it would aid in the differential diagnosis. Blood was almost invariably present in fracture of the skull, and also in many apoplexies. The diagnostic value of its presence is considerably diminished by the fact that it is caused not infrequently by the puncture itself, presumably by wounding a meningeal vein. The symptoms belonging to the fracture itself are hemorrhages, ecchymoses, occasionally a watery discharge from the ear or nose, and deafness of the ear of the affected side. Hemorrhage from the ear, nose, or mouth is frequent, that from the ear being almost pathognomonic of a fracture through the petrous por- tion of the temporal bone ; it is usually slight but may be profuse. Konig refers to a case in which the flow from the middle ear through the Eustachian tube into the mouth was so abundant that he felt obliged to do tracheotomy to prevent suffocation. Bleeding from the ear which may be mistaken for that of a fracture of the base may be due to rup- ture of the membrana tympani or to injury of the external auditory canal by a blow upon the chin which has forced the condyle of the jaw backward, or even to a fissure of the vault extending to the mastoid process. Ecchymosis at certain points, not due to direct contusion, is signifi- cant of fracture. A frequent one is that beneath the ocular conjunctiva, spreading to that of the lids and then to the skin of the latter ; it is most constant and marked in fractures of the orbital plate and sphenoid. A slight ecchymosis behind the ear is often found after a day or two. A watery discharge from the ear after fracture of the base is not infrequent and is sometimes very profuse (in one case 63 ounces in four and one-half days). Four varieties differing in the amount and character of the discharge have been observed : (1) The flow is abun- dant and prolonged, the liquid contains a large proportion of chloride of sodium and but little albumin, and is then doubtless the cerebro-spinal liquid of the subarachnoid space and sinuses escaping through frac- ture of the internal auditory canal and rupture of the tympanum. (2) The flow is similar, but the liquid is highly albuminous and without chlo- ride of sodium ; autopsy in some cases has shown a fracture through the middle and internal ear but not through the internal auditory canal ; the liquid is probably lymph coming from the large arachnoid lymph- space which normally communicates with that occupied by the peri- lymph of the labyrinth or liquid Cotunnii. (3) The flow is abundant and albuminous, becoming scanty and purulent ; probably an inflam- matory discharge from the surface of the cavity of the tympanum. (4) The flow is scanty, appears late, is albuminous and reddish, and is probably the serum of extra vasated blood. 1 Deafness of the ear of the affected side is due to injury of the middle or internal ear or of the acoustic nerve in its passage through the bone. 1 For interesting details of these symptoms the reader is referred to Hewett, in Holmes's System, vol. i. ; Von Bergmann, in Deutsche Chirurgie, Lief. 30, and Roswell Park. 142 FRACTURES. Paralysis of other cranial nerves is occasionally observed, the result of direct injury of the nerve or of pressure upon it by extra vasated blood ; the facial is the one most frequently affected, then the abdu- cens. Paralysis of the limbs is caused by intracranial hemorrhage. Slowing of the pulse and irregularity of the respiration indicate hem- orrhage in the medulla. Fissured fractures of the vault are sometimes recognizable by a differ- ence in the level of the fr\vo sides and even in rare cases by the inde- pendent mobility of the two parts of the cranium. Auscultatory percussion has been alleged to be a means of recognition of a fissure, but I have found it wholly untrustworthy. The general symptoms are the same as when the fracture occupies the base and are dependent upon similar lesions of the brain. Emphysema of the scalp is a rare symptom and is due to the escape of air into it after fracture opening the mastoid, frontal, or ethmoid sinuses. The treatment of these fractures is medicinal and expectant : absolute quiet, light diet, laxatives, and cold to the head if indicated by rest- lessness, headache, or other symptoms of cerebral irritation. In frac- tures of the base with bleeding from the ear a light plug of iodoform gauze may be placed in the external meatus, but more active measures to disinfect this region seem to me wholly uncalled for in view of the fact that a route for infection from the mouth through the Eustachian tube remains and cannot be protected. Gushing l has reported excellent results in cases of bursting fracture with symptoms of compression from the " subtemporal decompressive operation;" 13 recoveries out of 15 cases. His incision runs from a point about midway between the edge of the orbit and the top of the ear upward and backward. The fibres of the temporal muscle are drawn widely apart, a disc four centimeters in diameter removed from the temporal bone, and the dura opened. Drainage is maintained for two days. I do not think it should be adopted as a routine treatment. Some cases are plainly hopeless from the beginning; others — 35 per cent, in my statistics — recover, generally without having shown alarming symp- toms at any time ; others, in an intermediate class, those which without evidence of a probably fatal injury at the beginning, do not improve but instead grow worse, may be proper subjects for decompression. When the fracture involves the vault and is compound the wound should be thoroughly cleansed, and to this end it is proper to chisel away the sides of the fissure, but I do not think it judicious to enlarge the wound in the scalp in order to follow up the fissure and treat it thus throughout its entire length. The interference is solely for disin- fection, and in fresh cases we may be confident that infection has not passed much beyond the limits of the external wound. Depression of one side of a fissure of the vault is not a justification for making an incision through the unbroken skin. 1 Cushing: Annals of Surg., May, 1908, p. 641. FRACTURES OF THE SKULL. 143 The same principles apply to the treatment of the intermediary group — extensive comminuted fractures with marked general cerebral symptoms. The important lesion is that of the brain, and it is not probable that good can be got by removal of fragments or relief of depression that will compensate for the risk incurred in dividing the unbroken scalp. Possibly the relief of tension by draining away the exudate through an incision may be an important advantage, but this has not been demonstrated. If the fracture is compound the wound must be cleaned and protected, and advantage may be taken of it to do whatever the condition of the bone requires, but this cannot be expected to have any important influence upon the progress and out- come of the injury. Certain exceptional forms of injury require separate description. Possible Fracture of the Internal Table. When the skull has been contused (compound) by a blow of the kind known sometimes to produce fracture of the internal table, such as a glancing bullet or a sharp blow by some small object, there can be no serious objection to trephining in order to insure cleanliness and determine the condition of the internal table, if care is taken not to open the dura ; and even when the skin is not broken, if well-marked symptoms of localized cerebral injury are present, a similar interference would, I think, be justifiable as an attempt to relieve a local and limited injury. But, I repeat, the known instances of fracture of the internal table alone are very few, and almost ail of them compound and fatal by infection through the scalp wound. If it is claimed that there are many simple (not compound) ones which pass unrecognized because the patient recovers, it must be added that that then is proof that an operation is not always necessary. The diagnosis of probable fracture of the internal table has been not infrequently made for no better reason than that no other could be positively made. Such mis- takes would be less frequent and officious treatment would be rarer if the fact was fully appreciated that early general cerebral symptoms mean generalized cerebral lesions, and that such cannot be relieved by local measures. For the latter there must be local indications. Rupture of the Middle Meningeal Artery. Rupture of the middle meningeal artery or of one of its branches by a fracture crossing its course, or even without fracture, is a not infre- quent injury of great importance and requiring immediate operative relief. As the vessel lies in a groove on the inner surface of the bone and is covered by the 'dura, the hemorrhage commonly takes place between the dura and the bone, stripping up the former sometimes for a considerable distance and causing symptoms of local and sometimes of general compression. Usually there is an interval, half an hour to three hours (occasionally very much longer, even eight days in one of Konig's cases and four and nine days respectively in two of mine), be- tween the blow and the development of the symptoms, an interval 144 FRACTURES. during which the patient may seem entirely well, but which in other cases may be masked by the symptoms of cerebral injury occasioned by the primary violence ; the recognition in the latter case must then come through the steady increase in the symptoms and frequently the limited paralyses caused by pressure upon portions of the motor area. The pulse becomes slow (pulse of pressure), and the pupils unequal, that on the side of the injury being usually dilated. The paralyses, of course, are on the opposite side of the body ; if limited they indicate a hemor- rhage between the dura and the bone ; if diffuse, a hemorrhage into the arachnoid space. Left to itself the injury terminates fatally in the great majority of cases. Relief must be given by removal of the extra vasated blood and arrest of the bleeding. The difficulty may be to determine the point at which the trephine is to be applied to meet the indications; the guides thereto are furnished by external evidences of injury, the seat of the fracture, the situation of the centres corresponding to the paral- yses, the anatomical relations of the artery, and the relative frequency of hemorrhage at different points. The artery runs from the foramen spinosum across the middle fossa and upward along the greater wing of the sphenoid and there divides into two branches. The most fre- quent seat of rupture and hemorrhage corresponds to the lower anterior portion of the parietal bone (anterior branch of the artery) ; the next, but much less frequent, corresponds to the lower posterior portion of the parietal and the adjoining portion of the occipital (posterior branch). The size of the extravasation varies greatly ; I have seen one of less than an ounce directly above the ear in which the symptoms — stupor and limited paralysis — were well marked and which was cured by operation. If the exact position of the extravasation cannot be determined and if no indication is furnished by a line of fracture or paralysis, an open- ing made near the point where the frontal, parietal, and temporal bones meet, say two finger-breadths above the zygoma and an inch behind the external angular process of the frontal, will expose the most fre- quent seat and also the anterior branches of the artery. An opening about three inches directly behind this will expose the posterior region. The opening should be made with the trephine or by removing a broken fragment, and if the extravasation is not at once encountered the dura should be carefully separated from the bone in different direc- tions in search of it. When found the blood should be picked or washed out if clotted, and bleeding points should be secured if possi- ble, or, failing that, the wound should be packed in their neighborhood. The artery is often difficult to secure, especially when its point of rup- ture is not within the opening made by the trephine. Temporary pressure with the finger, an artery clamp, or even a pad of gauze has been successfully employed. In all my own cases the bleeding has stopped spontaneously before the removal of the clot. FRACTURES OF THE SKULL. 145 Perforating Fractures of the Base through the Orbit. Perforating fractures of the base through the orbit are extremely grave and rarely accessible to treatment, the important lesions being usually that of the brain. In the extent of these lesions and their consequences the variations are very great. I have seen the breech-piece of a shot gun, about six inches long, driven into the brain through the nose and orbit and carried there, unrecognized, for more than two months, the patient recovering sufficiently to take a railway trip to the city in order to have the deformity of his face relieved; and in another a single birdshot which entered just above the tendo oculi and passed through the lower part of the frontal lobe directly back nearly to the Sylvian fissure caused death in a week without any evidence of inflam- mation and with only a minute intracranial hemorrhage. Sometimes an important feature is the wounding of the cavernous sinus or of a large artery. Another, and frequent one, is the infection of the deeper portion of the Mvound by the vulnerant body even if the superficial portion of the wound is small and heals kindly. The common cause is the passage of a small body — a bullet, cane, pencil — through or even between the eyelids. I have seen two cases in which a slender stick (the end of an umbrella in one) had thus penetrated and had broken off; both patients died, one after removal to another hospital and opera- tion there by the large omega-flap to expose the base of the brain, pro- fuse venous bleeding which could not be arrested was encountered and the patient died shortly after removal from the table. Similar wounds through the nose and mouth are even more exposed to infection. Summary. The principles of treatment may be thus summarized : Danger to life and function comes mainly from generalized contusion of the brain, large or small intracranial hemorrhages, and intracranial infection through an open wound; the fracture itself, as such, even when asso- ciated with depression, is rarely a factor in the fatal result. Against generalized cerebral injury the only treatment is medical — rest, sedatives, laxatives, cold to the head, unless experience should con- firm the value of Cushing's decompression. Against infection we have prevention and disinfection ; after it is fairly established disinfection and drainage have a restricted availability. Consequently, fractures of the base and fissured fractures of the vault not compound do not require operation. When compound, the wound may be enlarged suf- ficiently to permit disinfection of the area already exposed to infec- tion; and for the purpose of this disinfection a fissure may be enlarged, but this enlargement should not be carried much beyond the limits o^ the original wound. Depression of a portion of the skull below its normal level is not a condition which always needs to be corrected. The associated condi- 10 146 FRACTURES. tions which indicate its correction are limited paralyses or localized irri- tation due to pressure of the depressed portion upon the underlying portion of the brain. Conditions which justify its correction are an associated wound of the scalp and, in simple fractures with a well- defined small area of depression, the absence of symptoms of general- ized injury of the brain and consequently of fissures radiating from the depressed area which would favor the extension of infection if it should occur in the wound made for the relief of the depression. Epidural or subdural hemorrhage (rupture of the middle meningeal artery) requires operation for the removal of the extravasated blood and the arrest of hemorrhage. A monoplegia promptly following a blow upon the head is an indi- cation for the application of the trephine over the corresponding cor- tical centre, with the expectation of thereby removing a clot or a fragment which is making pressure on that portion of the brain. Late functional cerebral disturbances (epilepsy, etc.) appear to be so much more closely connected with injury of the brain and meninges which cannot be corrected by a primary operation than with traumatic irregularities on the inner surface of the skull which can be thus cor- rected, that an early operation for their prevention is not indicated. Severe meningeal or cortical inflammation, not connected with an external wound, is so rare that operation for its prevention is not indi- cated, and is, indeed, more likely to produce it than to prevent it. CHAPTER XL FRACTURES OF THE VERTEBRA. Fractures of the vertebrae have this in common with fractures of the skull, that most of their importance depends upon the associated injury of the nerve-centres and trunks contained within their canal, but they have in addition the importance due to the function of the spine as a support for the head and trunk. Upon the integrity of this support depend not only the power of locomotion, but also grace of carriage and dexterity in the use of the limbs. The spinal cord, occupying the centre of the vertebral column, is efficiently protected against any external violence that is not sufficient to break the bones that constitute the latter, or the ligaments and mus- cles that bind those bones together ; and the column itself is constituted in a manner that combines elasticity and mobility with the necessary firmness and rigidity. The bodies of the vertebrae, increasing in size from above downward in correspondence with the variations in the weight and strain which the different ones are called upon to bear, are composed of spongy tissue and separated from each other by the elastic intervertebral cartilages, and prevented from changing their positions by the interlocking of the articular processes upon the sides. The general form of the column is that of a long slender cone with a double antero-posterior curve, and its component parts are strongly bound together by ligaments and muscles allowing a range of motion which, while small between each pair of vertebrae, is in the aggregate consid- erable. Mechanically, therefore, the spine is exposed to fracture by direct violence, like other bones, and by indirect violence through exaggeration or straightening of its normal curves. In the displacements following fracture the corresponding joints may be dislocated, and as in dislocation there may be associated fracture, and as the symptoms in the two forms of injury are in many respects the same, they are sometimes grouped as " fracture-dislocations " of the spine. Fractures of the vertebrae are relatively rare, 0.5 per cent, in my statistics (Chapter I.). Gurlt collected 270 cases, with 444 fractures, and found that fractures of the cervical aud dorsal vertebrae are about equally frequent, 178 and 184 respectively, while those of the lumbar vertebrae, 82, are much less common ; that the fatal cases of fracture of the cervical vertebrae are, however, considerably more numerous, actually and relatively, than those of the two other regions ; that the fifth and sixth cervical, the last dorsal, and the first lumbar are more frequently broken than any of the others; and that it is common in fractures of the cervical and dorsal regions for more than one vertebra to be broken at the same time. They are extremely rare in childhood and old age, and relatively infrequent in women. 147 148 FRACTURES. The part most frequently fractured is the body of the vertebrae — that is, in about two-thirds of all cases, or in more than half of the fractures of the cervical vertebrae, in about seven-eighths of those of the dorsal vertebrae, and in about all those of the lumbar vertebrae. Or, in general terms, fractures of the bodies of the vertebrae begin at about the middle of the cervical region and increase in frequency down- ward. Simultaneous fracture of two or more vertebrae is common in the cervical and upper dorsal regions, less common in the lower dorsal, and rare in the lumbar region. Fracture of one or more of the ver- tebral processes either of the same or of adjoining vertebrae is common. Pathology. The fracture of the body of a vertebra may be complete or incom- plete ; the line of fracture may extend only partly through it or en- tirely across it, or it may be broken into several fragments, or com- pressed, or impacted. The line of fracture, if single, may be vertical, horizontal, or oblique in any direction ; the first being found almost exclusively in the cervical and upper dorsal regions, the two latter and multiple fractures occurring everywhere. The transverse and oblique fractures lie, as a rule, nearer the upper than the lower Fig. 58. Fig. 59. Transverse fracture of vertebra. Displacement of the vertebrae causing compression of the spinal cord. border of the bone, and may pass from the upper to the anterior sur- face, leaving the posterior and lower surfaces unbroken, and in these cases the upper fragment preserves its relations to the overlying ver- tebra and is displaced with it forward and downward, producing a change in the long axis of the spine characterized by an angle having its apex directed backward at the seat of fracture. This displacement narrows the antero-posterior diameter of the spinal canal and lacerates FRACTURES OF THE VERTEBRM. 149 Fig. 60. or compresses the spinal cord within it. If the line of fracture is oblique, and if fracture or dislocation of the articular processes is asso- ciated with it, the displacement is inclined to the corresponding side either directly or by rotation. Compression of the body of a vertebra is found either in combina- tion with comminuted fracture or alone, and involving one or several vertebra?. It is apparently caused by forcible forward flexion, in which either the posterior portions of the vertebra? must separate from each other or the anterior portions must approximate by condensation of the intervertebral disks or of the bone. The compression may be so extreme that the intervertebral disks above and below the affected vertebra are brought into contact with each other in front, the substance of the bone being partly compressed and partly forced out upon the sides or behind into the spinal canal (Figs. 61 and 62),eompressing the cord. With this compression may be associ- ated fracture or fissure of the body, and especially fracture of the processes of the same or the adjoining vertebra. anterior portion of the body may be produced by splintering of part of the bone or by impaction of one fragment into another lying above Compression of the last dorsal vertebra. The same shortening of the Fig. 61. Fig. 62. Fracture with compression of the third and fourth lumbar vertebra 1 or below it. The intervertebral disk may be partly squeezed out, bringing with it a scale of bone from either or both vertebrae. Fracture of the vertebral arches, according to Gurlt, is found in about half the cases of fracture of the cervical vertebrae, and onlv in one- 150 FRACTURES. seventh of those of the dorsal, and one-eighth of those of the lumbar. 1 He attributes the frequency of this form of fracture in the cervical spine to the comparatively greater breadth and less height of the arch and to the absence of that protection which is furnished in the dorsal and lumbar regions by the larger and stronger spinous, transverse, and oblique processes. When the arch is broken on each side the interme- diate portion bearing the spinous process may be driven into the spinal canal and cause fatal laceration or compression of the cord. Gurlt's statistics contain six such cases, affecting the fifth, sixth, and seventh cervical vertebra?. The spinous processes are broken most frequently at those points where they are longest and thinnest, nearly one-fourth of the cases occurring in the cervical spine, more than half in the dorsal, and about one-eighth in the lumbar ; and often several adjoining ones are broken at the same time. In the dorsal region this fracture is usually found only in combination with fracture of the body of one of the vertebras above or below it. Isolated fracture of a spinous process may occur as the result of direct violence, or of muscular action, and the displacement is either directly downward or to one side. Fracture of the transverse or articular processes occurs in combina- tion with other fractures in about one-sixth of all cases, but is rare except in such combination. In the few instances in which it has occurred alone it was the result of gunshot injury. As a complication of other fractures the proportion of its occurrence for the transverse process is greatest in the cervical and next in the lumbar and dorsal regions ; for the articular processes it is greatest in the cervical and smallest in the lumbar. Fracture of a transverse process of a dorsal vertebra may lead to fracture of the rib which articulates with it, and fracture of the transverse process of a cervical vertebra may seriously injure the vessels contained in the vertebral canal. Fracture of an articular process exposes to dislocation of the vertebra with all its accompanying dangers. The ligaments which bind the different vertebras together are torn in fracture to an extent which varies with the severity of the injury and the degree of the displacement, and the intervertebral disks may be torn, displaced, or compressed. In rare cases the injury may be confined to the ligaments and disks — real dislocation or diastasis with- out fracture — although the distinction cannot be made during life. The spinal cord, the diameter of which is considerably less than that of the canal in which it lies, is suspended within the dura mater, which is itself loosely connected with the bones and separated from direct con- tact with them in most places by a rich venous plexus. The medul- lary portion of the cord ends at the first or second lumbar vertebra, and its lower portion is enveloped by the numerous nerve trunks which pass downward to form the cauda equina and the lumbar and sacral plexuses. The cord is injured directly only when the lumen of the canal is considerably encroached upon by the displacement of a frag- 1 For cases of doubtful character in the lumbar vertebrae, see section on Course and Ter- minations. FRACTURES OF THE VERTEBRM 151 ment or of a vertebra, but it can be compressed by extravasated blood or by inflammatory exudations, or torn by elongation. T have seen it so injured in fracture of both laminae of the sixth cervical without displacement, by anterior flexion of the neck, as to cause immediate paraplegia and death in a week. Occasionally the cord is penetrated by a sharp fragment, but usually the dura mater is untorn and the cord is crushed between the anterior portion of one fragment or vertebra, usually the lower, and the posterior portion of another, usually the upper. This crushing presents all degrees, from a slight flattening to complete disorganization, and apparently the medullary portion is more easily and permanently injured and destroyed than the nerve-fibres in the columns beside it. Hemorrhage, Haematomyelia. Hemorrhage, without division of the cord, may be extra- or intra-dural, or within the substance of the cord (haematomyelia). Hemorrhage outside the cord spreads upward and downward within the canal and produces changes and symptoms by pressure upon the cord. Haematomyelia is apparently caused by forcible elongation of the cord in hyperflexion or extension of the column, with or without recog- nizable lesion of the ligaments or bones; it is seen almost exclusively in the lower cervical and upper dorsal region, but sometimes near the junction of the lower dorsal and lumbar regions. The condition, first pointed out by Thorburn and Minor, of Moscow, about 1890, has been recently studied in detail by Bailey 1 and Bolton. 2 The hemor- rhage takes place in the gray matter of the cord and may be very closely limited to it, spreading upward and downward in it through two, three, or even more segments. If the lesion is more severe the hemorrhage may extend into the white columns as a clot, or appear there as punctate extravasations. If the patient survives the blood is absorbed, leaving cavities within the cord which contain a viscid liquid and tend toward obliteration by formation of connective tissue. The elements of the gray matter, cells and fibres, which are injured by the hemorrhage appear to be incapable of repair with restoration of function, but pressure-effects upon adjoining parts may be, and ap- parently frequently are, recovered from. Consequently, the recogni- tion of the condition is of great importance in prognosis and in deter- ring from active surgical interference. Apparently most of the cases of injury to the neck which recover after having presented symptoms of severe injury to the cord are cases of haematomyelia. In a notable number of them the injury has been caused by diving into shallow water, the head being thrown forcibly back to avoid contact with the bottom. Etiology. The immediate causes are muscular action and external violence. The former is very rare and acts either by a direct pull of the muscle upon the process to which it is attached or by the momentum given by the head in sudden dorsal flexion of the neck or rotation of the head. The most frequent examples of the latter (producing either 1 Bailey: Med. Record, Nov. 19, 1898. - Bolton: Annuls of Surg., An-.. 1899. 152 FRACTURES. fracture or dislocation of the cervical spine) have been in cases in which the patient has dived into shallow water and has thrown his head backward to escape contact with the bottom. The commonest cause is the forcible bending of the spine in a fall or, less frequently, by the weight of a falling object or by the com- pression of the body in a narrow space, as in driving under an archway (indirect fracture). The relative frequency of the injury at> the lower part of the cervical spine and at the junction of the dorsal and lumbar segment seems to be associated with the fact that at these points the more flexible and the more rigid portions of the column meet, such meeting points being specially liable to break in all combinations of flexible and rigid bodies. Fractures by direct violence are infrequent and are usually found in the posterior portion of the vertebra. Symptoms and Diagnosis. (See also Dislocations of the Vertebrae.) The symptoms of fracture of the spine vary with the position and the portion of the vertebra involved, and therefore need a separate and detailed consideration in connection with the different groups of frac- tures. But there are certain general symptoms common to most which may first be mentioned. After the first shock of the injury, which usually passes off without permanent impairment of the intelligence, the patient complains of a localized pain at the seat of fracture increased by manip- ulation or movements. There is usually a recognizable deformity con- sisting of a change in the direction of the spine, a more or less marked angular projection backward with or without swelling of the surround- ing soft parts ; crepitus can sometimes be made out by the surgeon, but more commonly it is appreciable, if at all, only by the patient himself when his body is moved. The most important and constant symptom is paralysis, motor and sensory, more or less complete, of the limbs and the portion of the body lying below the fracture. If complete its upper limit is usually sharply defined by a line crossing the trunk and corresponding to the adjoining limits of the regions supplied by the nerves that leave the column immediately above and below the point at which the cord has been injured. The consequences of this paralysis, if it involves the abdominal muscles, bladder, and rectum, are reten- tion of urine and feces, followed by incontinence of one or both, by alkaline fermentation of the former, and cystitis. Respiratory diffi- culties, sometimes severe enough to cause death, appear when the frac- ture involves the upper portion of the spine, the result of the paralysis either of the abdominal muscles or of the diaphragm, or of vasomotor injury. There is also a great tendency to sloughing at all points of pressure within the paralyzed region, especially over the sacrum and trochanters and along the back. The sloughs appear promptly, some- times within two or three days, are usually symmetrical, and often hasten death even if they are not its immediate cause. Paralysis is, of course, only a symptom of injury to the cord and FRACTURES OF THE VERTEBRJE. 153 may follow violence that has caused neither fracture or dislocation. Thus, a diastasis of two vertebrae, followed by immediate return to their normal relations, may cause hemorrhage into the canal or may even injure the cord by elongation and thus cause paralysis. A paral- ysis appearing shortly after an injury, and increasing, generally indi- cates hemorrhage into the canal, but I have seen it caused by displace- ment, with pressure, occurring during the transfer of the patient to hospital, the condition being shown by autopsy. Extension of paralysis indicates hemorrhage or an ascending mye- litis. In hsematomyelia there is immediate motor paralysis (usually para- plegia, but occasionally hemiplegia, when only one gray column is affected) which is transient except for those muscles whose spinal nuclei in the gray matter have been destroyed by the hemorrhage. Thus, when the lesion is situated in the lower cervical region the paral- ysis of the lower limbs and the sphincters promptly disappears, but that of the muscles of the forearm and hand remains in part. The interference with sensation is constant and characteristic : there is loss of sensibility to heat and cold (thermo-anaesthesia) and usually insensi- bility to pain (analgesia) also, but tactile sensibility is not aifected. Bailey says the distribution of these disturbances is the same as that of the anaesthesia of a corresponding transverse lesion of the cord, but that it may present the Brown-Sequard type, namely, motor paralysis of one arm and leg with loss of pain-sense and temperature-sense in the arm and leg of the opposite side. The tendency is toward improvement, and sometimes recovery is complete. The reflexes are at first lost, then slowly regained. In complete transverse injury there is permanent complete paraplegia and loss of all kinds of sensation and of the reflexes. In incomplete transverse injury there is irregular paraplegia, the sensibility to pain, touch, and temperature may persist or be regained in limited areas below the lesion, and the reflexes return and become exaggerated. Priapism, more or less complete, was observed, according to Gurlt, in 31 of 96 cases of fracture of the cervical and two upper dorsal ver- tebrae, 16 times in 133 cases of fracture between the third dorsal and second lumbar vertebrae, and never in fracture below the latter. It appears promptly, usually on the first or second day, and seldom lasts longer than a fortnight. Notwithstanding the insensitiveness of the penis it may be caused or increased by the use of the catheter. On the other hand, in one case the erect organ became relaxed as soon as the catheter had passed over half the length of the urethra. Ejaculations are very exceptional, there being only four instances in Gurlt's collec- tion, all of them in cases of fracture of the cervical spine. Fracture of Atlas and Axis. The intimate relations existing between these two bones and the medulla oblongata, and their position above the roots of the phrenic nerve as well as above those of the other nerves supplying other 154 FRACTURES. Fig muscles which aid in respiration, make their injury especially danger- ous, and have probably led to the generally received opinion that their fracture is, as a rule, immediately fatal. Gnrlt's cases show, however, that this opinion is not correct, for in the eleven in which the nature of the injury was demonstrated by the autopsy, death occurred imme- diately in only two, and in only two others within an hour after the injury was received. In the other cases the patients survived for a considerable length of time, thirteen days in one, although some of them at the last died suddenly, apparently by displacement of the ver- tebrae due to incautious movements. The fractures were all caused by external violence, sometimes slight, as a fall from the bed while trying to reach down to the floor. The parts broken in ten of these eleven cases were : the odontoid process alone once ; the odontoid process and posterior arch of the atlas three times ; the posterior arches of the atlas and axis three times ; the poste- rior arch of the axis alone once ; the spinous process of the axis twice. In six of the cases there was associated fracture of other cervical or dorsal ver- tebrae, and in no case was the trans- verse ligament torn. Figure 63, taken from a specimen in the museum at Braunschweig, shows a fracture of the superior articular surface of the axis. The patient was twenty-four years old, and died in a few hours after falling out of a wagon upon his head. The symptoms of this fracture are so variable and so indefinite and have so much in common with simple dis- location of one bone upon the other, or of the atlas upon the skull, that the diagnosis is extremely diffi- cult. On the one hand, the patient may die instantly ; on the other, he may survive a longer or shorter time, either completely paralyzed or presenting no important symptoms, and then die suddenly by dis- placement of the fragments or gradually by extension of the symp- toms, or in consequence of other injuries, or, if the diagnosis in some such cases may be accepted, may even get well. The symptoms of local pain and stiffness of the neck are too indefinite to be of any ser- vice, and paralytic symptoms may be entirely absent, as in Gurlt's second case, where the patient walked for two hours after the accident to reach home and developed no paralysis until the following day. Death took place suddenly on the eighth day, and the autopsy showed fracture of both arches of the atlas and of the odontoid process. The symptoms in those of Gurlt's eleven cases which survived long enough to present any, or in which any are recorded, were complete paralysis of all the parts below the fracture in some, partial paralysis in others, only a slight diminution of sensibility in the left arm in one, pain in the neck or occiput in six, rigidity of the neck in most, absence Fracture through the superior articular surfaces of the axis. (Gurlt.) FRACTURES OF THE VERTEBRJE. 155 of recognizable deformity in all, distinct cripitus in one, and falling forward of the head upon the breast in one. All of these symptoms — pain, rigidity, paralysis, sudden death — may be the result of dislo- cation as well as of fracture, and, as dislocation has in addition no general or local characteristic symptoms which serve to distinguish it, the differential diagnosis must usually remain in doubt. Fractures of the Lower Five Cervical and First Two Dorsal Vertebrae. The special characteristics of fractures of this region are due to the inclusion within it of the roots of the phrenic nerve and brachial plexus. The former passes out through the intervertebral foramen between the third and fourth cervical vertebrae, either coming from the fourth cer- vical pair alone, or receiving branches also from the third and fifth pairs. The brachial plexus is formed by the four lower cervical and the first dorsal pairs. Consequently, if the fracture is accompanied by displacement of the fragments and injury to the spinal cord, paralysis of the upper limbs also is caused, and if the fracture is high enough in the region to involve the phrenic nerve directly or by extension death follows promptly, preceded by the respiratory symptoms peculiar to lesion of this nerve. Here, too, as after fracture of the altas and axis, are found cases in which the patients present only symptoms of paralysis for a longer or shorter time, and then die suddenly of asphyxia in consequence of some accidental or intentional movement of the head, which probably causes compression of the phrenic nerves by displacement of the fragments. The paralysis in fractures of the portion of this region below the fourth cervical vertebra shows many variations. From the relations of this part to the brachial plexus it might be expected that paralysis of the upper limbs would be a constant symptom, excluding those cases in which there is no displacement, but Gurlt's tables show this paral- ysis to have been present in less than one-fourth of the cases, that in the majority complete paralysis of the lower portion of the body extended upward at first only to the middle of the breast, the second rib, rarely to the neck, clavicle, or shoulders, and sometimes not even to the umbilicus, although it often advanced to a higher point later in the progress of the case. Paralytic symptoms appeared in the arms, as a rule, either later on the day of the accident or on the following day. The paralysis may be complete in one arm and partial or absent in the other ; it may be complete of motion and incomplete of sensa- tion, or the reverse ; it may be limited to the arm or to the forearm : or the injury to the nerves may be evidenced by abnormal sensations, such as numbness or prickling in the limb. Probably incompleteness of paralysis is due in most cases to the conservation of some of the nerve fibres, although the medullary position of the cord is completely destroyed by crushing. Hyperesthesia affecting the whole or part of the limb is occasionally observed, and is sometimes associated with sharp, lancinating, continuous or intermittent pain, which may be spontaneous or may be excited or increased by the slightest touch of the surface. Tonic or clonic spasms are seen somewhat more 156 FRACTURES. frequently than hyperesthesia, sometimes limited to the arms alone, sometimes involving other muscles also. An important consequence of the paralysis is the change in the respiratory act due to the withdrawal of the aid of the accessory mus- cles when the phrenic nerve is uninjured. As a consequence of the paralysis of the intercostal and abdominal muscles, inspiration is effected by the diaphragm alone, and expiration by the weight of the abdominal walls and viscera which sink back to the positions from which they have been displaced by the contraction of the diaphragm. As the expiration is thus purely passive the patient cannot sneeze or cough strongly, and as he is thus prevented from clearing his lungs of the mucus which collects in them it gives rise to plentiful moist rales. If the phrenic nerve shares in the injury the diaphragm acts very slowly, perhaps not oftener than twice or thrice in the minute, the breathing is noisy or sighing, and the shoulders may be slightly raised at each inspiration. Sometimes a change in the position increases or diminishes the difficulty by modifying the pressure upon the cord. A noticeable slowing of the pulse accompanies this defec- tive respiration. The local symptoms are usually few and obscure, often nothing more than the pain that is felt at the seat of fracture and is increased by pressure or motion. Sometimes there are positive objective signs: an abnormal projection or depression of one or more spinous pro- cesses, an irregularity on the posterior wall of the pharynx produced by the displaced body of a vertebra, lateral displacement of one or more spinous processes, irregularity in the line of the transverse pro- cesses, and possibly crepitus or abnormal mobility. The position and mobility of the head vary greatly in different cases. In some cases they show nothing abnormal, in others the head can be moved freely to either side, but not forward or backward, and in others it is held firmly fixed in some one position and any attempt to change that position causes pain. This rigidity is due not to change in the relations of the articular surfaces, but to the involuntary spasmodic contraction of the muscles which is nature's method of pre- venting the infliction of pain by movement of the parts. It is to be borne in mind that, as stated above, this is the region in which traumatic hsematomyelia almost exclusively occurs, and that examination of the sensibility to heat, cold, and pain should be made whenever, in connection with more or less motor paralysis, there is preservation of the touch-sense. It is apparent that the diagnosis of fracture of this region may be difficult or impossible. The most that can be done in many cases is to recognize approximately the seat of the injury. Thus, paralysis or symptoms of irritation in the arms, even if they first appear after some delay, indicate a lesion above the second dorsal vertebra, although in a few exceptional cases this symptom has existed when the injury was lower on the spine, and was then due probably to an associated brain lesion or a large collection of blood within the spinal canal. If all local and functional signs are absent the diagnosis is, of course, impossible, and the real nature of the injury may be entirely over- FRACTURES OF THE VERTEBRAE. 157 looked uotil the progress of the inflammation or a chanee displace- ment of the fragments brings it to light. The prognosis is extremely unfavorable. Gurlt's tables contain 96 fatal cases, and only 8 which ended in recovery, and in one of these the symptoms reappeared after a fall and the patient died in conse- quence. In one-third of the cases death took place within the first four days; in 20 between the fifth and twelfth; in 11 between the thirteenth and thirty-sixth ; and in one case the patient survived five months. I have known two cases in which life was prolonged more than a year, without change in the paralysis. In hsematomyelia the prognosis is much more favorable. Fractures of the Lower Ten Dorsal and First Two Lumbar Vertebrae. This region includes another point at which fractures are very common, the lower dorsal and the first lumbar vertebrae. Its position below the origin of the brachial plexus prevents the involvement of the arms in the paralysis except in rare cases where this unusual exten- sion is due apparently to the spread of inflammatory softening of the cord or to the pressure of extravasated blood. Paralysis of the lower limbs, the bladder, and rectum, which is one of the common results of fracture in this division as well as in the higher ones, may be entirely absent at the beginning, especially after fracture of the second lumbar vertebra, or, more frequently, may be incomplete, the motor paralysis being, as a rule, more marked than the paralysis of sensation. The latter may extend as high as the lower part of the breast, or may stop at the groin, and sometimes even does not reach above the lower part of the thigh. A common result of the paralysis is the immediate retention of urine and feces, followed, as before mentioned, by incon- tinence and by alkaline decomposition of the urine and cystitis. This incontinence persists until death takes place or improvement begins. The disturbance in the function of the bowels aided by the flaccid ity of the abdominal muscles produces tympanites, which makes its appearance usually within a day or two and may be sufficiently marked to interfere with respiration by crowding the diaphragm upward and opposing its contraction. In other cases, even of apparently severe injury to the body of a vertebra, there may be an entire absence of paralytic symptoms and even of those of meningeal irritation. The diagnosis is aided by objective symptoms, which are more marked and distinctive than those found after fractures of the upper portion of the column, because as the fracture in the great majority of the cases involves the body of the vertebra, and is comminuted or accompanied by displacement, there is usually a recognizable deformity consisting in an angular change in the long axis of the spine, with projection of the spinous process of the broken vertebra or of the one immediately above it. This change in the position of the spinous process is sometimes so marked that the finger can be pressed deeply in between it and the next lower one. The possibility of traumatic hsematomyelia in the lower part oi % this region must not be overlooked. 158 FRACTURES. The prognosis, as regards both life and recovery of function, is more favorable than after fracture at a higher point. Fractures of the Lower Three Lumbar Vertebrae. Fractures of this portion of the spine appear to be exceedingly rare. 1 The absence of paralytic symptoms and recognizable displace- ment would make the diagnosis during life practically impossible. As this portion of the spinal canal contains only nerve trunks, which are better fitted by their texture and comparative independence of each other to resist or escape damaging pressure by displaced fragments than the spinal cord itself is, paralysis may be absent even when the dis- placement is marked ; in some cases it has been Complete, both of motion and sensation, over the limbs and abdomen. The patient may, however, be unable to walk in consequence of the loss of support occa- sioned by the fracture, or he may walk only feebly and in a bent pos- ture. But if union takes place, even if the deformity persists, he may be as strong and capable as before. In short, the prognosis is favor- able as regards both life and function. Course and Terminations. The course and terminations of fracture of the spine, with their many variations as regards both the life and principal functions of the patient, have been indicated in the preceding section ; we have now to consider the changes effected in the broken bone by the process of repair, and to describe some of the later symptoms with more detail. Repair takes place by a callus which may remain fibrous, but is usually bony and possesses ample solidity notwithstanding the com- mon persistence of displacement. In fractures that have been healed for a long time is found the same absorption of projecting angles and sur- faces which has been noticed in connection with other fractures, and this absorption is especially marked in the bodies of the vertebrae. If several adjoining vertebrae are broken at the same time the inter- vertebral disks disappear in part by absorption, and the remaining portions undergo partial or complete ossification, uniting structurally with the vertebrae, and thus forming a more or less extensive, rigid, bony mass. The length of time required for consolidation appears to be greater than for that of other spongy bones. A number of instances of complete pseudarthrosis have been re- corded and their origin differently interpreted. Gurlt collected 21 such cases : 1 of the odontoid process, 4 of the spinous processes of the cervical, dorsal, and lumbar vertebrae, and of the sacrum, 3 of the transverse processes of lumbar vertebrae, 11 of the arches of lumbar vertebrae, and 2 of the side of the upper false vertebra of the sacrum. Meckel considered the 11 cases involving the arches of lumbar ver- 1 If the specimens of supposed ununited fracture of the arch of these bones, which have been found upon the dissecting-table, in museums, and in old Indian graves, are accepted as such, they raise the question whether similar fractures are not more common than has been supposed, and whether they may not be present, without displacement, in some of the severe, so-called strains of this region. FRACTURES OF THE VERTEBRJE. 159 tebrae as instances of arrest of development, comparing them with the vertebrae of some reptiles, which consist normally of a separate body and arch, and in which many of the processes also remain ununited. Otto opposed this view, because the position of the false joint does not correspond to that of the line between the diaphysis and epiphysis, and Wyman, 1 who reported eleven additional cases and did not know of these earlier ones, held the same opinion for the same reason. Gurlt accepted Meckel's opinion concerning the arches of the lumbar verte- brae, and claims that it is probably true also of the other cases. His reasons are that there is no trace of injury to other parts, and that it is known that fracture limited to a vertebral arch, a spinous, or a trans- verse process is exceedingly rare ; that most of the cases relate to the lowest lumbar vertebrae, fractures of which, of any kind, are rare, and in the case of the fifth unknown ; and that the identity of the position of the joint in all corresponding cases, and its perfect structure, point strongly to an arrest of development, and are incompatible with a frac- ture by external violence. Shepherd 2 reports another of the fifth lumbar vertebra found in the dissecting-room. Suppuration at the seat of fracture, which is very rare in other bones, seems to be more common after simple fracture of the spine, and is attributed by Gurlt to the greater complexity of the anatomical condi- tions and to the less perfect immobility maintained during the progress of the case. His statistics contain eight cases in which, excluding instances of suppurative meningitis, more or less pus was found after death at the seat of fracture. As to the recovery of the cord after injury, with restoration of func- tion, nothing definite is known beyond the fact that a number of autop- sies made at various periods after injury have shown the cord more or less completely divided, or reduced to pulp at the compressed part, or replaced by fibrous tissue. There is nothing to prove that a disinte- grated portion can be restored, or that divided cords can be reunited, and it is not easy to see how proof of such a fact could be furnished except by experiment. In those cases in which paralysis has disap- peared after a time, it is impossible to know exactly what was the nature of the lesion of the cord that caused it, but probably most of them are cases of moderate haematomyelia. In one or two cases recently published, in which a partial division of the cord has been demonstrated by operation, partial recovery of function has followed. I doubt if this can be held to prove more than that nerve-fibres of the cord can reunite, with re-establishment of conduction. That destruction of the gray matter can be made good must still be deemed unproved, and unfortunately that destruction is the common lesion in fracture. The troubles created by paralysis of the bladder are very serious, and often hasten a fatal termination. They begin, usually promptly, with retention, which if not looked for by the surgeon may pass unno- ticed, since it gives the patient no pain, until the distention of the bladder has become so great that the urine begins to dribble away 1 Wyman : Boston Medical ami Surgical Journal, August U, 1869, 2 Shepherd : Montreal Medical Journal, June, 1892. 160 FRACTURES. through the urethra. The symptoms aud usual consequences of the consequent cystitis are such as are commonly observed when the same affection is excited by other causes, and do not require a detailed de- scription here ; but in addition to these common ones there are occa- sionally observed others of great gravity, such as sloughing of the wall of the bladder, and pericystitis with formation of abscesses. Every effort should be made to delay the appearance of this compli- cation and to diminish its severity, and with this object the water must be regularly drawn as soon as the first signs of retention appear. It is usually sufficient to use the catheter twice a day ; it must be steril- ized and passed with even more than the usual precautions and gentle- ness because the patient's insensitiveness creates an additional risk of doing damage unwittingly to the urethral wall. After cystitis has appeared and the urine has become turbid, the bladder should be washed once or twice a day. Permanent drainage of the bladder through a perineal or suprapubic incision has been employed with advantage. Bed-sores appear promptly after any fracture that has caused para- plegia by a complete transverse lesion of the cord, but are absent in hsematomyelia. The skin at first becomes white, then mottled, and then sloughs, and the slough spreads peripherally and in depth. The commonest seat is the skin covering the convexity of the sacrum, then other prominent points upon the back and legs. The cause of this early sloughing has been thought to lie in injury to nerves or nerve centres presiding over the nutrition of the parts; but Mr. Shaw 1 explains it by the pressure which is continued for a length of time and with an absence of interruption unknown except in connec- tion with paralysis. Not only is the patient unable to move, but he is insensitive to the prolonged pressure, and does not seek to change his position or to have it changed. He lies absolutely motionless in one settled position ; the pressure interrupts the circulation at certain points, and, if this interruption continues unrelieved, the part dies. The presence of urine or liquid feces may prove an additional source of irritation, as may also creases or irregularities in the bed-clothing, and lack of attention and scrupulous cleanliness. The rapid improve- ment which sometimes takes place in these sloughs, even when the paralysis remains complete, as soon as the consolidation of the fracture is sufficiently advanced to allow the patient to be readily moved, is corroboration of the opinion. Some cases which have recovered with permanent paraplegia have shown, on the other hand, a very marked tendency to the formation of sloughs on slight provocation, and in one case 2 the tarsal bones of both feet became necrotic. In those cases in which the patients survive the injury and its more immediate consequences, it is sometimes found that the paralysis grad- ually diminishes and may even disappear entirely. The beginning of the improvement is sometimes marked by the appearance of sharp darting pains in the limbs and of muscular twitchings excited by slight causes, such as pinching or touching the skin ; then the power of vol- 1 Shaw : Holmes's System of Surgery, Am. ed., vol. i. p. 810. 2 Courier Medical, November 11, 1882. FRACTURES OF THE VERTEBRA. 161 untary motion returns, first in one muscle, then in another. Sensation returns usually before motion ; the bladder is found to be again able to retain a certain quantity of urine and to expel it with some force ; and a similar improvement is presented by the rectum, although, as a rule, even in the best cases, the functions of the rectum and bladder remain partially and permanently disabled. The improvement in the paralysis may be very slight, or it may go on to complete restoration of function, or it may be arrested at any intermediate stage. Cases have been referred to in which a permanent deformity existed, but the functions of the body and limbs were in no manner disturbed by it. Finally, after a short period of apparent recovery, symptoms of progressive degeneration of the cord or of pachymeningitis may appear. Treatment. The indications, as in other fractures, are to reduce displacement and to immobilize until repair shall have taken place, but the limita- tions which exist in so many other fractures exist here to an even greater extent because of the uncertainty as to the character of the displacement, the difficulty in modifying it as desired, and the fre- quent association of dominant lesions of the cord which cannot possibly be remedied. The condition of the cord, as indicated by the symp- toms, should usually determine the measure of benefit to be expected from treatment, but unfortunately we cannot distinguish with certainty between a complete division or crush of the cord which cannot be repaired and compression by bone or extravasated blood which will be recovered from if the pressure is relieved. We know that in the great majority of cases, a majority which is greater the higher the injury is situated in the vertebral column, the condition of the cord is hopeless or at the most can only be mitigated. In the first care of the patient — transport, undressing, examination — he must be handled with constant watchfulness to avoid producing or increasing displacement. Then, if the fracture is of a spinous pro- cess alone or of the column without recognizable displacement and without symptoms of injury of the cord, confinement to the bed, pref- erably aided by a plaster-of-Paris corset, is all that is required. If there is recognizable displacement — gibbosity of the spine — with- out cord symptoms immobilization in the plaster corset is indicated, with or without an attempt to correct the displacement. If symptoms of pressure on or injury of the cord coexist an attempt should be made to relieve the condition by correcting the displacement. The means of accomplishing this are traction upon the trunk to straighten it by elongation, direct pressure forward upon the project- ing angle, and open operation. When the injury is in the cervical or upper dorsal region traction can be made by turning the patient upon his side and pulling by the chin and occiput; and by gradually changing the direction of the traction by moving the head backward while pressure is made against the spine below the fracture the angular displacement can sometimes be completely corrected. But when the injury is at a lower point, and 11 162 FRACTURES. especially if the patient is large and heavy, traction thus made is not sufficient even with the aid of anaesthesia ; and even pressure with the knee or hand against the angle (the patient being on his side) while the hips and shoulders are pressed backward may fail to make any change in the condition. Suspension by the apparatus used in disease of the spine has been employed by some with advantage, but I have not ventured to try it. Fig. 64. Fracture of spine. Correction of the displacement by suspension and plaster jacket. Instead, I have used a long plank, placing the patient upon it, secur- ing his shoulders to one end, and then gradually raising that end so that the lower limbs would make the desired traction by their weight. While the patient is thus supported pressure forward upon the angle can be made by a bandage or stick passed between it and the plank. If the materials for a plaster corset have been previously prepared, in the form of broad strips of muslin or canton-flannel soaked in plaster cream, and placed at the proper point upon the plank before the patient has been laid upon it, the dressing can be easily and rapidly FRACTURES OF THE VERTEBRA. 163 completed while the patient remains suspended by bringing forward the ends of the strips around the body on each side. Dandridge recommends horizontal suspension on a narrow strip of stout muslin, like a hammock, which is then included in the plaster jacket. The method is praised by those who have employed it in Pott's disease of the spine. Or partial suspension can be made by a bandage resting against the angle of the gibbosity (Fig. 64). In a few cases an existing paraplegia has immediately disappeared during suspension, and although in others the symptoms have been temporarily aggravated I think we are justified in deeming the method safe and probably efficient to correct an angular displacement due to fracture or crushing of the body of a vertebra or of the pedicles or articular processes and also, though less certainly, a forward displace- ment of one segment. It cannot correct the much less common dis- placement forward into the canal of the posterior portion of the ver- tebral arch, the spinous process with one or both lamina?, or probably a fracture-dislocation in which one or both inferior articular processes of an upper vertebra have lodged in front of the corresponding supe- rior processes of the next lower one. In reduction by open operation a longitudinal incision is made along the median line with its centre at the apex of the angle of the frac- ture, and the soft parts separated on each side from the spinous process and laminae of the vertebra forming the upper part of the angle, cut- ting through both laminae, if unbroken, and removing them with the spinous process. If indicated the opening in the spinal canal is enlarged upward or downward by removal of the adjoining spinous process and laminae, and the displacement of the body of the vertebra is corrected by manipulation guided by the eye and perhaps aided by traction with a blunt hook passed into the spinal canal. Hemorrhage beneath the dura is relieved by evacuation through an incision. A large number of cases have been thus operated upon during the last few years, and apparently with marked benefit in some, but it is still too early to formulate a rule of practice. It is admitted by all that the operation can do good in only a small proportion of cases, and it is probable even that that proportion is less than is indicated by the statistics because it is not clear that the improvement which has sometimes followed was the result of the operation ; similar improve- ment has been noted in apparently identical cases not operated upon, some of them probably cases of haematomyelia. It must also be admitted, I think, that the operation is not likely to do harm and that occasionally it discloses an important condition which could not other- wise be recognized and corrected. My own inclination is strongly toward reliance upon traction and the plaster jacket, systematic use of which might show a gain as great as that which Bun-ell 1 found in the Boston City Hospital : 33 per cent, of recoveries as against 2'2 per cent, under expectant treatment. I believe, for reasons above given. that in the common form of injury with angular displacement — gib- bosity — reduction can almost always be accomplished as well in this way as by operation, and that the latter may find its special indica- 1 Burrell : Annals of Surgery, February, 1895. 164 FRACTURES. tions in eases of intraspinal hemorrhage and those rare ones in which the posterior portion of the arch is driven into the canal and presses upon the cord. Thorburn, 1 after a personal experience of seven cases of operation and study of about 200 published cases, says he has found no clear evidence of benefit from it. Nevertheless, he deems laminectomy justifiable " (1) in compound fracture ; (2) in injuries of the laminae and spinous processes with lesion of the cord when the crush is probably incomplete; (3) when the symptoms are mainly or entirely due to thecal or perithecal hemorrhage; (4) in pachymenin- gitis or peripachymeningitis, which may follow an injury after a very long period ; and (5) in cases of compression of the cauda equina." Of the great value of the plaster jacket, applied during suspension, in aiding consolidation of the fracture in cases in which the disability is due to the fracture rather than to injury of the cord, there can be no question. 2 The general treatment, when paraplegia is present, is to place the patient upon a water-bed, carefully prevent irritation of the skin by moisture or creases in the sheets, and regularly empty the bladder and bowels. Later in the case electricity may render some service. 1 Thorburn : Lancet, August 11, 1894. 2 See Papail, De l'emloi du corset platre dans les lesions de la colonne vertebrale, Paris, 1887. CHAPTER XII. FRACTURES OF THE BONES OF THE FACE. 1. Fractures of the Nose. Under this term we include not only the two nasal bones, but also those upon which they rest, the septum, the nasal process of the supe- rior maxillary, and the nasal spine of the frontal. The fracture may involve one or both nasal bones or adjoining processes ; it may be simple or compound, multiple or comminuted ; and it may be associated with other fractures of neighboring bones, the most important of which is fracture of the cribriform plate of the ethmoid. In the great majority of cases the fracture is a more or less comminuted one, occupying the lower half of the nasal bones, the main line of fracture running trans- versely or obliquely, and the fragments are displaced backward or back- ward and to one side, according to the direction of the force that has produced the injury. In rare cases the fracture involves only one nasal bone, or there may be dislocation of one or both bones. The cartilages which form the alse may be broken or torn from their attach- ments to the bone, and that which forms the septum is frequently broken in connection with fractures of the bones themselves, or sepa- rated from the vomer. The symptoms by which fracture may be recognized are deformity, mobility, and crepitus. If the nose is grasped by the thumb and finger lateral mobility with crepitus can usually be recognized, and displace- ments may at the same time be appreciated. The separation or fracture of the septum is recognized by exploration within the nostrils. The swelling of the soft parts, which appears promptly, will mask any but an extreme displacement. Other symptoms which may be present, but which are by no means pathognomonic, are free bleeding from the nose, and occasionally emphysema of the eyelids and face. Bleeding is often severe and sometimes recurrent and difficult to arrest, but rarely endangers life. Emphysema generally has its origin in an effort of the patient to blow his nose ; the air is forced into the subcutaneous cellular tissue through a rent in the mucous membrane and spreads promptly to the eyelids and sometimes over the rest of the face. An occasional symptom, when the fracture has extended into the adjoining portion of the superior maxillary bone, is obstruction to the flow through the lachrymal duct in consequence of its inclusion in the line of fracture. Another and more common one is the difficulty or impossibility of breathing through the nose, the result of inflammatory swelling of the mucous membrane; and, finally, in the comminuted fractures that are or have become compound, suppuration may be 165 166 FRACTURES. maintained for weeks or months until all the necrosed fragments have worked their way out or have been removed. It occasionally happens, too, that a tendency is manifested toward inflammatory complications in the neighborhood, abscesses form in and about the nose, portions of bone or cartilage become necrosed and are exfoliated, and a constant purulent discharge from the nostrils is maintained. It is so important that displacement should be corrected that an anaesthetic should be used if a thorough exploration cannot be made without its aid, and the surgeon should spare no pains to satisfy him- self as to the condition and position of the bones. The examination cannot prudently be long postponed, for the bones of the face unite promptly, and more than once it has been found impossible to correct a displacement after eight or ten days had elapsed ; firm union may be expected within a fortnight or three weeks. The prognosis as regards life is favorable, except in those cases in which the skul] is at the same time broken, and in those few others in which recurrent hemorrhages, of which no satisfactory explanation is given, show themselves. But as regards the avoidance of deformity the outlook is not so favorable, because it is not always easy to recog- nize or correct a displacement through the swollen tissues and the persistence of even a slight one is likely to be a noticeable blemish. The treatment consists mainly in the reduction of the displacement, for it is seldom possible to apply any apparatus or dressing that will prevent a recurrence of the displacement if there is any tendency toward it. The reduction when there is depression is accomplished by pressure made from within the nostril, upon the septum, if broken or displaced, as well as upon the bones, aided by manipulation or model- ling of the fragments on the outside. The interval between the septum and the side of the nose at the part of the nostril corresponding to the nasal bone is so small that a strong flat instrument, such as a perios- teum elevator, must be used, one that is small enough to work within the narrow space next the nasal bone, and strong enough to transmit considerable pressure. The fingers of the left hand placed upon the nose serve to guide the instrument and to recognize the degree of reduc- tion that has been obtained. Cocaine may be used to diminish the sen- sitiveness of the mucosa. Ordinarily there is but little tendency to recurrence of the displacement, except when the fracture is comminuted and the septum badly broken ; the only forces that tend to change the position of the fragments are the swelling of the external soft parts and the pressure of the air when the patient seeks to clear his nose by snuffing or blowing. The idea of supporting the fragments by pressure from within the nostrils suggests itself so readily that it is not surprising to find recorded many instances and several varieties in the methods of its use. The simplest one consists of packing the lower, and perhaps the middle, meatus on the side toward which the septum is displaced with strips of iodoform gauze for a few days, so as to hold the septum in place and thus support the nasal bones. This is the method which we have used for several years at the Hudson Street Hospital. The more elaborate ones are arrangements of rods supported by straps crossing the upper FRACTURES OF THE BONES OF THE FACE. 167 lip, and capable of adjustment in length and direction within the nos- tril so as to hold the fragments in place ; they are said to have been efficient in some difficult cases. The use of plaster or gntta-percha splints moulded upon the outside seems to me to be entirely illusory ; if swelling takes place under them it will tend to reproduce the displacement by pressure, if it is present when the mould is applied its subsidence soon creates a gap between the splint and the skin. The best plan appears to be repetition of the reduction as often as the displacement recurs. Occasionally the bridge has been held up by transfixion with a pin which rests upon the solid bone on each side. Recurrence of a lateral displacement may be opposed by a pad of gauze secured against the side of the nose by a strip of adhesive plaster crossing both cheeks. Separation of the cartilaginous septum from the vomer can be treated with a pair of forceps, one branch of which is passed into each nostril, lapping and grasping the bone and cartilage so as to hold them in line. The depression of the bridge, the " saddle nose/' which so often is seen after this fracture, constitutes so marked a disfigurement that many attempts have been made to correct it. Operations upon the bone, designed to detach and raise the bridge, have, as a rule, failed so com- pletely that I . was led to try to meet the indication by introducing a suitably shaped foreign body between the skin and the bone. It proved entirely successful in restoring the profile, and the pieces of aluminum and gutta-percha have remained in place for several years without causing irritation. (Annals of Surgery, June, 1896.) Of late, sub- cutaneous injection of warm paraffin has proved very satisfactory. 2. Fractures of the Malar Bone and Zygoma. Isolated fractures of this bone are rare, and, so far as can be inferred from the small number of cases in which a direct examination has been possible, single fractures are rarer than multiple ones, and the rarest is that which is almost a simple diastasis, a separation at the sutures with some splintering. Partial fractures involving the lower and outer por- tion of the bone or the margin of the orbit have been observed, and also single fractures of the frontal and zygomatic processes, extending possibly into the bones with which they articulate. In most cases there is depression of the entire bone with fracture of the malar process of the superior maxilla and crushing of the anterior wall of the antrum, the malar bone being displaced inward toward the antrum or sometimes backward into the zygomatic fossa. The force and direction of the violence may be such that adjoining portions of the cranium will be broken, with possible laceration of the brain. Fractures of the zygomatic arch alone have been caused by external violence acting from without inward, and in two cases from within outward, the patient having fallen forward upon a stick held in the mouth. In some of those I have seen a portion of the arch has been separated by two lines of fracture and depressed ; in one of them one of the lines of fracture extended into the temporo-maxillary joint. The displacement follows the direction of the fracturing force. 168 FRACTURES. The symptoms upon which the diagnosis must be made are deformity, mobility, and crepitus. Unless there is much inflammatory swelling the deformity, which consists usually in a depression or flattening of the cheek just below the outer half of the eye, can be recognized by sight and touch, and the irregularity of the line of fracture can be readily felt on the margin of the orbit, or, if it extends to the malar process of the superior maxillary bone, on the under and anterior surface of this process by the finger within the mouth. Mobility and crepitus are perceived more rarely ; the latter can be sometimes produced by the movement of the jaw. Anaesthesia or a sense of formication in the cheek, nose, upper lip, and gum of the corresponding side is sometimes observed, and is due to an extension of the fracture to the infra-orbital canal and tearing or bruising of the superior maxillary nerve. This symptom may be asso- ciated with the extravasation of blood in the posterior part of the orbit sufficient to force the eye forward and showing itself also under the conjunctiva and in the eyelids. Bleeding from the mouth or nose is occasionally seen as the result of the extension of the fracture through the mucous membrane of the mouth or antrum. When the fracture involves the zygomatic arch, and the fragments, as is usually the case, are driven inward, movement of the jaw may be difficult or impossible, either because the masseter has been injured, or because the depressed fragments of the arch are forced against the coronoid process of the inferior maxilla, or into the tendon of the tem- poral muscle. In one case the tip of the coronoid process was broken off by the same blow that fractured the arch. The same interference can be produced by the displacement backward of the main portion of the bone. Swelling, discoloration, and pain are the natural and con- stant results of the fracture and the bruising of the soft parts. The natural course of these fractures is toward rapid repair without excessive callus, and with gradual disappearance of any difficulty that may exist at first in the movement of the jaws. It is seldom possible to reduce the displacement completely, because, as has been said, it is generally inward, and there is no way of acting very efficiently upon the bone, except through a wound of the skin. The attempt must be made to move the bone in the desired direction by engaging the end of the thumb or finger under it in the zygomatic fossa, introducing it through the mouth if the cheek is swollen. It has been proposed, and occasionally practised, to cut down upon the bone opposite the zygo- matic process, divide the fascia overlying the masseter muscle, pass a stout hook under the process, and raise the bone by drawing upon it, or to make a smaller incision over the body of the bone and screw an elevator into it, by which it could then be raised. Inward displacement of the zygomatic arch cannot be directly acted upon except by a hook introduced through the skin or an incision. In only one of the recorded cases has the displacement interfered seriously and for any length of time with the movement of the jaws ; in this one the difficulty increased steadily for some time until the patient could barely separate the teeth, and then one morning while yawning he felt something snap, and the motion of the jaw at once became and remained free. FRACTURES OF THE BONES OF THE FACE. 169 3. Fractures of the Superior Maxilla. While the body of this hone, protected as it is by outlying processes and other bones, is rarely fractured, its own processes are not infre- quently broken or involved in the fractures of those bones with which they are continuous. Thus, a blow upon the nose breaks not only the nasal bones but also the nasal process of the superior maxilla, and a blow upon the malar bone may force in the anterior wall of the antrum on which it rests. The fractures are always produced by direct vio- lence, and present, consequently, considerable variety in their extent and the parts involved, but a fissure may extend to this bone from a fracture of the cranium. The alveolar process may be broken off in part or entirely by a blow received on it or on the teeth. A blow received in front, at or below the level of the nostrils, may produce a horizontal line of fracture separating the alveolar and palatal processes from the body of the bone, and including also the pterygoid plates. Falls from a height have caused a vertical line of fracture or diastasis between the two bones along the median line of the mouth, extending even through the soft palate, and associated with fracture of the malar or nasal bones. In a very few cases a line of fracture on each side at the canine tooth has separated the intermediate portion, Avith marked dis- placement and mobility. Fractures of the alveolar process, even with much displacement and mobility, present but little gravity, for they heal rapidly and without necrosis except of small pieces of the sockets of teeth displaced at the same time. It occasionally happens that one or both bones are driven in with multiple and comminuted fracturing of them and of the adjoining ones. The earliest known case of the kind was reported by Wiseman, and has been extensively quoted. The upper jaw was driven in so far that the finger could not be introduced between the palate and the posterior wall of the pharynx. Wiseman inserted a blunt hook through the mouth and easily drew the bone forward into place; as, however, the displacement recurred very easily, he left the hook behind the palate and had it drawn upon constantly by the patient or his friends until consolidation had taken place. Quite a number of similar cases (Gurlt collected upward of twenty) have been reported, all the result of great violence, either by falls from a height or the passage across the face of a heavy wagon, or a violent blow. In one of my own, a blow by a descending elevator upon an upturned face, the nasal bones were separated from the frontal along the suture line, the right malar and zygoma broken, and both superior maxilke displaced downward and backward and separated from each other along the median line of the hard palate. In one case the bones of the face were so movable that they moved up and down when the patient swallowed, as if they were restrained only by the skin. In most of them the patients recovered, and it is worthy of remark that, notwithstanding the degree of the vio- lence and the extent of the injury, it seldom happens that the fracture involves the cranium. The reason lies apparently in the direction in which the fracturing force is applied, a direction outside of and more or less parallel to the surface of the cranium and not in the line of one 170 FRACTURES. of its diameters. The bones of the face are, as it were, torn off the cranium rather than driven back upon it. Very extensive mutilation of the face has been caused by gunshot wounds, especially in attempts at suicide when the muzzle of the gun has been placed within the mouth, but it is rare for ordinary violence to lead to much loss of tissue. Malgaigne speaks of the following case as unique in this respect in his experience : A boy was kicked in the face by a horse ; the superior maxillary, nasal, and palatal bones were extensively comminuted, and the skin torn and bruised. Recovery took place, but with much deformity. The nasal bones, the anterior portion of the alveolar arch, and the greater part, if not all, of the hard palate had disappeared. There was no longer either nose or mouth ; the lips were united by a firm cicatrix, and the mouth and nostrils were represented by an oval opening between the nasal pro- cesses of the superior maxilla?. Through this opening the patient breathed, spoke, drank, and ate. The diagnosis of fracture is ordinarily made without any difficulty, since large portions of the bone are open to direct examination with the finger through the mouth and on the cheek. Irregularity of out- line, mobility, displacements, and crepitus can be readily recognized. In some few cases where there was no displacement the diagnosis has been in doubt, and Guerin 1 has pointed out a symptom which might be useful under such circumstances. It has been said that the ptery- goid apophysis is always broken when the line of fracture crosses the jaw horizontally between the alveolar process and the malar bone, and Guerin found that pressure with the finger upon the inner plate of this process caused pain and sometimes showed mobility when there was no other sign of fracture. Ecchymosis of the hard or soft palate indicates fracture. Repair in cases of average severity takes place in from thirty to forty days with a scanty formation of callus, and not infrequently in less time. The vitality of the bone is exceptionally great, hence the rule laid down by Malgaigne and some of his predecessors, and repeated by all subsequent writers, to leave every fragment that is not absolutely and entirely detached. Although the rule is a sound one, it occasionally happens that fragments become necrosed and have to be removed. This is thought to happen more frequently with fragments of the alveolar border than with any others. Displacement is seldom noticeable after repair is completed, except in the nose, but it usually exists to a greater or less degree, and the ingenuity and the patience of the surgeon are often severely taxed to overcome the constant tendency to the recurrence of the displacement. Salivation is often profuse, and the discharge offensive. Division of the lachrymal canal by the fracture may lead to its obliteration. Displacement of the entire bone may be treated as in Wiseman's case, or the retention may be aided by securing the lower jaw against the upper one, with or without the intervention of interdental splints or moulds of gutta-percha or metal shaped to fit the teeth and alveolar arch. Lateral pressure cannot well be made upon the cheeks to over- 1 Guerin : Archives Generates de Medecine, July, 1866, vol. ii. p. 5. FRACTURES OF THE BONES OF THE FACE. 171 come separation along the median line of the palate, but fortunately it is not always necessary. In Simonin's case, quoted by Maigaigne, the gap began to contract spontaneously by the tenth day, and was completely closed by the thirty-third, with no other displacement than a slight difference in level between the two halves. In another case, quoted by Hamilton, the gap was large enough to admit the little finger, and was still open six weeks after the receipt of the injury. After fracture of the alveolar process the frag- ment should be carefully readjusted and fixed by wiring the teeth to the adjoining ones, or by a splint of gutta-percha or metal. Agnew says he has used for this purpose with great advantage a piece of cork with grooves cut in its upper and lower sur- faces to receive the teeth of both jaws. The reduc- tion is made, the cork inserted, and the jaws firmly bound together. No attempt should be made to remove the corresponding teeth, for not only are the chances in favor of their becoming firm again in their sockets, but the attempt to draw them, even if they are loose, may bring away an important piece of the bone. The gutta-percha or metal mould may be held in place by binding the lower jaw against it after it has been fitted to the upper one, or by an apparatus similar to one devised by Graefe for the purpose, and shown in Fig. 65. If the splint is to be supported by the lower jaw it should be so constructed that an interval will be left, through winch food can be given and the mouth cleansed. The cavity of the mouth should be repeatedly cleansed. Intrabuccal splint for frac- ture of the upper jaw. 4. Fractures of the Inferior Maxilla. Fracture of the inferior maxilla occurs more frequently than that of any other of the bones of the face. It is rare in childhood and old age, most frequent between the ages of twenty and thirty, and is appar- ently more than ten times as common in males as in females. Gurlt collected 143 published cases in which the character and posi- tion of the fracture were described with sufficient accuracy to allow of their use as statistics: of these 80 were single, 49 double, and in 14 there were three or more lines of fracture. Of 75 single ones (exclud- ing 5 in which the fracture was limited to the alveolar process) the fracture occupied the median line in 25, the region of the incisor teeth in 22, that of the back teeth in 15, behind the teeth in 8. and the con- dyloid process in 5. In 85 double fractures both halves of the bone were broken 20 times, and at points on the two halves corresponding closely with each other ; one side alone 8 times, and the median line by one of the fractures 7 times. One or both of the condyloid pro- cesses were broken in several of the multiple fractures. These figures show that, exclusive of partial fractures of the alveolar border, which are very common, and often caused by the drawing of a tooth, the most frequent seat of fracture is at or near the median line, and that single fracture of the ramus, or of the alveolar or condyloid process is com- 172 FRACTURES. paratively rare. They differ materially from the estimates made by various writers, but as the latter differ quite as much among them- selves, and appear to have spoken in most cases from general impres- sions rather than from figures, the preference should be given, I think, to Gurlt. Double fractures of the lower jaw are relatively more common than those of other bones, while comminuted ones are rare. Compound fractures are common, both because the gum overlying the fracture is frequently torn and because the lip and skin are often involved in the direct injury that has caused the fracture. The fracture is complete or incomplete, the latter rarely except when the alveolar border alone is involved. A portion of the lower border of the bone may be broken off by a blow. The line of fracture in the body of the bone is usually vertical or nearly vertical ; at the angle or in the ramus it is oblique or rarely transverse. At the median line there is but little displacement, if any ; but, when present, it may be in either of three directions : a difference in the horizontal level of the edge of the teeth, a displace- ment forward and backward of the fragments upon each other, or a lateral separation of the two. In the fractures between the median line and the canine tooth the line is still much more frequently vertical than oblique ; but displacement is the rule, although no one form of it seems to be more common than the others. Between the canine tooth and the angle of the jaw it is either vertical or inclined backward and doAvnward, and usually, instead of crossing the bone from without inward at a right angle to the surface, it is inclined backward and inward, so that the anterior fragment is lengthened on the inner side and the posterior fragment on the outer side. The inferior dental nerve is crossed by this fracture, and is sometimes torn or bruised. Fracture behind the teeth is comparatively rare, only eighteen cases being contained in Gurlt's statistics, and it is frequently double or multiple or associated with other fractures. Fig. 66. When the fracture lies at the junction of the body of the jaw and the ascending ramus, it is usually oblique, running from behind the last tooth backward and downward toward the angle of the jaw ; but it may be vertical. Displacement is usually slight or lacking, the parts being kept well together by the masseter and internal pterygoid muscles (Fig. 66). Fracture of the condyloid process is usually accompanied by other fractures of the same or other bones of the face, and may be pro- Fracture of lower jaw behind duCe< ? h Y a bloW either U P 0n the chin 0r ll P 011 the teeth. the side of the jaw near the joint. The line of fracture passes through the neck, and the few specimens furnished by autopsies and museums do not show a greater frequency at any point or in any direction than at any other. Fracture of the coronoid process is exceedingly rare and has been seen only in association with other fractures of the same or adjoining bones. A portion of the alveolar process with the teeth in place is some- FRACTURES OF THE BONES OF THE FACE. li?j times broken off. The size of the piece varies within wide limits, and the displacement is habitually inward. In one or two entirely excep- tional cases a similar piece, including a portion of the body of the bone, has been broken off. Comminuted fractures, except as the result of gunshot wounds, are comparatively rare ; double and treble fractures are less so ; and one case is on record in which there were five distinct and separate lines of fracture. The most frequent cause of fracture, exclusive of partial fractures produced by attempts to draw a tooth, is violence received upon the chin ; fracture by pressure upon the sides is much less common, the other occurring thrice as frequently. Fracture of the condyloid pro- cess may be produced in either of the same two ways — a blow upon the chin or upon the cheek. The objective symptoms of fracture of the lower jaw are the same as those of other fractures : abnormal mobility, crepitus, displace- ment, pain. The bone is so accessible to the touch both within and without the mouth that irregularities in the outline of its body can be easily recognized by the fingers and sometimes by sight. The teeth show differences in level, vertically or antero-posteriorly j those which adjoin the fracture are usually loosened and may be entirely dis- lodged. Mobility and crepitus are detected by manipulation. When the fracture is situated at or above the angle of the jaw its recognition is by no means so easy ; by passing the finger within the mouth along the inner and outer surfaces of the ramus irregularities of outline and localized points of pain may be recognized, and pain at a fixed point is caused by biting. The degree and direction of the displacement vary much. As a rule, when the fracture is single and lateral, the anterior fragment tends toward the inside of the mouth. In double fractures, the inter- mediate piece is almost invariably drawn downward and backward by the unopposed action of the muscles of the neck which are attached to it. Fracture of the condyloid process was first studied by Desault and Bichat, and but little if anything has been added to our knowledge of the subject since their time. The symptoms are pain, increased by motion, diminished mobility of the jaw, often crepitus on manipulation, irregularities in the region of the condyle, the ease with which the con- dyle can be pushed forward into the zygomatic fossa, its failure to share in the movements of the jaw, and its almost constant displacement forward by the contraction of the external pterygoid. Ribes pointed out an additional symptom which is sometimes present, deviation of the chin toward the affected side. This is effected by the displacement of the ramus upward and backward on the outer side of the condyle and neck, and the more easily if the fracture is a double or multiple one. Gurlt quotes the description of a specimen of this kind from a work by Bonn, published in 1785. The condyle was united by a bony callus to the ramus just above the orifice of the dental canal. Swelling of the gums, face, and glands follows promptly upon the injury, and is often increased by the direct bruising of the soft parts themselves; the secretions of the mouth, increased in quantity by the irritation, mingle with the pus that comes from the fracture it' com- 174 FRACTURES. pound or from the ulcers produced by the stomatitis, decompose, aud cause an offensive odor that can scarcely be kept under control even by the most careful attention. Abscesses may form and open within the mouth or upon the sides of the jaw or the neck below it ; they are almost invariably associated with the presence of detached splinters or the exfoliation of portions of the jaw, which require, of course, to be removed before a permanent cure can be obtained. Small fragments may long escape recognition, and the only indication of their presence may be a sinus; larger fragments force themselves promptly upon the surgeon's attention by the profuseness of the discharge and the amount of local reaction. A few cases of extensive necrosis have been reported. Simple fractures unite in from thirty to forty days, and, even when there has been a considerable loss of bone by splintering or necrosis, the final result may be a very good one, in this sense, that the jaw is strong enough to support artificial teeth in the place of those that have been lost by the accident, is sufficiently regular in form to avoid deformity, and is free in its movements. Failure of union, pseudarthrosis, is rare. Gurlt's statistics contain only two cases which can be properly considered as such, and they were both cured by operation. It is more common after fracture with much loss of substance by elimination of splinters, and may interfere with mastication. The prognosis is a relatively favorable one ; the probabilities are that union will take place promptly, that no serious complications will arise, and that no important deformity or disability will remain. Danger to life may come from two quarters : the proximity of the bone to the cranium carries with it the possibility of associated injury to the brain or to its case ; retention of pus in a compound fracture in communica- tion with the cavity of the mouth exposes to the grave danger of absorp- tion of the decomposed secretions and, though rarely, to the burrowing of the decomposed pus along the deeper planes of the neck into the anterior mediastinum. Treatment. Displacement following fracture of the body of the jaw can usually be readily overcome by the pressure of the thumb and fingers upon the teeth and the lower border of the bone ; in some cases the interlocking or wedging of the smaller pieces or of displaced teeth may render the reduction impossible until after they shall have been removed. In simple cases where the tendency to displacement is slight it is sufficient to immobilize the lower jaw by binding it against the upper one with a four-tailed bandage, the centre of which is at the chin, as shown in Fig. 67. Splints are applied either to the front and under surface of the jaw outside the mouth, or to the teeth, or the inner surface of the jaw, and two kinds are sometimes used in combination. Outside splints are available only in cases in which there is not much tendency to displace- ment and in which the lateral pressure of a simple bandage would cause the fragments to override in one direction or another. They may be made of leather, pasteboard, gutta-percha, or plaster of Paris, and consist essentially of a cup-shaped piece embracing the chin and extending nearly to the angle of the jaw on each side, and to the fold of the neck below. FRACTURES OF THE BONES OF THE FACE. 17 5 Interdental splints are made of metal, gutta-percha, or vulcanized rubber ; they are fitted to the crowns of the teeth of both fragments after reduction of the displacement, and are held in place either by binding the jaws together with an outside bandage, or by braces con- necting the splint with a pad under the jaw, or by a special arrange- ment of lateral braces as in Kingsley's apparatus (Fig. 68), or by fastening them to the teeth with wires. Some are fitted only to the broken jaw and are intended only to immobilize the fragments on each other ; others are fitted to both jaws and enable the upper one to be used as a splint for the lower. Ackland l describes one capable of ready adjustment to almost any fracture of the body : a metal gutter partly filled with softened gutta-percha, pressed down upon the teeth, and secured to a plate beneath the chin by two adjustable clamps. Fig. 67. Fig. 68. Four-tailed bandage for fracture of the lower jaw. Kingsley's splint applied. In one difficult case I used a carpenter's small wooden vise, one end of which lay on the edge of the teeth, the other under the chin ; after a few day's use the displacement ceased to recur. Gutta-percha splints may be made either of thin strips or of thick lumps or wedges. The former have a length of three or four inches, and a breadth sufficient to overlap the crowns of the teeth from gum to gum ; they are softened by immersion in hot water, moulded to the teeth, cooled as rapidly as possible, taken off, and trimmed suitably. Then the splint is reapplied and the jaws bound together. If the tendency to displacement is slight the bandage may be loosened during the day to allow the introduction of liquid food, or a wedge may be kept between the jaws so as to create an interval to be used for this purpose. or advantage may be taken of the absence of teeth, especially from the upper jaw. In a ease quoted by Gurltr 2 two fragments oi^ the alveolar 1 Ackland: British Medical Journal, April 1. 1893, 2 Gurlt: Loc. cit., vol. ii. p. ;>5K>. 176 FRACTURES. border carrying eight teeth were secured by a splint of sheet lead moulded to the teeth and fastened down by silver wire, the ends of which were brought out under the chin by means of a needle and tied over a roll of plaster. The wire caused no irritation and was left in place forty-seven days. Gutta-percha wedges were introduced by Dr. Hamilton -to meet a double indication, that of fixing the fragments securely and of allow- ing the easy introduction of food. Two pieces of gutta-percha of suit- able size are softened and formed into wedges and introduced between the jaws, the edge of the wedge directed backward. The jaws are closed upon them, the fragments pressed up until the line of the teeth is straight, and the wedges moulded to the sides of the teeth above and below. As soon as the gutta-percha has hardened it is removed, trimmed suitably, and reapplied, and the jaws are bound together with a bandage. Fig Kingsley's interdental splint. Vulcanized rubber is a valuable substitute for gutta-percha in some difficult cases, but its employment requires special skill and experience which are found usually only among the dentists. Casts of one or both jaws are first taken in wax ; from these plaster models are made, and upon these latter the splint. Figs. 68 and 69 show the splint as made by Dr. Kingsley, of New York, with attached bars by which the splint and jaw can be bound firmly together, the bandage passing from one bar to the other underneath the chin. Fig. 70. ,a fft jr' if jf~ /-■' i * '■■''. * ' m 1/ J P * , V Matas's splint. The Matas * splint (Figs.' 70, 71, 72) is said to be easily adaptable to individual cases of fracture of the body of the jaw, and consequently 1 Matas : Annals of Surgery, January, 1905. p. 1. FRACTURES OF THE JAW. Fig. 71. 177 Matas's splint for fracture of lower jaw, Fig. 72. 12 Matas's splint. 178 FRACTURES. Fig. 73. Hammond's wire splint for fracture of the jaw. of value in hospital service. It consists of a gutter of soft block tin roughly shaped to the line of the teeth and attached by hinged rods to a cup-shaped chin-plate of aluminum, as shown in the figures. The gutter is notched on each side so that it may be more easily fitted, and it should be partly filled with dental wax so as to fit snugly about the teeth. Another method, which dates back to Hippocrates, is to fasten together the teeth on opposite sides of the frac- ture by thread. In some cases I have found this to answer perfectly, in most to fail entirely. The ligature should be attached to the second or third tooth from the fracture on each side, and should be drawn very tight. A wire loop exactly moulded to the sides of the teeth and secured to them at several points by encircling loops (Fig. 73) has been found efficient; also Angle's 1 "anchor splint," in which the wire is attached to the teeth by metal collars cemented on. In a few cases it has been found effectual to bind the jaws together by ligatures applied to opposing teeth. Direct suture of the fragments by stout wire passed through holes drilled well below the alveolar border is said by Konig to be the method which he has employed exclusively for several years. Others have passed the suture through holes drilled in the lower border of the bone through an incision beneath the chin. Repair takes place so rapidly that, except in compound fracture with much suppuration, there is rarely any tendency to displacement after the tenth day, and, therefore, the discomforts incidental to the contin- uous closure of the jaws do not need to be borne for any great length of time. If the importance of the case warrants it, if the displacement can be prevented only by keeping the jaws constantly in contact with each other, the patient can be fed through a tube passed behind the last molar tooth, or through the nose, or by the rectum. Cleansing and disinfecting washes containing chlorate of potash, borax, or alum will be found to add much to the comfort of the patient whenever they can be used. In two fractures of the lower part of the ramus Knapp 2 obtained good results by pressing the anterior fragment forward and upward by means of a strap of adhesive plaster crossing beneath the jaw and at- tached above to the end of a long piece of tin projecting in front of the forehead and shaped to the top and back of the head and made fast thereto by a plaster-of-Paris bandage. 1 Angle : Medical Record, August, 1890. 2 Knapp : Medical News, February, 27, 1904, FRACTURES OF THE JAW. 179 After fracture of the neck of the condyle the tendency is to the dis- placement of the condyle forward by the traction of the external ptery- goid muscle, and as the fragment is too small to be acted upon directly by any dressing this tendency, if manifested, cannot well be overcome. The treatment, therefore, is to reduce the displacement if it exists, and then to immobilize the jaw after having pressed it upward to inter- lock the fragments. Ribes reduced the displacement by passing his forefinger into the mouth and along the inner side of the ascending ramus until be reached the condyle and was able to press it back into place. Fountain obtained a good result by drawing the jaw well for- ward and wiring the teeth together, so as to maintain the position. Fracture of the coronoid process is not open to any treatment except immobilization. Fractures of the alveolar border are best treated, like fractures of the body, by immobilization after careful reduction of the displace- ment, and it is advisable not to make haste to remove loose or semi- detached teeth. They may become firmly adherent again, or, if this should fail, they may be removed subsequently without having caused any serious trouble or delay. Delayed union and pseudarthrosis are to be treated by the removal of the cause, if any definite local one exist, or by operative interference, freshening of the surfaces of fracture, and wiring of the fragments. When a gap has been created by loss of bone, every effort should be made to keep the fragments in proper position, for it will usually be maintained spontaneously after the lapse of two or three weeks. CHAPTEE XIII. FRACTURES OF THE HYOID BONE. This comparatively rare lesion has received the attention of writers only within the present century. Malgaigne collected 8 cases, Hamil- ton added 2, and Gibb 3; in 1864 Gurlt collected 27 cases, 21 being of the bone alone, while in 6 there was associated fracture of the thy- roid or cricoid cartilage or of the trachea. I have seen 3 of the greater cornu and 2 others were received at the Hudson Street Hospital in 1902 and 1903, which I did not see. In 3 of Malgaigne's cases and in 5 additional of Gurlt's the fracture was caused by hanging, judicial or suicidal, one of the latter surviving ; in 6 of these one of the greater cornua was broken, in the remaining 2 the body. In the other cases of the li*t the cause was violent grasping of the neck, or a blow, or fall, and in 2 cases apparently muscular action, general muscular contrac- tion during a fall. Valsalva reports a case of " dislocation of one of the greater horns from the body," caused by the eifort to swallow a large piece of food. In the great majority of the cases the fracture was of one of the greater cornua, and usually at or near its junction with the body. In only three cases was the body of the bone broken, and in none the lesser horn. Symptoms. The symptoms of fracture of one of the larger cornua, without accompanying injury to the larynx or trachea, are, according to the records, quite well defined and characteristic : sharp pain at the seat of fracture increased by pressure, speaking, or swallowing ; swell- ing in the same region appearing soon after the accident and due in part to extra vasated blood ; recognizable displacement or mobility of the fragment ; crepitus ; and sometimes free bleeding into the mouth, the result of perforation of the mucous membrane of the pharynx by the bone. Exploration of the pharynx will enable the surgeon to recognize displacement of the horn inward and perforation of the mucous membrane if they exist. The patient is seldom able to move the tongue freely or without pain, and in some cases attempts to depress it or put it out have caused paroxysms of suffocation. In all the cases it has been difficult to swallow, even a drop of water some- times causing the patient to cough and choke, and in many of them it was necessary to give food through an oesophageal tube, in one case for twenty days. In my own cases there was localized pain on press- ure, and the mobility of the cornu could be recognized by grasping the bone with the thumb and finger on either side of the neck. The sub- jective symptoms Avere not urgent except when fracture of the larynx was associated ; one such died by suffocation while tracheotomy was being done. In the single case in which a fracture of the body of the hyoid bone 180 PLATE V Fracture of the Hyoid Bone. FRACTURES OF THE HYOID BONE. 181 Fig. 74. was observed during life the symptoms were severe paroxysms of coughing, dyspnoea, lividity of the face, and abundant bloody sputa, and were relieved by the reduction of the displacement. The local and general reaction after the injury has been quite marked and although the bone appears to have united promptly con- valescence has been delayed by the persistence of the dysphagia and of the change in the voice. In two cases an abscess formed at^the seat of fracture, and three months afterward the necrosed posterior frag- ment was cast out. In an unreported case of which I have heard a sluggish abscess without necrosis formed, and the diagnosis was made when the pus was evacuated. The possibility of repair by a bony callus is shown by three speci- mens : one, taken from the body of an adult man without a history and presented to the London Patho- logical Society by Gibb, showing a fracture of the right greater horn which had united with overriding to the ex- tent of one-quarter of an inch, and dis- placement inward ; another (Fig. 74) in the pathological collection of the college at Brunswick, showing "a frac- ture of the right greater horn united with some shortening and displacement downward ; the third, 1 found in the dissecting-room, a fracture at the junc- tion of the left cornu and body, united with angular displacement. Prognosis. The prognosis, so far as life is endangered by the injury to the bone, is favorable, but the associated have often been such as to cause death, ries fracture of the larynx is prominent. Treatment. The treatment requires the reduction of displacement, if possible ; and this might be facilitated by the introduction of the finger into the pharynx. It is unlikely that a bandage would be of any service in opposing a tendency to the recurrence of displacement. Immobilization of the head and neck by a stiff collar has been sug- gested. The dysphagia may render nourishment through an oesophageal tube necessary, and associated injury of the larynx may require tracheotomy. 1 Scriber : Medical Age, Detroit, January, 1892. United fracture of the hyoid boae. (GURLT.) njuries in the recorded cases Among these associated inju- CHAPTEE XIV FRACTUKES OF THE CARTILAGES OF THE LARYNX AND TRACHEA. This injury, although actually rare, is more frequent and much more dangerous than fracture of the hyoid bone and has received more atten- tion from writers. Gurlt's collection published in 1864 contained 47 cases, Dr. Hunt l collected and analyzed 27 cases but did not give the details, andHenoque 2 collected 52 cases, to which Mr. Durham 3 added 10, making 62 in all, or including 4 of Gurlt's in which the trachea alone was injured, QQ. Piatt 4 reports one terminating fatally by broncho-pneumonia in three days, and Stephens 5 one combined with fracture of the hyoid, followed by death in a few minutes. The following table shows the relative frequency with which the different parts are affected : Cartilage broken. Cases. Deaths. Recoveries Thyroid alone 24 18 6 Cricoid alone . . ." 11 11 Thyroid and hyoid bone • 5 3 2 " " cricoid 9 9 " " " and hyoid bone 2 2 " " " " trachea 2 2 Cricoid and trachea 2 2 " " " and hyoid bone 1 1 "Larynx" 7 3 4 Trachea alone . 4 3 1 67 54 13 The causes are blows, falls, hanging, and the grasp of the hand in a fight, or in an attempt to strangle. The injury is seen more fre- quently in males than in females, and in middle life than at any other period, but youth and old age are not exempt. The mechanism of the fracture of the thyroid or cricoid is usually either lateral compression on both sides or pressure backward against the vertebral column ; the first causes commonly longitudinal fracture of the thyroid cartilage near its middle, together with flattening or depression of its sides, and either a double lateral fracture of the cricoid cartilage or a single fracture in the anterior median line ; the second causes irregular and multiple lines of fracture. The mucous membrane of the larynx is frequently torn, and extravasations of blood take place under the skin and mucous mem- brane or among the muscles. 1 Hunt : American Journal of the Medical Sciences, April, 1866, p. 378. 2 Henoque : Gazette Hebdomadaire, Sept. 26 and Oct. 2, 1868. 3 Holmes's System of Surgery, American edition, vol. i. p. 697. * Piatt : Med. Chronicle, Dec, 1899. 5 Stephens : Guy's Hospital Reports, vol. liv., 1900. 182 FRACTURES OF CARTILAGES OF LARYNX AND TRACHEA. 183 Symptoms. — The symptoms of fracture of the larynx are frothy bloody expectoration with convulsive coughing and usually much dyspnoea and its attendant symptoms. The voice is affected or lost, and swallowing often difficult and painful, although not so much so as after fracture of the hyoid bone ; and in all severe cases, when there is laceration of the mucous membrane, emphysema appears promptly and spreads steadily over the neck, face, trunk, the extremities, and mediastinum, being sometimes more marked in the intermuscular than in the subcutaneous connective tissue and sometimes causing pneumo- thorax without wound of the lung. The additional objective symptoms are deformity of the region and abnormal mobility of parts of the larynx upon each other, but both these signs may be unrecognizable on account of the swelling. I have seen one case in which the only symptom was the mobility with crep- itus of a small fragment at the upper posterior angle of the larynx ; there was also slight hoarseness. In some cases there have been no marked symptoms beyond a change in the voice, although the character of the injury was made clear by careful examination, and the difference seems to be due to the absence in these cases of any obstruction or narrowing of the air-passages by displacement or swelling. The course in the severe cases is toward prompt death by suffocation, either by gradual increase of the dyspnoea or by the sudden intercur- rence of oedema of the glottis. Occasionally the dyspnoea does not make its appearance until some days after the injury. In the mild cases the symptoms gradually subside, and recovery follows. It seems probable that repair is by a bony, or at least by a calcified, callus. Treatment. The treatment in the milder cases consists of local anti- phlogistics and quiet ; in the severer ones, of tracheotomy whenever the dyspnoea is great or increasing. It is not safe to wait until it has become extreme, for its increase at the last is often so rapid and sudden that death takes place before relief can be given. It is, therefore, the part of prudence to interfere early and before the interference is made actually necessary by the defective breathing. Advantage should be taken of the opportunity afforded by the operation to reduce any dis- placement that may exist and that can be overcome by manipulation through the wound. Trachea. The symptoms of fracture of the trachea are similar to those of fracture of the larynx, except the local ones due to the dis- placements ; the diagnosis is difficult because of the lack of symptoms distinctive of the seat and character of the lesion. The prognosis is unfavorable, and the treatment has usually been insufficient to avert the fatal termination or relieve the suffering, because in the few recorded cases the seat of injury has been beyond reach by operation. The indication for treatment is to insert a tube into the trachea past the point of fracture so as to insure free breathing. CHAPTER XV. FRACTURES OF THE STERNUM. The sternum, formed originally of several pieces, has an irregular and uncertain development, only one feature of which needs here to be mentioned. The upper portion, the manubrium, may unite by ossification with the central portion, the body, at some time during adult life, and in such case a traumatic separation of the two portions is a fracture, not a dislocation. Fracture is rare, almost unknown, before the age of twenty years, and is frequently associated with other fractures, especially of the ribs and vertebrae. The fracture may be incomplete, multiple, transverse, oblique, or longitudinal. Of the first form there are but two recorded instances ; in both the infraction occupied the posterior surface of the bone at or near the junction of the lower and middle thirds and was accompanied by an abundant extravasation of blood into the anterior mediastinum. Of compound fractures, except such as were gunshot or stab wounds, there is but one example, reported by Duverney in 1751. A quarry- man, while at work lying upon his side, was caught under a heavy stone about five feet long which compressed his chest laterally with such force as to separate the middle portion of the sternum from the upper portion and force it through the skin. Death was immediate, by rupture of the heart and lungs. Of pure longitudinal fracture there is but one certain example, but there are two other cases in one of which there was a longitudinal frac- ture of the manubrium, and in the other of the body of the sternum associated with a transverse fracture at its upper end. The first case was that of a man who was overthrown and crushed by a falling wall ; in addition to numerous contusions, the sternum was broken longitu- dinally through its entire length, the right half being depressed from eight to ten lines below the level of the left half. There was profuse bloody expectoration and difficult breathing. Reduction was accomplished by drawing the right arm back and making forcible press- ure upon the middle of the sternal ribs of the right side and gentle pressure upon the left side. The patient recovered in six weeks. Cases of congenital fissure of the sternum have been mistaken for longitudinal fracture. Simple transverse fractures form the great majority of fractures of the sternum, and occupy most frequently the junction between the manubrium and the body of the bone or its immediate neighborhood — that is, the region of the second intercostal space ; next in frequency are fractures at or near the middle of the bone, corresponding to the 184 FRACTURES OF THE STERNUM. 185 third rib and the third intercostal space; they are rarely high in the manubrium and below the middle of the body, and very uncommon as separations of the ensiform appendix from the body. Fractures of the manubrium occur most commonly a short distance, two or three lines, above its lower border ; the periosteum sometimes remains untorn upon either the anterior or the posterior surface ; in some cases there has been no displacement, in others either the upper or the lower fragment has been displaced forward, and in one case there was angular displacement, the apex of the angle being directed backward. In several of the cases -the fracture was produced by muscular action, by straining during childbirth, or by the effort to raise a heavy weight with the teeth, the back being bent far back. In a large proportion of cases in which the lesion was produced by external violence there was also fracture of the ribs, clavicle, or vertebrae. Fig. 75. Fracture of the sternum. Fractures of the border have been observed in three instances, once in connection with fracture of the ribs, a scale of bone corresponding to the articulation with the first rib being broken off; a second time in connection with dislocation of the sternal end of the clavicle, the por- tion to which the sterno-cleido-mastoid was attached being torn off and drawn upward nearly half an inch ; and in a third case in connection with a transverse fracture lower down. 186 FRACTURES. Transverse fracture at or near the junction of the manubrium and body of the bone, and diastasis at this point, which is not always to be distinguished from fracture, are the commonest forms of injury. In the great majority of cases the lower fragment is displaced so as to lie in front of the upper one, and sometimes to override ; it is ex- ceptional for displacement to be absent or for the upper fragment to lie in front of the lower one. There is reason to think that the periosteum is almost invariably torn upon the anterior surface, but that it sometimes remains untorn behind, a fact which derives considerable importance from its bearing upon the escape of blood into the ante- rior mediastinum. One or both of the second pair of ribs usually remain attached to the manubrium. Out of a total of 105 cases of fracture of the sternum collected by Gurlt, 27 are described as partial or complete diastasis at the junction of the first and second portions, the character of the lesion having been determined by post-mortem examina- tion in fourteen of them. Fractures of the body of the sternum (Fig. 76) occur most frequently between the second and fourth costal cartilages, are usually transverse, but sometimes oblique laterally or from before back- ward. The displacements are the same as after fracture at the junction of the manubrium and sternum, and there is the same relative frequency of the projection of the lower fragment. Comminuted fracture of the body of the sternum has been rarely seen except in connection with gunshot and punctured wounds. Of triple fractures Gurlt found only two cases, and of double fractures only six, all of them associated with fracture of other bones, usually the ribs or vertebra?. Of fracture or diastasis of the ensiform appendix, Gurlt collected only four examples, and the list does not appear to have been increased by subsequent writers; one was a fracture, the other three diastases. The fracture was produced in a man sixty years old by a fall upon the sharp edge of a grain measure, and, when last examined, nine months after the accident, was still ununited, and crepitated on pressure, but caused no inconvenience. In the other three cases the prominent symp- tom was persistent vomiting, which in one lasted for two years, recurring every five or six days, and then ceased spontaneously ; in another it was cured by grasping the process between two fingers and bending it back into place ; and in the third, after it had lasted a month and death by exhaustion seemed imminent, it was instantly relieved by the reduction of the displacement, which was accomplished by in- serting a blunt hook into the abdominal cavity through an incision, and drawing the process forward. The patients were aged respectively twenty-eight, eighteen, and nineteen years. Transverse fracture of the body of the sternum. FRACTURES OF THE STEBNUM. 1X7 The effusion of blood, which is observed after all fractures, may attain an especial importance after fracture of the sternum, by the pressure which it may exert upon the underlying heart. The blood, coming from the torn vessels of the bone and periosteum, makes its way forward into a region where it can do no harm if the periosteum on the posterior surface remains untorn ; but if this membrane shares in the injury, and especially if one of the internal mammary veins or arteries is ruptured, the blood makes its way into the anterior medias- tinum, and sometimes in sufficient amount to cause death promptly. Rupture of the pericardium, or of the heart, has been observed in a few cases; as has also probable laceration of the lung, evidenced by the appearance of subcutaneous emphysema or pneumothorax. Etiology. Fracture of the sternum may be produced either by mus- cular action or by external violence. There are four recorded cases in which the bone has been broken by straining during labor, and three in which the fracture has occurred during an effort to lift a heavy object. External violence acts either directly by a blow upon the breast, or indirectly by forcibly bending the body forward or backward, or pos- sibly by a combination of the two forms in the fall upon the body of a heavy object, or the passage across it of a loaded wagon, or, according to Lane, by depression of the shoulder acting through the clavicle and the upper ribs. It is not necessary that the force which acts directly should be very great to produce fracture ; it is sufficient for it to act upon a limited area, as in a fall upon a stone, or stick, or the edge or corner of a box. The violence which produces indirect fracture is, in most cases, a fall either upon the shoulders or buttocks, or with the back or breast across some fixed object, so that the trunk is bent sharply forward or back- ward ; in the one case the bone is broken by being bent forward, in the other by traction exerted through the muscular attachments at either end. Diagnosis. The diagnosis is readily made by the objective symp- toms — the displacement, mobility, and crepitus — and by the localized area of pain excited by pressure, change of position, and the more forcible respiratory acts. I have seen a few cases in which the only symptom was pain on pressure, with late ecchymosis. The examination of the bone must be made carefully in order, on the one hand, to avoid mistaking some irregularity of development for a traumatic displace- ment, and, on the other, not to overlook a second or third fracture, or even a single one in case there should be no displacement. In cases of supposed injury to the ensiform appendix the frequent irregularities in the shape, position, and mobility of that part must be borne in mind. The importance of the injury is by no means so great as the mor- tality of the recorded cases would indicate, for this mortality is largely due to associated lesions. Gurlt tabulated 98 cases with reference to this point, among others, and found that of 54 simple eases 4(> recov- ered and 8 died, while of 44 complicated eases, eases, that is, in which there was some severe associated injury, only 1 recovered and 4;> died. Of k 20 eases in which the fracture was certainly caused by direct vio- 188 FRACTURES. lence, 15 recovered and 5 died, 3 of the latter being complicated cases. Course. The course in the uncomplicated cases is uneventful ; if pain and oppression are marked at first they soon diminish and disappear, as do also expectoration of blood, dyspnoea, and orthopncea. The principal danger is from pulmonary complications, especially in the old and alcoholic. In exceptional cases the local reaction may be great and may lead even to the formation of an abscess about the fracture. The pus may make its way to the surface between the fragments or on the sides, and if it collects upon the posterior surface and is discharged imperfectly through a small opening, the sinus may persist indefi- nitely, or the unnatural conditions may lead to extensive caries of the bone. Both conditions require treatment by active operative inter- ference. Usually repair takes place in from four to eight weeks, and by a bony callus. The persistence of a certain degree of displacement is not uncommon, and in some cases the deformity has been extreme. Failure of bony union has been observed in a few cases, but does not appear to have caused any disability beyond a temporary difficulty in abduction and adduction of the arms. Gunshot fractures may be penetrating or non-penetrating. A num- ber of illustrative cases of each kind are given in the Surgical History of the War of the Rebellion. The latter do not differ materially from compound fractures due to any other cause, but in the former the prog- nosis is rendered very grave by the associated lesions. Treatment. The first indication is to reduce such displacement as may exist. This is not always possible ; the most intelligently directed and persistently conducted efforts have sometimes failed. The usual method is direct pressure upon the projecting fragment, aided, espe- cially when there is overriding, by traction upon the two pieces. The traction must be made, in part at least, through the muscles attached to the ends of the bone, and is accomplished sometimes by resting the back upon some rather firm object, as a cushion or box, and bending the head and shoulders forcibly backward. At the same time the patient may be directed to take a full inspiration, and the surgeon presses downward against the upper edge of the lower fragment if that one, as is usual, projects, or he draws this fragment downward by taking hold of the projecting ribs that are attached to it. Various modifications of the plan have been employed, but all have the same fundamental idea, that of traction in opposite directions upon the frag- ments by forcible bending of the body backward. In one case reduc- tion was gradually effected in three days by keeping the patient recum- bent, with the head and shoulders thrown back. A number of operative methods have been proposed for use in those cases in which the displacement cannot be reduced by manipulation, such as to raise the depressed fragment by a sort of gimlet screwed into it, or by an elevator or blunt hook passed under it through an incision, or to cut away the projecting portion, or to press it back with a rod carried directly down to it through an incision. Most of these remain as suggestions that have not been put to the test. One case FRACTURES OF THE STERNUM. 1 89 has been already mentioned in which the ensiform appendix was drawn forward successfully by means of a blunt hook passed into the per- itoneal cavity ; in another, of fracture at the upper part of the sternum with depression of the lower fragment, an incision was made with the intention of introducing a hook, but the pleural cavity was opened and the surgeon felt it necessary to close the wound immediately. In another the upper fragment was raised to the proper level by screwing a sort of gimlet into it and drawing it forward, but it afterward sank partly back again, and a second attempt to raise it was defeated by the tearing of the screw. Unless the displacement is actually causing dangerous or distressing symptoms these methods of removing it by operation are hardly justi- fiable, because they carry with them risks that should not be lightly run. The subsequent treatment consists in immobilization of the chest, and, if necessary, in the use of measures to allay local inflammation and to prevent coughing. A convenient dressing is a broad flannel bandage pinned tightly about the chest after forced expiration, or bands of adhesive plaster extending from side to side across the front of the chest and covering the entire length of the sternum. If the formation of pus behind the bone is recognized or suspected it should be promptly sought for and evacuated by cutting through the bone at the seat of fracture. CHAPTER XVI. FRACTURES OF THE RIBS AND THEIR CARTILAGES. Fractures of the Ribs. These are among the commonest of all fractures, more common in men than in women, and almost unknown (or unrecognized) in infancy and childhood ; probably many cases pass unrecognized, and the fre- quency is even greater than the statistics show. Pathology. The fracture may be partial or complete, simple or com- pound, single or multiple. Partial fractures may be constituted either by a fissure involving only one of the borders of the rib and, perhaps, separating entirely a longer or shorter fragment of that border, or by an infraction. The former is very uncommon. Complete fractures may be transverse, oblique, irregular, or multiple, and may be limited to a single rib, or may involve all the true ones on one side, and in some cases even many on both sides. The central ribs are the ones most frequently broken. Fracture of the twelfth is very rare ; Gurlt could find only two recorded cases, the causes being a fall against the edge of a step and a table respectively. I saw one at the Hudson Street Hospital in 1896, in a man, fifty years old, who had been caught about the waist in the loop of a hawser. He died a few days later of coincident rupture of the large intestine ; the twelfth rib was broken obliquely at its centre. For another case, see Chapter XL., Dislocation of Head or Rib. In 1905 I saw another, a sailor carried by a wave against the corner of a hatch. Fracture of the first rib was formerly thought to be almost equally rare, but the observations of Lane l and Marsh 2 indicate that fracture of it or its cartilage may be rather common. Lane found four speci- mens in a series of 200 bodies in the dissecting-room, and Marsh saw four cases in six months' hospital service. According to Lane this rib is easily broken by forcible depression of the shoulder acting by direct pressure of the clavicle. The symptom is said to be pain behind the upper part of the sternum on lifting with the corresponding hand. The fracture of a rib may occupy any part of it, but is most fre- quent on the side and anterior half. The periosteum may remain untorn, and the fragments preserve their relations to each other, or they may form a re-entrant or a salient angle, or override each other. If several ribs are broken at the same time and forced inward the depression may remain both broad and deep. Overriding of the frag- ments is impossible unless several ribs are broken at the same time, for the muscular and fibrous attachments of the adjoining ones hold the fragments in place, and the ribs above and below act as splints to pre- 1 Lane : British Medical Journal, 1887, vol. ii. p. 119. and Guy's Hospital lieports, 1886, p. 429. 2 Marsh : Lancet, June 30, 1888. 190 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 191 vent shortening. In double or multiple fracture of one or several ribs the intermediate piece or pieces may be so loosened that they move in and out with every inspiration. In compound fractures the wound of the soft parts is rarely, if ever, caused by the projection of the broken end of the rib, but always by the object which produced the fracture. The complications include injuries to the muscles, which are rarely important, to the intercostal arteries, and to the thoracic and abdom- inal viscera. The intercostal arteries are rarely seriously injured, although moderate hemothorax is not uncommon after fracture of the middle third, especially of the sixth to the ninth ribs. Fatal hemor- rhage into the pleural cavity has occurred in a few cases, even after fracture of a single rib and by slight violence, and a case of traumatic aneurysm has been reported (see p. 79). A wound of the pleura and of the lungs is a rather common com- plication, and is generally caused by the sharp end of a fragment, but in some cases fatal injury of the lung has been caused by the crushing effect of the external violence acting through the, perhaps unbroken, ribs; the thorax is compressed by the force, and the lung is put upon the stretch in such a manner that it is actually torn, not perforated by the bone. The consequences of the wound vary with its size and with the relations existing between the lung and the thoracic wall. If these latter are normal — that is, if the lung is not adherent at the wounded part — air and blood escape more or less freely into the pleural cavity, and the lung collapses ; if, on the other hand, the lung is adherent, the escaping air makes its way into the meshes of the connective tis- sue, and may spread through the mediastinum, under the pericardium and pleura, and into the interlobular tissue of the lung itself and the subcutaneous tissue on the surface of the body. Emphysema of the surface may be produced also when the lung is not adherent ; the air which has escaped into and filled the pleural cavity is forced by the contraction of the chest during expiration out through the opening at the fracture, and its place is supplied at the next inspiration by fresh air drawn in through the wound of the lung, and thus a small quan- tity is pumped into the outer cellular tissue at each respiration, and this will continue until one or the other opening is closed by a clot or exudate or a change in the relations of its walls. Wounds of the heart are much rarer, and even more dangerous. Gurlt collected six cases, in only four of which the wound of the heart appears to have been caused by the broken rib ; in the other two it appears to have been caused by the compression of the heart between the anterior chest-wall and the vertebral column, for the pericardium was untorn. Etiology, Fractures of the ribs may be caused by muscular action or by external violence. Of muscular action the most common form by far is coughing; others are sneezing, lifting a heavy object, even turning in bed. The lower ribs, especially the eleventh, arc the ones most frequently broken in this way, but it has happened to the second, fourth, fifth, and sixth. It is much more common on the left than on the right side. (Sec forty cases collected by Tunis in University Med- 192 FRACTURES. ical Magazine, November, 1890, and thirteen personal cases by Cliel- monski in Centralbl. f. Chir., 1901, p. 1188.) The so-called sponta- neous fractures are observed almost exclusively in the insane, whose bones are frequently very soft. By far the most common cause of fracture is external violence, by a blow, fall, or excessive pressure. The fracture may be direct or indirect, but it is not often easy to distinguish between these two varieties. In indirect fractures caused by pressure upon or near the sternal ends of the ribs the fracture is found most frequently in either the anterior or the posterior third, and the point of greatest frequency seems to be very near that at which the force is received, an inch or two on the outer side of the sternal end of the bone. Double or triple fractures of one or more adjoining ribs may apparently be caused in either of two ways : Extreme violence acting at one point breaks the rib at that point by direct pressure, and then depressing the broken ends breaks the bone again at a distance indirectly on one or both sides ; or, the force acting more broadly, breaks the bone simultaneously at a point on each side. Symptoms. The symptoms of fracture of a rib in the less severe cases are likely to be obscure. The breathing is shallow and some- times catching through pain or fear of pain, and occasionally there is very troublesome reflex cough. Pain is provoked by pressure, inspi- ration, coughing, sneezing, and certain movements of the body; its diagnostic value comes from its limitation to one point under the dif- ferent causes and especially when pressure is made on the affected rib at a distance. Abnormal mobility is sometimes present, but the elasticity and mobility of the ribs make its recognition uncertain. It may sometimes be made out by placing a finger on each side of the suspected fracture, and pressing alternately with one and the other. The same manipula- tion may produce crepitus, but usually this is more readily recognized by placing the hand flat upon the chest, and pressing slightly at dif- ferent points, or asking the patient to cough or draw a long breath. It may also be heard sometimes on auscultation of the chest in the usual manner, and may be accompanied after a day or two by a pleu- ritic friction sound, the result of a pleurisy excited by the trauma- tism, and usually limited in area to its immediate neighborhood. It is not uncommon for the patient himself to recognize the crepitus. Emphysema is, in itself, a very positive sign of injury to the lung and of fracture of a rib if there is no penetrating wound to account for it otherwise. Pneumothorax, or hemorrhage into the pleural cavity from a lacerated lung or an intercostal artery may be present in any of the severer cases ; and bloody expectoration, which also points toward fracture, is often present even in slight cases, and is not infrequently absent in grave ones. The symptoms of partial fracture or infraction are seldom definite enough to permit a positive diagnosis. The course of a simple uncomplicated fracture is usually quite uneventful ; the patient remains quiet, sometimes keeping his bed, and breathes carefully and superficially to avoid pain ; after two or three weeks he finds these precautions unnecessary, and the surgeon finds on examination that the local tenderness has disappeared, and that crep- FRACTURES OF THE RIBS AND THEIR CARTILAGES. Fig. 77. itus and mobility can no longer be detected. Union by a bony callus takes place almost invariably, notwithstanding the defective immobili- zation of the parts, but, as a consequence of the latter, the callus is likely to be large, and, when two or more ribs have been broken, to unite the adjoining ones by a bridge of new formation. Solidity is given at first by an ensheathing callus, and the union between the fractured surfaces, even when they are in apposition, may remain fibrous for several months. Failure of union is rare. Displacement upward or downward of a fragment may lead to its union with the adjoining rib, or to the formation of a lateral joint between them, as in the next following case; or, if adjoining ribs are displaced in opposite directions, a gap may be left between them which may lead to hernia of the lung, as in a case which is recorded in the Gazette 3Iedwale de Paris, 1832, p. 465, and pictured in Cruveilhier's Atlas d' 'Anatomie Pathologique, a gap in the right side in front between the first and fourth ribs, four inches long and two inches wide. The patient had survived the accident about forty years. The course and symptoms in the severer cases vary with the degree and character of the complications which give them their gravity. Emphysema may be slight and transitory, or it may continue for days and spread over a large portion of the surface of the body. If the air escapes into the cavity of the chest, or if the frac- ture is compound with a penetrating wound, the resultant dyspnoea and oppres- sion may be extreme, and the physical signs of pneumothorax will be found upon examination. If, in addition to the escape of air, there is also free hemorrhage into the chest from the torn lung or an inter- costal artery, the physical signs will be correspondingly modified. Extreme dysp- noea, due to congestion of the lung follow- ing promptly upon the injury, is not un- common, and pneumonia occasionally results and leads to a fatal termination in the old and feeble. I have observed in half a dozen cases of severe compression of the chest with fracture or dislocation of ribs or, more commonly, costal cartilages, a peculiar dusky discoloration of the skin of the face, neck, and upper part of the chest, together with marked subconjunctival bul- bar ecchymosis nearly limited to the interpalpebral space. The dis- coloration does not disappear on pressure and is apparently due to the coloring-matter of the blood, possibly through innumerable minute capillary extravasations. It appears immediately, is evidently due to the compression of the chest, and disappears slowly. 1 Legros Clark 2 claims that serious functional derangement, without Fracture of ribs, with excessive callus. (V. Bergmann.) 13 1 New York Medical Journal, March 1, 1890. 8 Clark: Diagnosis ol' Visceral Lesions, j>. 213. 194 FRACTURES. organic lesion of the lung, may result from contusion or concussion of the chest, that it may be transient or may be followed by inflammation, local or general, of the affected lung, and that it is sometimes observed in the lung on the side opposite that which has sustained the injury. Prognosis. The prognosis depends largely upon the complications. Simple fractures without important complications do well, as a rule; the exceptions are found mainly in the old and feeble, whose lives may be endangered by congestion of the lungs, pneumonia, or pleurisy. Cases complicated by wound of the heart or pericardium are usually promptly fatal. Wounds of the lungs are serious, but there are many instances of recovery even in cases where the laceration of the lung was probably extensive and accompanied a fracture that was in itself severe. Treatment. The indications for treatment are to reduce any displace- ment that threatens to produce a complication or that causes pain, to immobilize the chest-wall, and to relieve or prevent pulmonary inflam- mation or congestion. Outward angular displacemont may be corrected by pressure upon the projecting angle, and inward angular displacement may sometimes be corrected, when the broken surfaces are still in contact and the frac- ture is situated near the middle of the rib, by pressing the sternum backward and thus springing the bone out. If the fragments have overriden this manoeuvre is worse than useless, for it can only increase the displacement. Relief may also be obtained by making the patient strain or draw full deep breaths. Ravaton relieved the pain and cor- rected the displacement in one case by suspending the patient upon two rods passed under his axillae. When the displacement was greater and one of the fragments was pressed inward Malgaigne ingeniously made use of the other to elevate it, pressing it in until the ends met and became locked together by the irregularities of their broken surfaces so that the elasticity of the second should serve to raise the first. For the elevation or removal of a depressed fragment by operation a number of methods have been proposed, but very few instances are known of the use of any of them. If such elevation should seem necessary, and if approach through an incision were deemed inadvisable because of the risk of the admission of air to the pleural cavity, the old suggestion of raising the bone by means of a hook passed through the skin and behind the upper border of the bone might be used. Immobilization of the chest is best effected by surrounding it with a broad, snugly drawn piece of adhesive plaster, or with two or three narrower strips. The guide to the amount of pressure is the comfort of the patient. Malgaigne preferred a bandage three or four inches wide and long enough to pass once and a half around the chest, and he did not place it lower than the ensiform appendix, believing it to be sufficient, whichever ribs might be broken, to restrain the move- ments of the middle ones. When a circular bandage cannot be borne he recommends that a long narrow strip of plaster should be carried from the anterior end of the seventh rib on the right side, for example, across the front of the chest, under the left arm and across the back to FRACTURES OF THE RIBS AND THEIR CARTILAGES. 195 and over the right shoulder, thence again across the chest in front and around the left side and back to end at the crest of the right ilium. This immobilizes the left side of the chest very effectually and leaves the right side free. He suggests that in addition the arm should be fixed to the side. The pressure of a bandage is useful also to prevent the spread of emphysema. This complication seldom requires any more active treat- ment, although scarifications have been made or the air drawn off through a trocar. If either method is used the instrument should be applied at a distance from the fracture. The more dangerous variety of emphysema, that in which the air makes its way into the mediastinum and the interlobular tissue of the lung, is not amenable to operative, treatment. In pneumothorax it may be desirable to draw off the air through an aspirating needle or a canula in order to relieve the pressure, and if blood accumulates within the pleural cavity in quantities sufficiently large to endanger life by interference with the action of the heart and either or both lungs, it may become necessary to remove it by aspira- tion or incision, but the indications should be very plain before the surgeon decides to interfere in this manner, since the removal of the blood and the relief of pressure may only lead to a return of the bleed- ing. Persistent internal hemorrhage can be treated only by indirect measures, because its source cannot be recognized, and, if recognized, probably could not be reached, It has been found useful to constrict the thighs circularly at the groin with rubber tubing or a roller-bandage just sufficiently to arrest the venous current ; this withdraws a consid- erable amount of blood temporarily from circulation and acts as a venesection. It sometimes arrests bleeding instantly. When life is threatened by pulmonary engorgement with extreme dyspnoea, blood should be taken from the arm immediately and freely, and the bleeding should be repeated if the symptoms reappear. The older records are full of cases showing the benefit of this practice, and, among modern surgeons, Mr. Bryant recommends it unhesitatingly and forcibly. He says : " Bleed with no sparing hand. . . . When relief has been obtained arrest the flow immediately, as syncope can only do harm/ 7 then follow with antimony. Fractures of the Costal Cartilages. The first mention made of this lesion appears to have been by Zwinger in 1698, and it is not again referred to in medical literature until 1805, when Lobstein, at Strasburg, and in 1806 Magendie, at Paris, each described it with cases. Additional observations were made by Delpech, Sir Astley Cooper, and Velpeau, and in 1841 Malgaigne l published a paper upon the subject which, six years afterward, he reproduced in part in his book on fractures. Since then but little work has been done upon the subject, most writers contenting them- selves with reproducing in substance Malgaigne's chapter, luirlt col- lected more than thirty cases for the chapter upon it in his book on 1 Malgaigne: Bulletins de Therapeutique, 1841, p, 227. 196 FRACTURES. fractures, and Paulet, 1 who appears not to have known of Gurlt's work, gives fourteen cases which he obtained by a partial search through French periodical literature, only four of which are mentioned by Gurlt. Bourneville 2 (1880) and Pozzi 3 (1888) raised the list to seventy- nine cases. I have seen two or three. Fractures occur much more frequently at or near the junction of the cartilage and rib than at any other point, and more frequently in the seventh and eighth ribs than in any other. The fracture may be double, and may involve several cartilages on one side or on both. All the recorded fractures have been complete with the exception of one case ; they have been perpendicular to the long axis of the cartilage, or very slightly oblique, and the surface has always been smooth, without ser- rations or splinters. It is probable that persons advanced in life are more liable to this fracture than the young, because of the calcification or ossification of the cartilages, but it has occurred in young men (seventeen years) and even in a child seven years old. Displacement has been absent in a very few cases ; in most it takes place in the antero-posterior direction, and in some the fragments have overriden in the direction of the long axis of the rib. This latter form, probably, is possible only in the longer and more curved ribs, or when several adjoining ones are broken. The separation in either of these two directions may amount to as much as an inch, but is rarely so great. Either fragment may lie in front of the other, although the costal fragment projects more frequently than the sternal one ; the dis- placement, however, appears to depend entirely upon the direction of the fracturing force and upon the position occupied by the patient. No instance of a compound fracture of a costal cartilage is on record, and the complications are less frequent and, as a rule, less serious than those accompanying fractures of the ribs. In some cases wdiere the violence has been extreme and many cartilages have been broken fatal injury has been done at the same time to the heart or great vessels, but not by the penetration of one of the fragments ; the viscera are crushed or torn by the continued action of the force after the wall of the chest has yielded under it. Hernia of the lung has been observed in three cases, one after frac- ture of the third and fourth cartilages and rupture of the intercostal muscles by the fall of a heavy weight, the second, a double one, after fracture or diastasis due to paroxysms of coughing, and the third, observed by Legros Clark 4 after a blow received from the shaft of some vehicle. In this one the cartilage of the second rib was driven in, creating a gap through which a tumor as large as the fist appeared at each inspiration and disappeared at each expiration, leaving a depres- sion capable of containing at least two ounces of liquid. Recovery in three weeks, the gap persisting but " evidently occupied by some plastic deposit." 1 Paulet : Diet. Encyclopedique, First Series, vol. xxi., art. Cotes, 1878. 2 Bourneville: Progres Med., 1880. 3 Pozzi : Ibid., October 20, 1888. 4 Legros Clark : Loc. cit., p. 206. FRACTURES OF THE RIBS AND 1HEIR CARTILAGES. 197 In seven cases the fracture has been produced by muscular action, either an excessive effort, as to avoid a fall or to throw a heavy object, or coughing or sneezing. Thus Broca l reported the case of a porter at the market who having placed a sack of peas upon his shoulder asked a comrade to add another to it. The latter threw the second sac heavily upon him, and in the effort to avoid a fall under the weight he fractured the cartilages of the sixth, seventh, and eighth ribs on the right side at points seven or eight centimetres from the median line. Fractures by external violence may be direct or indirect. Gurlt, thinks the indirect fractures take place at or near the costo-chondral junction, the force acting upon the rib itself in such manner as to spring its anterior end outward, while in the direct fractures the force is exerted upon a restricted area of the cartilage itself, as in a fall upon the edge of a tub or step, the blow of a fist, the kick of a horse. The symptoms are local pain and deformity. Crepitus and abnormal mobility are not often recognizable, but if displacement is present it can usually be made out by following the outline of the rib and cartilage with the finger and by observing that it can be increased or diminished by pressure upon one or the other fragment. It may not be easy in some cases to say whether the fracture involves the rib or the cartilage and in others whether it is a fracture of the cartilage or a dislocation of its sternal or costal end, but the question has no practical impor- tance. The prognosis, independent of complications, is favorable, and the fracture may be expected to unite in three or four weeks. Our knowl- edge of the mode of repair has been obtained partly by experimentation and partly by examination of specimens. When the fragments remain end to end and the fractured surfaces are more or less completely in con- tact, a fibrous band unites them, and the union is strengthened by an external ring of spongy bone. In a specimen obtained by Basserau 2 and examined microscopically by Malassez, and in one reported by Pozzi, 3 it was found that the central band was partly cartilaginous, and it is asserted that in other specimens points of ossification have been found. Fig. 78. Fig. 79. Repair of fracture of a costal cartilage. (Guri/t.) Repair of fracture of a costal cartilago. When the fragments override, they take, so for at least as the broken ends are concerned, little or no part in the repair. Union is accom- plished by an intermediate band which is at first fibrous or cartilaginous and may become bony (Fig. 78), or if the fragments are in contact 1 Broca: Quoted by Paulet, loc. cit., p. 83. '-' Basserau : Paulet, loo. oit., p. B8 :i Pozzi : Loc. cit. 198 FkACTURES. the new bone forms on the sides and the ends (Fig. 79), and in both cases it envelopes the pieces more or less completely like a ring. This ring originates apparently in the perichondrium, and its ossification is the final result of the formative irritation created by the traumatism, and is analogous to the ossification seen so constantly not only in carti- lage which would normally be transformed into bone, but also in others, such as that of the larynx, whose normal evolution does not include that change. Treatment. The treatment is similar to that of fracture of the ribs : reduction of a displacement if necessary and possible, and immobiliza- tion. The former must be accomplished, if at all, by placing the patient upon the opposite side or upon his back, by drawing the shoul- ders back, or by deep inspirations ; the latter by a body bandage, strips of adhesive plaster, or, following Malgaigne's example, by a hernial truss so placed as to restrain the fragment that tends to project. CHAPTER XVII. FRACTURES OF THE CLAVICLE. Fracture of the clavicle is a common injury and is especially frequent in childhood, taking the place at that age, as was pointed out by Kronlein, of dislocation of the shoulder by direct violence later in life. That is, a fall upon the shoulder breaks the clavicle of a child but dislocates the shoulder of an adult. Pathology. It has been found convenient by most modern authors for the pur- poses of study and description to divide the fractures into three groups, according as they occupy the inner, middle, or outer third of the bone. The average length of the clavicle is six inches, and this division into thirds of about two inches each corresponds to anatomical differences of considerable clinical importance. To the flattened outer third are attached the trapezius and deltoid muscles and the strong coraco-clavic- ular ligament binding it to the coracoid process, the inner fasciculus of which, known as the coracoid ligament, marks the inner limit of this portion, and can sometimes be readily felt upon the living body. The dividing line between the inner and middle thirds is not so definitely marked anatomically, it corresponds approximately to the point where the clavicle crosses the lower or outer edge of the first rib. The inner third is attached to the sternum by the sterno-clavicular ligaments, and to the cartilage of the first rib by the costo-clavicular or rhomboid ligament. To its upper border is attached the sterno-cleido-mastoid muscle, to its lower the pectoralis major. Since the outer third is broadly attached by ligaments to the scapula it is apparent that after fracture of the bone in the inner or middle third the outer fragment will not be able to change its relations to the scapula materially, and that its displacement, therefore, will be gov- erned by the change of position of the latter, by its sinking inward and forward to the side of the chest in consequence of the loss of its anterior support. The outer portion of the middle third is by far the most common seat of fractures observed clinically, but Lane's 1 observations in the dissectiug-room and his experiments indicate that fractures of the outer third may be very frequent and usually unrecognized. The fracture may be partial or complete, single or multiple, simple or compound ; the most frequent form is simple complete fracture. Compound fracture is so rare that Gurlt says he could find only four examples of it, and Hamilton, who gives the same four eases, says he had never met witli an example. I have seen one : A laborer was 1 Lane: Guy's Hospital Reports, L886, vol. xliii. 199 200 FRACTURES. struck by a falling stone upon the shoulder and sustained a fracture of the right clavicle at a point nearly two inches from the sternal end of the bone. The line of fracture was oblique from above downward and inward. A large ragged wound extended backward across the clavicle and shoulder, in which some of the divided fibres of the trapezius could be seen. The outer end of the inner fragment was directed sharply upward, the outer fragment lying below and a little distance from it. The wound healed almost entirely in about six weeks, but when last seen there was still a sinus over the end of the inner fragment through which a probe could be passed to the bone. Incomplete or partial fracture is, according to Hamilton, who gave much attention to this variety, very common. He thinks that 34 of the 157 fractures of the clavicle recorded by him l were partial fractures, and says that at least eleven of these were immediately and spontaneously restored to their natural axes. The symptoms accepted for this diagnosis are the history of a fall upon the shoulder, or at least indirect violence, the youth of the patient, a swelling upon the upper surface and front or rear border of the middle third of the bone appear- ing within two or three days after the accident, possibly a change in the axis of the bone, and possibly ability to straighten it with slight crepitus. 1. Complete fracture of the middle third may be oblique or transverse, the former variety being found most commonly in adults, the latter in children. The line of an oblique fracture usually runs inward and downward or backward, but may take any other direction and may be nearly transverse, or extremely oblique (Fig. 80), or practically longi- Fig. 80. Oblique fracture of the clavicle. tudinal, as in a case observed bv Chassaignac and mentioned by Polail- lon, 2 in which the fracture ran from the centre of the acromial end to a point just external to the sterno-clavicular articulation, dividing the bone into two longitudinal halves. Multiple and comminuted fractures are rare. When the fracture is multiple or doubly the intermediate fragment is likely to occupy a very irregular position. The most common displacements are produced by the falling for- ward, downward, and inward of the shoulder, the consequence of the loss of support normally furnished by the clavicle, and depend some- what upon the direction of the line of fracture. The commonest form is that in which the sternal fragment is drawm upward by the sterno- cleidomastoid muscle or pushed upward by the outer fragment, which 1 Hamilton : Fractures and Dislocations, 6th ed., p. 90. 2 Polaillon : Diet. Encyclopedique, art. Clavicule, p. 682. FRACTURES OF THE CLAVICLE. 201 is displaced inward along the under or anterior surface of the other and has at the same time changed its direction somewhat by the sink- ing of its acromial end. The shortening may be very notable, nearly one-third of the entire length of the bone in a specimen mentioned by Malgaigne. Another form is found where the line of fracture is such that the fragments do not readily leave each other, and the broken ends are displaced together upward and backward by the falling in of the shoulders so that the bone forms an angle at the seat of fracture. In some exceptional cases the outer fragment has lain upon the upper or posterior surface of the inner fragment. Malgaigne 1 says this variety was mentioned by Hippocrates, and that he himself saw one, but only one, example of it. Under these circumstances the sternal fragment is held down instead of being pushed up by the other one, and the displacement is mainly in the direction of the latter, the inner end of which is turned upward, forming a projection at the seat of fracture. Fig. 81. Fracture of the clavicle. Union with extreme displacement. Fig. 82. Fracture of the clavicle. In transverse fractures the broken surfaces seldom leave each other, and the only displacements possible are in thickness and direction, the lateral and angular. The latter is the one usually seen, the angle being directed, for reasons that have been already stated, upward and backward. The most common and persistent cause of these displacements is undoubtedly the tendency of the scapula and shoulder to fall forward and inward upon the chest, but it is aided largely in the first place by the fracturing force which continues to act after the bone has yielded to it. Thus, in a foil upon the shoulder or the outstretched hand, the clavicle breaks by the exaggeration of its normal curves, and as the direction of the line of fracture is usually downward and inward the outer fragment is forced inward on the under side of the other and necessarily turns the outer end of the latter upward. 2. Fracture of the Outer Third. This variety is next in frequency to the preceding, and may be produced by direct or indirect violence. The direction of the line of fracture is more commonly transverse than 1 Malgaigne: Loc. cit., p. 468. 202 FRACTURES. oblique. The degree of displacement varies greatly in different cases, being very notable in some and slight or entirely absent in others. When displacement exists it is usually an angular one, the apex of the angle being directed backward. In some specimens 1 bony union has taken place between the clavicle and the scapula, presumably by ossification of the coraco-clavicular ligament. It is in the form of a prop extending from the under side of the clavicle to the base of the coracoid process, and sometimes to the notch of the scapula, and usually convex posteriorly. Fig. 83.. Fracture of the clavicle, outer third. Extreme angular displacement. (R. W. Smith.) When the fracture is external to the trapezoid ligament — that is, when it lies within the outer inch of the bone — angular displacement is the rule, the outer fragment turning forward and inward until its axis is at right angles with that of the inner fragment ; sometimes its broken surface lies against the anterior border of the inner one, and sometimes the outer fragment lies under the inner one. Malgaigne describes a case in which, after fracture within half an inch of the articular sur- face, the inner fragment was elevated an inch above the other, and there was shortening of nearly half an inch ; the appearance, in short, was that of a dislocation upward of the acromial end of the clavicle. 3. Fracture of the Inner Third. The older division, which was into fractures of the body and fractures of the outer end, took no special notice of this variety which received its first separate description from Malgaigne. It is the least common of the three ; Delens, 2 who wrote the first formal article upon the subject, collected twenty-eight cases, to which Polaillon two years later added three. I have seen one caused by a direct blow with a baseball. The fracture may occupy any point in the division, and is more often oblique than transverse. It was asserted at first that the displacement did not occur if the fracture was within the region of the attachment of the costo-clavicular ligament, but the contrary has since been proved ; displacement may take place in any direction, but the commonest one is downward and forward of the inner end of the outer fragment, or of the adjoining ends of both fragments if they do not separate from each other. Polaillon attributes the principal part in the production of this displacement to the action 1 Smith : Dublin Jonrn. Med. Sci., 1842, p. 478, and Fractures in the Vicinity of Joints, p. 212. 2 Delens : Archives Generates de Med., 1873, vol. i. p. 529. FRACTURES OF THE CLAVICLE. 203 of the pectoral and deltoid muscles upon the outer fragment, and finds support for his opinion in the fact that this displacement has always been observed after fracture by muscular action ; and as in this variety the fracture is usually near the inner articular surface, in a region, that is, where displacement after fracture by other causes is slight or absent, the argument is not without weight, although the obliquity of the line of fracture in such cases as that represented in Fig. 84 cannot be entirely foreign to the direction and degree of the displacement. When the fracture is transverse the lateral displacement may be slight or entirely absent and the periosteum may remain untorn. Longitu- dinal fracture with comminution was seen in one case, and Hamilton reports another in which the line ran from the articulation upward and outward for one and a half inches. The fragments overlapped three- fourths of an inch and were firmly united. In two cases the end of the outer fragment lay underneath the inner one and both were directed upward and backward. The outer end of the inner fragment is acted upon more strongly by the sterno-cleido-mastoid muscle than by any other, the effect of which is to draw it upward, and this effect is increased by the pressure of the outer fragment when that is forced in front of and below the other, so that whenever the two fractured sur- faces leave each other the inner fragment is likely to incline upward. Fig. 84. Fracture of the clavicle, inner third. (Gurlt.) Multiple Fractures. But few cases are recorded in which the bone has been broken in two or more places ; in some the fracture was by direct, in others by indirect, violence. Both fractures have been found in the middle third, but more commonly they occupy different thirds. When one fracture has been in the acromial, and the other in the inner or middle third, the intermediate piece has not shown much displace- ment, and each fracture has followed the usual course of a single one ; but when the fractures have been within or close to the limits of the middle third, the displacement has been very notable. Complications. Complications of fracture of the clavicle consist in injuries to the vessels, nerves, and lungs, and are exceedinglv rare, excluding gunshot wounds in which the complications are produced by the ball and not by the fractured bone. Taylor l reports a case of meurism of the subclavian artery and quotes another seen by Heath. Gallois and Piollet 2 report a case of arterio-venous aneurism (sub- clavian artery) and collected three others. Dupuytren speaks in a 1 Taylor : Annals of Surg., 1903, p. 638. 2 Gallois ami Piollet : Rev. do Chir.. 1901, 204 FRACTURES. lecture of having seen two or three cases of aneurism following fracture of the clavicle, a~nd Jacquemiev gives a case observed by Blandin, of an aneurism of the acromial branch of the acromio-thoracic artery fol- lowing fracture by direct violence. Taylor l reports a case of aneurism of the subclavian caused by a splinter from the fractured clavicle and quotes 3 others by Heath, 2 Boulby, 3 and Twyman. 4 Taylor's recovered after operation. Meinhold 5 reports a case of gradual interruption of the current in the subclavian artery, becoming complete three and a half months after fracture in the middle by direct violence, healing with angular displacement ; relieved by resection of the angle. In a case reported by Fisk 6 of rupture of the subclavian and of four of the roots of the brachial plexus, with a subperiosteal fracture of the clavicle without displacement, by the fall of a heavy piece of iron upon the patient's shoulder, the fracture seems to have been an unimportant, non-causative incident, and the artery and nerves to have been torn by extreme depression of the shoulder. ( Cf. similar rupture of the nerves in Flaubert's case quoted in Chapter XXXIV., Emphysema of Cel- lular Tissue.) A few cases are reported of injury to the subclavian or internal jug- ular vein, in some of which the diagnosis was verified by autopsy. (See First Edition and Taylor, above quoted.) In the museum of St. George's Hospital is a specimen in which the fractured end of the bone was driven through the internal jugular vein. A man 7 fifty-nine years old broke the right clavicle in the middle third by a fall upon the shoulder. The fracture was very oblique from without inward and backward, and the vein was torn completely across by the outer fragment. The artery and nerves Avere not injured. Fifteen cases 8 have been reported in which symptoms indicating injury to the brachial plexus have appeared immediately or after an in- terval. In most of those in which they appeared promptly the causa- tive violence was great and the displacement of the fragments marked, but in mine there was no displacement. In one (Yelpeau) extensive subcutaneous emphysema showed injury to the lung, and fracture of no rib could be detected. In two (Earle, Stimson) there was paralysis of the scapular muscles supplied by the supi^a-scapular nerve which leaves the plexus above the clavicle. In two (Davis, Mauclaire) the displace- ment was corrected by operation with relief of symptoms, and in one (Poir.ier) the arm was amputated because of the pain. In six cases (Hassler, Sieur, Delens, Polaillon, Lequyer, McCosh) the symptoms appeared late ; they were due to excessive callus in the first-named five and to a cicatrix involving the plexus in the last ; all were relieved by operation ; but Lequyer's only slightly. Baylor : Trans. Eoyal Acad, of Med. in Ireland, 1903, p. 225. 2 Heath: Med. Chir. Soc., vol. 63. 3 Boulby : Path. Soc., London, vol. 42, p. 79. * Twyman : Lancet, 1890, vol. i. p. 1352. 5 Meinhold : Munch. Med. Woch., 1904, No. 17. 6 Fisk : Annals of Surgery, 1904, p. 1011. 7 Prog. Med., 1882, No. 16. 8 Desault, Velpeau, Earle, Gibson, quoted by Gurlt, loc. cit., ii. pp. 601, 604, 606; Polail- lon, loc. cit., p. 696 : Mercier, Des Complications des Fractures de la Clavicule, 1881 ; Delens, Arch, de Med., Aug., 1881, p. 170; Stimson, N. Y. Med. Journ.', June 11. 1887; Poirier, La Semaine Med., Sept. 2, 1891 ; Mauclaire. Ibid., Oct. 17, 1894 ; Hassler, Lyon Med., January 12, 1896 ; Sieur, Bull, de la Soc. de Chir., vol. 25, p. 503 ; Davis, Annals of Surg., Feb., 1895; McCosh, Annals of Surg., 1902, vol. 35, p. 110; Lequver, Gaz. med. de Nantes, 1906, No. 15, abst. in Ztlblatt fur Chir., 1906, p. 1016. FRACTURES OF THE CLAVICLE. 205 Iujmy to the lung, as evidenced by emphysema, has been recorded in five cases where this symptom seemed to be demonstrative, and in two others in which it is much more likely that the emphysema was due to the introduction of air through a wound of the soft parts. The first five cases are those of Vigarous, Velpeau, Huguier, Ruble, and Mercier. All except the fourth are described with all the details obtainable in a thesis by Mercier. 1 (See First Edition.) The anatomical demonstration of the immediate agency is lacking in all these cases, but the notes in all but one show that the surgeons were mindful of the possibility that a fracture of a rib might coexist and might have been the cause of the wound in the lung, and that they were unable to detect such a complication. In most of them, too, mention is made of the depression of the outer fragment, and as the relations of the clavicle to the upper portion of the thoracic cavity are such that it is not difficult to admit the possibility of a wound of the apex of the lung by the broken bone, I think the clinical evidence may be accepted as sufficient. Etiology. The clavicle may be broken by muscular action, by direct violence, or by indirect violence. Gurlt 2 and Delens 3 collected and analyzed a number of reported cases of fracture by muscular action. The efforts by which the frac- tures were caused were various : lifting a heavy weight ; striking with the hand, a whip, or racket ; making a vigorous effort that involved the contraction of many muscles, as in Legros Clark's case of a lad who, while swinging by the feet from a trapeze, tried to raise himself so as to seize the bar with his hands : the clavicle broke in its inner third during the effort. It is probable that the clavicular fibres of the deltoid and pectoralis major are the most efficient agents in pro- ducing this fracture, since their contraction tends to draw the unsup- ported central portion of the clavicle downward and outward toward the humerus when the arm is fixed. Closely allied to these cases are those in which the fracture has been produced by a blow or other force acting at the hand ; thus, an old woman broke her clavicle by closing the door of a wardrobe forcibly, and a lunatic at Bicetre broke his by striking violently with a heavy stick against some iron bars. In a very few of the cases the fracture has been produced by two efforts, or a blow and an effort, separated by a longer or shorter inter- val ; the patient feels pain at some point in the clavicle after a fall or a blow or an effort, which persists, perhaps, but is not severe and does not interfere with the use of the arm ; and then in a few days, after another violence or effort, the bone breaks. If the second violence were sufficient in itself to account for the fracture, the first one might be regarded as a mere coincidence, but it has generally been less than the first, 1 Mercier: Des Complications des Fractures de la Clavicule, These de Paris, issi. 2 Gurlt: Loc. cit 3 Deleus : Loc. cit., and Arch. Gen., 1875, vol. i. p. 257. 206 FRACTURES. Direct fractures are produced by varied causes, and may occur at any part of the bone, but most frequently in the middle and outer thirds. The commonest form of violence is a blow falling upon the centre of the bone in a direction that is backward and downward. Indirect fractures, which constitute the great majority, are most frequently produced by a fall upon the shoulder or upon the hand or elbow, the arm being extended and the muscles rigid. In a few cases the fracture has been caused apparently by the sudden depression of the shoulder, by which the clavicle was bent over the first rib. Malgaigne l reports one : an incomplete fracture at the middle of the bone due to the slipping of a burden from the shoulder to the arm ; and Polaillon 2 another : a man who held the end of a lever which was to receive part of the Aveight of a heavy stone, the stone slipped suddenly upon the lever and drew the arm which held it downward. The man heard a snap and felt pain in the shoulder ; the clavicle was broken in its middle third. The clavicle has been broken in a number of cases during intra- uterine life by external violence, and occasionally by the midwife or obstetrician during parturition. Symptoms and Course. The rational and physical signs common to most fractures are found in those of the clavicle. These are the deformity, mobility, and crepitus, the localized pain, and the diminution of function. Besides the deformity due to the displacement of the fragments, there is also that which is produced by the falling inward of the shoulder and which is most apparent when viewed from behind, and with it goes a very noticeable projection of the posterior border and inferior angle of the scapula. In fractures of the middle third there is usually displacement of such a character and extent that there is no difficulty in recognizing it and its cause; the fragments can be separately grasped and moved upon each other. Crepitus, however, is not always produced by this manoeu- vre, for the broken surfaces may not be in contact, and in order to get this symptom it may be necessary to have the shoulder drawn back- ward and outward, so as to reduce the displacement. Localized pain on direct pressure or when the shoulder is pressed inward is a valuable sign in partial fractures and in fractures without displacement, and it may be the only one that is present immediately after the injury ; the appearance within a week of a firm oval mass at the point where pain was felt confirms the diagnosis of fracture. The interference with function seems to be largely the consequence of the pain which makes the patient unwilling to move the arm, rather than of any mechanical defect produced by the fracture. The patient can usually move the arm quite freely backward and forward, but cannot raise it or adduct it without pain, and if asked to put his hand 1 Malgaigue : Loc. cit., p. 463. 2 p laillou : Loc. cit., p. 679. FRACTURES OF THE CLAVICLE. 207 on his head, will usually flex the forearm, incline the body, and bend down his head to accomplish it. The fracture and displacement are not entirely without influence in this limitation of the movements, but they are not wholly responsible for it. Hurel, 1 who profited by his internat at the hospital for convalescents at Paris, to examine the later condition of patients with this fracture, found the movement of cir- cumduction of the arm the last to be regained, and that a shortening of half an inch or more delayed complete recovery considerably beyond the time that was sufficient for it when the shortening was less or absent. The patient's appearance is often quite characteristic ; he sits with his body and head inclined toward the injured side and supports the elbow with the other hand. The only cases in which the diagnosis can well remain in doubt after even a brief examination are those of incom- plete fracture, and some of fracture close to either end of the bone which may be mistaken for dislocation. On the other hand, the crep- itus which is so frequently present in dislocation of the acromial end of the clavicle, because of the chipping of the edge of the joint, may lead to a diagnosis of fracture. Either error may be avoided if the outline of the bone can be accurately traced. The progress of the fracture is simple and is rarely disturbed by complications or dangers. Union is usually firm by the end of the fourth week, sometimes much earlier, and failure of union is rare. Displacement and shortening, however, are the rule ; only those cases, apparently, are exempt in which the line of fracture is transverse and there is no displacement at first. The amount of the shortening may vary from a fraction of an inch to one and even two inches, and it may be produced by angular displacement, or by overriding, or by both. The complications that may occur in the course of the repair are the ordinary inflammatory ones that may arise at the seat of fracture in consequence of the bruising of the surrounding parts, or of the failure to immobilize the fragments, or special ones due to the pressure of the fragments or callus upon the vessels and nerves. (See above, Com- plications.) Delens's 2 case is very satisfactory. The patient was brought to the hospital January 1, 1881, with fracture of the left clavicle and two ribs. The arm was placed in a Mayor's sling, and union was complete by the end of the month. The patient returned on March 19th, complaining of great loss of power in the left arm ; examination showed marked overriding of the fragments, the outer lying in front of the inner one, with a hard, firm callus two inches thick, atrophy of all the muscles of the left arm, and passive conges- tion of the skin of the hand ; the pulsations of the left radial artery were much weaker than those of the right. The posterior and lower portion of the callus was removed by operation, the pulsations of the radial artery and the appearance of the hand at once became normal, 1 Hurel: Les Fractures tie la Clavicule, These do Paris, L867. 2 Delens : IV la resection d'un calde la Clavicule compriniant les vaisseauz et les aerfs sousclaviers, in Archives do Medeeine, August, L881, p. 170. 208 FRACTURES. and the patient gradually recovered the use of the limb. McCosh 1 briefly reports a case relieved by dissecting the plexus out of a mass of cicatricial tissue apparently caused by fracture. In another case Gosselin removed a portion of callus which had caused persistent ulceration of the soft parts covering it. A prompt cure followed. Ossification of the coraco-clavicular ligament has been observed in several cases after fracture in the outer third. No description is given of the modifications, if any, of the functions of the part produced by this anchylosis. Failure of union is rare, and in the few .cases which have been recorded it does not appear to have resulted in any diminution of func- tion ; in one case carefully examined by Hamilton where there was ligamentous union and overriding to the extent of half an inch the arm on the affected side was in every way as strong and as fit for use as the other. Simultaneous fracture of both clavicles is a relatively rare accident. Writing in 1881, I found twenty-eight cases collected by five authors, but a year seldom passes now without the report of one or more cases. In position, symptoms, and mode of production these double fractures do not differ materially from single ones. Sometimes they are pro- duced simultaneously by lateral pressure upon the shoulders, some- times successively by two different blows, and once simultaneously by a kick by a horse, each hoof breaking a clavicle. In three of the six cases collected by Malgaigne, union failed in both bones, and he has left a very complete account of the resultant disability in one of them which was under his own care. In the others there was apparently but little permanent interference with the functions of the arms. In none of the recently reported cases has failure of union been noted. In recent cases there is sometimes con- siderable dyspnoea, which Hurel thinks is due to the weight of the arms and shoulders upon the thorax, aided perhaps by the loss of power of the accessory muscles of respiration, those which pass from the neck or thorax to the clavicle and scapula. This dyspnoea is relieved by the dorsal decubitus if the shoulders rest upon a firm support. The condition of Malgaigne's patient on examination three years after the accident was as follows : the shoulders appeared to be below, in front of, and on the inner side of their normal positions, the shoulder- blades stood out posteriorly three or four inches from the chest-wall and were inclined forward and outward, and the upper part of the chest seemed much contracted. The clavicles were broken at the centre, and the outer fragments were below and behind the inner ones. The shoulders could be drawn back slightly, but not enough to over- come the displacement forward, and they could be drawn forward so far that they were separated by an interval of only three inches, meas- uring across the chest. The arms could be raised to the horizontal line in front and on the side, but not behind. 1 McCosh : Annals of Surgery, 1902, vol. xxxv. p. 110. FRACTURES OF THE CLAVICLE. 209 Treatment. The indications for treatment are to reduce the displacement and to prevent its recurrence. The means by which they are to be met do not differ materially in the different fractures, but in describing them I shall have mainly in mind fractures of the middle third. As has been already said, the FlG 85 shoulder and outer fragment are A usually displaced inward, forward, , /^^ / and downward, and the outer end ^T^^^^. of the inner fragment is displaced 1 //^ ^***^ W upward. The force which pro- yl ^^"*" ""^^^>^ duces the first displacement is the "11/ ^x^ weight of the shoulder. It must If \ be remembered that the shoulder /4 f^*^_ hangs out from the chest as a sign \f L V ' <2mS^ hangs out from the side of a house ; ^^pr the Scapula and clavicle are two Mechanism of displacement after fracture of lateral Supports, and the trapezius ^clavicle: a, acromion ;c, clavicle ;s,scap- , . * L r . ula ; a', position of the acromion after the muscle is a suspensory one. A f rac ture. glance at Fig. 85 shows how the fracture of the clavicle removes one lateral support, and how the weight of the shoulder, being no longer supported upon that side, swings forward and inward until a new equilibrium is found. This movement of rotation carries the posterior portion of the scapula away from the back at the same time that it brings the anterior portion nearer the front, and as the upper part of the chest is dome-like and not simply cylindrical, and as the movement, the change of position, takes place therefore in a vertical as well as in a horizontal plane, the shoulder drops and the inferior angle of the scapula rises, by compari- son at least, if not actually. Reduction, therefore, is to be accomplished by carrying the shoulder back to its former position, and retention by supplying the support previously given by the clavicle. These indi- cations have been clearly understood since the time of the earliest writers, but it has been found very difficult to embody them in practice, because there is no means of acting in the desired manner upon the shoulder that does not involve an amount of discomfort that patients will not ordinarily submit to. Moreover, in some cases surgeons have lost sight of the fact that the position of the arm is a secondary one, its importance being due solely to its use as a means of acting upon the outer end of the scapula, and that it is useless to press the elbow upward unless the scapula is left free to be raised by that pressure. Tt is entirely useless to bind the elbow to the shoulder on the same side ; such dressings do not raise the scapula. One of the methods of reduction employed by Hippocrates resembles in principle very closely the dressing suggested by Velpeau and em- ployed with much success by him and others. He placed the hand of the affected side upon the opposite shoulder and then pressed the elbow forcibly upward and outward. As the arm lies thus across the chest ils long axis is exactly in the direction in which pressure should be 14 210 FRACTURES. made to overcome the usual displacement. Another method employed by Hippocrates was to place the patient upon his back with a small, hard cushion between his shoulders, and then to press backward upon the acromion or the head of the humerus while the elbow was pushed up by an assistant. Paul us iEgineta made extension by drawing the arm upward and outward, and counter-extension by the neck or other arm (recently revived by Bardenheuer), and he also recommended the axillary pad with the elbow brought close to the side. Guy de Chauliac placed his knee between the patient's shoulders and drew them back- ward. These methods are the types of all that have since been used or that are now in use. Reduction, in short, is to be sought by carrying the shoulder upward, outward, and backward, acting either directly upon it or indirectly through the elbow, or using the arm as a lever. Polaillon recommends strongly a method based upon the latter principle; standing behind the patient he passes the hand or forearm into the axilla, and draws upward and backward with it, while with the other hand he presses the elbow against the side and thus forces the shoulder outward. In some cases it is necessary to have these efforts made by an assist- ant in order that the surgeon himself may be at liberty to make such movements of coaptation as may be needed to overcome the obstacles offered by points or irregularities upon the surface when the line of fracture is transverse or nearly so. In transverse fractures with only angular displacement upward and forward it is sometimes sufficient to make pressure upon the angle. The physical obstacles that need to be overcome in the treatment are so great and the success that has attended the different methods has often been so moderate that the number of plans that have been pro- posed and employed is very great, and the history of the treatment shows mainly a recurrence of periods marked at first by elaboration and multiplication of details and precautions and then by the abandon- ment of them all and the substitution of something very simple. The results obtained by the simple scarf or sling are often as good as those furnished by the most elaborate bandaging, and the discomfort to the patient during treatment is much less. The differences in the methods depend in great part upon the indi- cation which each surgeon has had more particularly in mind, upon the displacement which he sought to prevent. Thus, in some, the special object of the dressing is to maintain the shoulder elevated, in others to hold it back, and in others again to draw it outward. The type of the first class is a band passing under the elbow and forearm and around the neck, the forearm lying across the chest. That of the second is a pos- terior transverse splint to the ends of which the shoulders are made fast, or an anterior transverse splint pressing the shoulder back. That of the third is the axillary pad used as a fulcrum to force the shoulder out by pressing the elbow in. When the patient is sufficiently desirous to avoid any visible irreg- ularity in the outline of the clavicle to bear the discomforts of a prolonged rest in bed without change of position, and when the dis- placement can be reduced, treatment in the recumbent position holds FRACTURES OF THE CLAVICLE. 211 out the best prospect of recovery without deformity. The patient should be placed upon his back (or rather upon her back, for it is not probable that any one but a lady whose social position requires her neck to be left at times uncovered will submit to this confinement), upon a firm mattress with the neck bent so as to relax the sterno-cleido-mastoid upon the injured side, and the elbow fastened to the side or chest or raised upon a cushion so that the weight of the arm may tend somewhat to force the shoulder upward and backward, anatomically speaking. It has been recommended also that a firm narrow cushion be placed along the spine between the shoulder-blades, and Robert preferred to have the patient lie not entirely flat upon the back, but inclined slightly toward the uninjured side. In one case digital pressure was made upon the fragments throughout the treatment to insure accurate coaptation. The position must be kept practically unchanged for at least two, and probably for three, weeks. Goutrand l has modified this by keeping the arm dependent beside the bed for a week or two, and claims excellent results. The position is less irksome if the forearm is kept flexed by attaching the wrist either to the arm or to the side of the bed. Mayor's scarf or sling (Fig. 86) is made of a square of muslin, the diagonal of which is long enough to extend easily around the body. Fig. 87. Fracture of the clavicle, scarf. Mayor's Velpeau's dressing for fracture of the clavicle. The forearm is flexed at a right angle and laid across the breast : the cloth^ folded diagonally, is laid over it and tied around the body so that its folded border runs horizontally around an inch or two above the forearm, in front of which the cloth hangs down. The free point of the triangle is then brought up between the forearm and the body, and the two folds of which it is composed are secured, one on either side of the neck, by bands attached to the scarf behind and brought 1 Goutrand: Bull, et Mem. de la Soc. do Chir., 1907, vol. 83, p. tUt. 212 FRACTURES. forward over the shoulder ; or the forearm is placed between the folds of the triangle, the folded diagonal of which thus forms the lowest part of the dressing, while its ends are tied around the body as before. The folds that form the third point are tied together about the neck. This method is suitable for fractures without much displacement, especially for those in children with untorn periosteum. Velpeau's dressing (Figs. 87) is more secure. It is made with a long roller-bandage. The elbow is brought well in front of the chest and the hand placed on the opposite shoulder, and the limb is drawn snugly up toward the neck by successive turns of the roller which, beginning at the opposite axilla, pass obliquely across the back, over the shoulder, in front of the arm, under the elbow, and back to the axilla ; after three or four such turns have been placed the bandage is carried circularly around the body covering in the arm from below upward. The turns should be secured by stitching or by soaking in dextrine or plaster. Sayre's Dressing (Figs. 88 and 89). A very convenient and popular dressing is the one introduced by Prof. Sayre. It is made of Fig. 88. Fig. Sayre's adhesive plaster dressing for fracture of the clavicle. First piece. The same. Second piece. two strips of stout adhesive plaster, each about three inches wide and long enough to go once and a half around the body ; one end of the first strap is stitched closely about the arm just below the axilla, and the other carried around the chest from behind forward, as shown in Fig. 88. The second strap is then carried from the top of the shoulder on the uninjured side across the back, under the elbow, and along the fore- arm to the shoulder again (Fig. 89). The elbow should be drawn back while the first strap is applied, and well forward while the second is. FRACTURES OF THE CLAVICLE. 213 The object of the first strap is to fix the upper middle portion of the arm, so that when the elbow is brought forward by the second one the shoulder should be forced backward and upward. It is a convenience to the patient to have the plaster carried past the ulnar side of the hand so as to leave the latter uncovered. The action of the dressing is simply to press the shoulder upward and backward, and its principal advantage lies in the solidity which the use of the adhesive plaster gives. A thin pad of absorbent cotton may be placed in the axilla to absorb perspiration. The axillary pad, designed especially to prevent shortening by forcing the shoulder outward, has been in use for many centuries, and reached its highest development at the hands of Desault, of whose complicated dressing it forms the essential part. I believe that when- ever it is large and firm enough to accomplish its object it is dangerous, and whenever small enough to be free from danger it is useless. The dressings which are intended mainly to draw the shoulder back- ward are modifications of the figure-of-eight bandage and the posterior and anterior splints. The simple figure-of-eight carried across the back from one shoulder to the other, either in muslin or plaster of Paris, I have found to interfere too much with the circulation in the arms if effi- ciently applied. In two cases of marked displacement which could be reduced by drawing the shoulders back, but which recurred under the usual dressings, I obtained a satisfactory result by the use of a breast- plate made of crinoline soaked in plaster cream and covering the front of the chest and shoulders. The shoulders were held back and reduc- tion maintained until the plaster had set, and then the position was maintained by a figure-of-eight bandage. The heavy ends of the breast-plate in front of the shoulder prevented compression of the axillary vessels by the bandage, and the dressing was Avorn with com- fort for three or four weeks. Mayer and Cordua * recommend that the forearm should be fixed behind the back and the shoulder held back by a strip of adhesive plaster passing across its front to the back. Mayer had used it only in a case of fracture of the outer third, but Cordua appears to have gen- eralized its use. He says that patients soon adapt themselves to it. A modification of the figure-of-eight suggested by Recamier amounts almost to a posterior splint. He placed a large, hard square cushion between the shoulders behind and carried a bandage from each upper corner over the shoulder and under the axilla back to the lower corner. Posterior splints have been made in the form of a cross, against the arms of which the shoulders were drawn back, and as iron, wooden, and pasteboard splints crossing the back and extending usually beyond the shoulders, so that the traction of the bandages by which the shoul- ders were made fast should be exerted in an outward direction as well as backward. A fixed support shaped like the upper end of a crutch and fastened to the side of the chest by adhesive plaster has been occasionally sug- gested and even used. Like the axillary pad it is probably intolerable or dangerous if applied efficiently. 1 Mayer and Cordua: Zentralblatt fur Chir., 1906, pp. 1004 and 1200. 214 FRACTURES. It is apparent that while many different dressings may give good results in certain cases, none can be depended upon to do so in all, and that the displacement, the shortening, which is the rule in the adult, is the result in some cases of forces which cannot be effectually controlled, of the obliquity of the fracture, and not infrequently of the indocility of the patient, who, finding himself incommoded by the dressing, shifts it slightly, but often, until he obtains ease at the sacrifice of the object it was applied to secure. If the fracture is without displacement, especially the subperiosteal fracture of children, or if the displacement shows but little tendency to recur after reduction, the simple scarf or sling or Sayre's dressing will answer every purpose. If, on the other hand, the tendency to displacement is great, the choice of a method of treatment will depend largely upon the character and wishes of the patient. If he is indifferent to the deformity or intolerant of restraint, it is useless to attempt more than a simple dressing ; but if he is willing to submit to the confinement, the fracture may be treated by dorsal decubitus and digital pressure with a fair prospect of success, or by the plaster-of-Paris breast-plate and figure- of-eight bandage. Fortunately, persistence of displacement does not necessarily cause loss of function. In simultaneous fracture of the two clavicles, the dorsal position is strongly to be recommended. It is well to place in the axilla a pad of cotton wrapped in a com- press to absorb the moisture and keep the opposing surfaces from con- tact with each other ; and for the same reason a compress should be placed between the arm and the body, wherever the two would other- wise be in contact. The dressing should be worn for from fifteen to twenty days by children, and twenty to thirty days by adults. CHAPTEE XVIII. Fig. 90. FRACTURES OF THE SCAPULA. Feactures of the scapula clinically recognized are comparatively rare, about 1 per cent, of all fractures according to the best statistics at our command, but Lane's * observa- tions in the dissecting-room indicate that fractures of the acromion are very common and must, therefore, usually pass unrecognized. They are six times as common in men as in women, and in the great majority of cases the patients have been be- tween twenty and fifty years of age. The size and shape of the bone, and the presence of three irregular and prominent apophyses permit a diversity of fractures differing so greatly in their mode of production and symptoms that it becomes necessary to consider them sepa- rately. Most writers in the last hundred years have made from six to eight groups as follows: 1st, frac- tures of the body ; 2d, fractures of the inferior angle ; 3d, fractures of the upper angle and supra-spinous fossa ; 4th, fractures of the spine ; 5th, fractures of the acromion ; 6th, fractures of the coracoid process ; Fracture across body of the scapula, with (7,i n. , ,i i xi «i separation of a long piece of the spine. A. 7th, fractures through the surgical neck; 8th, fractures of the glenoid cavity. Of these varieties the 1st, 4th, and 5th are by far the most common ; the others are extremely rare. 1. Fractures of the Body of the Scapula. Fractures of the body of the scapula are single or multiple. The former are confined to the subspinous fossa, and the direction of the line of fracture is transverse or oblique. The fragments may preserve their normal relations to each other or there may be displacement, the lower fragment shifting to either side of the upper one ami overriding for a greater or less distance. This overriding is most marked on the axillary side and is due apparently to contraction of the teres major 1 Lane : Ciuy's Hospital Reports, 1886, vol. xliii. p. -US. •J 13 216 FRACTURES. is may some and serratus, while the lateral displacement is the result of the continued action of the fracturing force. In some cases the fragments have united after transverse or oblique fracture in such a position that they touch or override at one side and Fig. 91. are separated at the other. In multiple fractures the lesion extremely variable, the fracture be " starred," or comminuted, of the lines may be incom- plete, and the main one may be longi- tudinal ; the only condition, appar- ently, under which longitudinal fracture is met with (Fig. 91). The fracture may be partial, in the form of a fissure running from one border, or circumscribed, a cen- tral piece being broken out. The cause of the fracture has almost always been direct violence, usually a blow or a fall upon some angular object, but in three reported cases it appears to have been caused by muscular action, as in similar fractures of the inferior angle (q. v.), the line of fracture being somewhat The cases are those of Dobson, 1 Leidy, 2 Multiple (longitudinal) fracture scapula. the latter. the higher than in and Hoover. 3 The objective symptoms which may be met with are irregularity in outline, abnormal mobility, crepitus, and ecchymosis. The posterior border and inferior angle of the bone can be made prominent by carry- ing the elbow forward and inward, and then if the finger is passed along it a transverse or oblique fracture with displacement will be cer- tainly recognized. Abnormal mobility and crepitus can be recognized by grasping the inferior angle and moving it while the upper portion is steadied by the other hand. In multiple or partial fractures with depression the adjoining edge of bone may be felt if the patient is not too fat or muscular. The precaution should always be taken to make a comparison with the other scapula, and the normal ridges along the borders and at the base of the spine should be borne in mind. Ecchy- mosis, unless due to the action of the violence upon the soft parts, seldom appears until after the lapse of a few days. Localized pain on pressure and on movement of the arm is a con- stant symptom, and may make it impossible for the patient to ex- tend his arm horizontally and directly forward because it is so much in- creased by the contraction of the muscles concerned in this movement. The course in the simpler cases ends in recovery in four or five weeks, usually with preservation of function even if union has taken place 1 Dobson : Lancet, November 27, 1886. 2 Leidy : University Medical Magazine, March, 1891. 3 Hoover : Medical and Surgical Eeporter, 1893, p. 848. FRACTURES OF THE SCAPULA. 217 with some unreduced displacement. Multiple fractures are more dan- gerous because of the greater probability of suppuration at or in the neighborhood of the fracture, and of course if the fracture is a com- pound one the danger is still greater. In a very few instances there has been much disability due to failure of union or to union with dis- placement and exuberant callus. Gurlt quotes an example of the former in which the patient was unable to raise his hand to the back of his neck, and one of the latter in which the disability was almost complete and all communicated movements of the arm and shoulder were painful. Treatment. In simple fracture without displacement no other treat- ment is needed than immobilization of the arm and shoulder during the length of time necessary for consolidation. If displacement exist it must be corrected, if possible, by placing the arm and shoulder in various positions and pressing upon the fragments with the hands in the directions indicated by the displacement. When the latter is reduced as far as possible the arm and shoulder must be immobilized by binding the arm to the side or merely supporting it in a sling, and a broad strip of adhesive plaster may be laid across the scapula to aid its immobilization. In comminuted fractures the principal indication is to prevent the severe inflammatory reaction which is so likely to follow the bruising and laceration produced at the same time by the extreme violence that has caused the fracture. If the fracture is compound it must be explored through the wound and treated in accordance with the prin- ciples elsewhere laid down, and it is prudent in such cases to remove partly adherent fragments which could be safely left after fracture of other bones, whenever by such removal a free outlet that would other- wise be lacking is supplied to matter that may accumulate on the under (costal) surface of the bone. In a few cases of simple fracture pus has formed and caused much trouble by burrowing down the side of the body, confirming the experience furnished by some simple fractures of other bones, in which pus has formed apparently in consequence of imperfect immobilization. 2. Fractures of the Inferior Angle. These are included by some writers in the group of fractures of the body of the scapula, from which they differ merely by the proximity of the line of fracture to the lowest part of the bone, but as they pre- sent a more constant and well-defined displacement which cannot be readily overcome or prevented they deserve separate mention. The recorded instances of separate fracture are not very numerous. Gen- soul reported one produced by muscular action ; the patient saved him- self from falling to the ground while descending a sharp incline, either by catching hold of some support or by falling backward upon his outstretched hand ; the abstracts of the report are not clear upon this point. A triangular piece corresponding to the inferior angle was detached from the scapula and displaced forward and upward, and could be moved independently and with crepitus. Gensoul attributed the 218 FRACTURES. fracture to the sharp contraction of the teres major. Guinard 1 reports a second case and quotes a third, 2 the only one he could find. He adds a detailed study of fractures of the body and inferior angle by muscular action and quotes the reports of all the known cases. The histories of these cases and of those of fracture of the body suggest the possibility, even the probability, that muscular contraction was the cause in many others in which the history of a fall upon the back led to the easy assumption of fracture by direct violence. Symptoms. The symptoms are clear and unmistakable : displace- ment of the fragment forward and upward by the combined action of the serratus magnus and teres major ; abnormal mobility recognized by grasping the fragment with one hand and moving it, or by fixing it with one hand and moving the scapula with the other ; and crepitus. In one case 3 the displacement was said to have been downward. The displacement is difficult to maintain reduced, because the small- ness of the fragment prevents efficient control of it, and the tonicity of the muscles tends constantly to draw it away ; but while this ensures some deformity it is slight and does not add seriousness to the prognosis. 3. Fractures of the Upper Angle. These are very rare. Gurlt gives a figure of a specimen preserved in Dresden, and Hamilton of one in Philadelphia. In the latter a fissure extends well into the subspinous fossa. In both repair has taken place without much displacement. Gurlt records two cases observed during life ; in each the injury was the result of a fall upon the back ; in one there was no displacement, in the other the fragment was drawn upward and inward by the levator anguli scapulae. Texier 4 reports a case ; the cause was direct violence ; prompt recovery. Treatment. The treatment is to immobilize the arm and shoulder in the position that is most comfortable, securing the scapula with a body bandage or strips of adhesive plaster, and the arm by binding it to the body with the forearm flexed across the chest. 4. Fractures of the Spine of the Scapula. There are no known specimens of isolated fracture of the spine of the scapula, and our only knowledge of them is clinical. In those I have seen the diagnosis was readily made by recognition of the abnormal mobility, with crepitus, of the fragment, and sometimes of an irregularity in the outline of the spine. Treatment. The treatment is as before ; immobilization of the arm in a suitable position, and local antiphlogistic remedies if required. 5. Fracture of the Acromion. The alleged frequency of this fracture has been called in question by those who deem most of the museum specimens examples either of 1 Guinard: Archives generates de Med., April, 1896. 2 Sabatier : Union Medicale, 1857, p. 397. 3 Denuce : Journ. de Med. de Bordeaux, 1892, vol. i. p. 571. 4 Texier : Journ. de Med. de Bordeaux, April 5, 1896. FRACTURES OF THE SCAPULA. 219 a traumatic separation of the epiphysis or of n on -ossification. The former would still belong under the head of fractures, and, even if we exclude the others, there are still clinical instances in sufficient number to make the lesion one of the most common. The acromion is exposed to fracture by blows received directly upon it, and also through the humerus, as in a fall upon the elbow, and occa- sionally by muscular action. The line of fracture is usually perpen- dicular to the axis of the apophysis, but is sometimes oblique. It lies most frequently either in front of the acromioclavicular joint or at the root of the acromion, rarely at an intermediate point. The symptoms are those of fracture, and of the contusion if the agency has been direct violence ; and as the latter are prominent and may obscure the former, the fracture may be overlooked. The signs common to both are ecchymosis, local or extending down the arm, swelling, and pain. The additional signs of fracture are increase of the local pain on pressure and on moving the arm, usually complete inability to abduct the arm, abnormal mobility, and crepitus, and pos- sibly displacement. The displacement varies with the position and extent of the fracture. If the latter involves only the outer end of the apophysis, the displace- ment is slight and downward by the contraction of the attached fibres of the deltoid, the shoulder loses a little of its roundness in consequence, but the head of the humerus retains its place. If the fracture is near the base of the apophysis, the weight of the arm tends to draw the fragment downward and inward, turning it upon the outer end of the clavicle as a centre, and the shoulder is flattened. The finger passed along the spine recognizes an irregularity in the outline, usually a depression of the outer fragment, but sometimes an elevation or a transverse groove or gap in which the end of the finger can rest. Crepitus can often be got by lifting the elbow directly upward, so as to push up the acromion, or by abducting the arm ; and abnormal mobility must be sought by varied manipulations of the apophysis and by moving the arm. The commonest functional disturbance is the inability to raise the arm, although this is not a constant symptom, while the power of rota- tion is preserved unaltered, even if somewhat painful. Bony union appears to be the exception, the fragments uniting by a fibrous bond of greater or less length and solidity ; the rupture or the preservation of the periosteum must be of almost controlling impor- tance in determining the character of the union. Apparently, bony union takes place only when the fragments remain in close contact. In one case the distal fragment became necrosed and was cast out. Treatment. The treatment consists in reduction of the displacement by pressing the head of the humerus upward against the acromion, and in securing it in this position by a bandage passing about the body and the arm. The dressing should be worn lor about throe weeks. 220 FRACTURES. 6. Fracture of the Coracoid Process. This may be caused by muscular action or by direct or indirect vio- lence ; in the former the causative effort is sometimes comparatively slight — wringing wet clothes in one case — but more often is a powerful effort made with the arm. In fractures by direct violence other bones — ribs, arm, clavicle — are usually coincident!)' broken ; those by indi- rect violence appear, according to the observations of Lane/ to be most commonly produced by pressure of the tip of the process against the clavicle in forced flexion of the shoulder ; other instances are those in which the fracture is produced by the impact of the dislocated head of the humerus. The line of fracture is usually about an inch behind the apex of the process, but sometimes is further back, passing close to the upper edge of the glenoid cavity in a line that corresponds so nearly to the position of the epiphyseal cartilage that some observers consider some specimens to be examples of separation of the epiphysis, or even simply of delay in ossification. Normally this conjugal cartilage ossifies at about the fourteenth year. Bennett 2 pub- lished a case of separation of the Fig. 93. epiphysis, verified by autopsy, in a child six years old. In one of Mal- Fig. 92. Fracture of the coracoid process. Fracture at base of coracoid. gaigne's and in two of Gurlt's cases the end of the process was also split longitudinally into two pieces, one remaining attached to the ten- don of the biceps, the other to that of the pectoralis minor. A unique case of fracture across the base of the coracoid and the upper part of the glenoid fossa is reported by Braun 3 and represented in Fig. 93. The patient had been struck by a locomotive. The displacement is seldom great, because the fragment is prevented from yielding to the action of the attached muscles by the coraco-cla- vicular ligament ; still, in one of the last-mentioned cases the fragments were displaced more than half an inch downward. Petty 4 gives a ski- agram of a case of fracture by muscular action showing fracture at the middle with tilting downward and inward of the distal portion. 1 Lane : British Medical Journal, May 19, 1888. 2 Bennett: Dublin Journ. Med. Sciences, August, 1888. 3 Braun : Arch, fur klin. Chir., vol. 42, p. 110. 4 Petty : Annals of Surg., March, 1907. FRACTURES OF THE SCAPULA. 221 Symptoms. The symptoms are abnormal mobility and crepitus, but are not easily recognized, especially if the soft parts be much bruised and swollen ; the depth at which the process is placed, and the thick- ness of the overlying muscles, make it difficult to grasp the process between the lingers or to appreciate its independent mobility. I have also noticed localized pain on forcible voluntary adduction of the arm and flexion of the forearm. The fracture in itself involves no danger to life, and no probable disability, although the union is seldom bony. Of six specimens exam- ined by Gurlt bony union was found in only one ; in four cases men- tioned by him of which our knowledge is only clinical, mobility persisted in two. This failure of union does not seem to cause any loss of function. In Hulme's case the union was firm but the frag- ment somewhat displaced downward. Treatment. The treatment must be directed to immobilizing the arm in a position which will relax, as well as may be, the muscles attached to the process. Theoretically, the best position is that in which the forearm is flexed and the elbow carried across the front of the chest, but this cannot be carried out thoroughly without causing more discomfort than the benefit to be obtained by it will warrant ; and it is best, therefore, simply to fix the arm against the side with the forearm comfortably flexed. 7. Fractures of the Neck of the Scapula. Under this term, following Gurlt, I include not only fractures which pass from the suprascapular notch to the axillary border of the scapula in a direction parallel to the surface of the glenoid cavity, but also those which begin in front of the base of the coracoid process (sometimes even within the articular border) and pass obliquely down- ward and backward to the axillary border. There is no known exam- ple of fracture running close behind and parallel to the glenoid fossa along what is sometimes termed the anatomical neck. The small anterior fragment always carries with it the attachment of the triceps and usually the entire coracoid process ; but the liga- ments which bind the coracoid process to the clavicle and acromion remain untorn, as does also a ligament extending from the under sur- face of the spine of the scapula to the edge of the glenoid cavity, and they limit the displacement. The cases in which this fracture has been verified by dissection are six in number : the cases of Duverney, Neill, and Spence, a specimen in the museum of Guy's Hospital and another in that of the Royal College of Surgeons at London, and one found by Lane. 1 Gurlt de- scribes the first three, and Flower 2 mentions the next two. The exact character of Neill's 3 case is uncertain ; in Spence V* (Fig. 94) the frac- ture passed in front of the coracoid process ; in the others it appears to have passed through the suprascapular notch. 1 Lane: Loc. cit., p. 415. 2 Flower: Holmes's System of Surgery, Am. od.. vol. i. p. 851. :t Neill : American JoUTll. Mod. Sciences, new scr.. 1858, vol. xxxvi. p. 105. 4 Spence: Edinburgh Medical Journal, June, 1863, p. 1082. 222 FRACTURES. Cause. The cause has been a fall or blow upon the shoulder; May 1 reported a case caused in a girl by the effort of placing a handkerchief about her neck, but it seems more probable from the description that the injury was a fracture of the coracoid. Farabeuf found that if the anterior portion of the capsule was made tense by outward rotation of the arm the neck could be broken Fig. 94. Fracture of the neck of the scapula. Spence's case. (Guklt.) by a blow on the back of the head of the humerus or by one upon the elbow if the arm was also directed backward. Symptoms. The symptoms of the fracture are the flattening of the shoulder, the prominence of the acromion, the absence of the head of the humerus from the axilla (where it would be found if the injury were a dislocation), the easy reduction of the displacement by raising the elbow, its immediate return when the support is Avithdrawn from the elbow, and the crepitus which accompanies these movements. In two of Gurlt's cases the fragment could be felt in the axilla. The power of voluntary motion of the arm is lost, but passive movements are free, and, within certain limits, painless. On the other hand, manipulations which reduce the displacement or bring out crepitus cause much pain. Sometimes the lower edge of the fragment can be felt in the posterior and outer part of the axilla as a hard movable body which can be pushed upward, with pain and crepitus, but falls back as soon as the pressure is removed. In a case reported by Ash- hurst, 2 crepitus was obtained by grasping the parts between the fingers on the shoulder and the thumb deep in the axilla and rotating the arm. There was very slight displacement. In a personal case a point of pain on pressure could be found by passing the finger high up along the axillary border of the scapula. The most characteristic symptom is the easy reduction and the imme- diate return of the displacement, and it is this which distinguishes it most sharply from dislocation of the humerus, the prominent symp- toms of which are so similar. Prognosis. According to Gurlt, bony union is the rule, fibrous union the exception, but in both cases with slight displacement of the frag- 1 May : London Medical Gazette, 1842-43, p. 49. 2 Ashhurst: Trans. Coll. of Physicians, Phila., 1875, 3d ser., vol. i. p. 69. FRACTURES OF THE SCAPULA. 223 meiit forward and downward. His collection contains only two cases of fibrous union ; in one the patient had fair use of the arm, in the other the limb was entirely useless. In the cases where bony union was secured, repair was complete in from four to seven weeks; in some there was slight diminution of the usefulness of the limb, but in the majority its use was fully regained. Treatment. It is doubtful if the parts can be supported by any dressing so perfectly that union without any displacement can be secured. The indications of treatment are to oppose the constant dis- placement downward and forward or inward by supporting the elbow ; probably the dressing which I have found so efficient in dislocation of the acromial end of the clavicle (q. v.) would answer the purpose if the ends of the plaster strip were carried further inward on the shoulder. Fig. 95. 8. Fracture of the Glenoid Cavity. In almost all the instances that are on record this fracture has been discovered post mortem or during operation after dislocation of the shoulder. It is thought to be not uncommon, but as the diagnosis is very difficult its frequency cannot be determined. Usually the frac- ture is of the inner border of the articular surface, but sometimes the outer or lower border has been broken off ; and Flower says that frac- tures have been found running across the glenoid fossa and even split- ting it into several portions. Poland l showed a specimen of stellate fracture of the fossa with three lines radiating thence to the body ; there was also fracture of the acromion, but no dislocation. Agnew gives a similar figure, but does not state the source from which it was derived. Symptoms. The symptoms cannot be described because no case appears to have been recognized during life ; and it seems unlikely that a diagnosis could be made with any positiveness. The frag- ment is small and not accessible to direct manipu- lation, so that the only symptoms would be those of a dislocation together with crepitus on reduction, and perhaps a ready recurrence of the dislocation — signs that may be present under a variety of circumstances. Treatment. Treatment must be limited to reduction and immobili- zation, and the latter should be more complete and better guarded than after a simple dislocation, because of the greater ease with which the head of the humerus can escape from the glenoid cavity when the rim of the latter is broken. 1 ii_ Fracture of eda:e of arle- noid fossa. (V. Bruns.) Poland : British Medical Journal, January 23, 1S92. CHAPTER XIX. FRACTURES OF THE HUMERUS. The tables in Chapter I. show that, while fractures of the upper extremity ( including the clavicle ) constitute nearly half of all fractures, those of the humerus are only 4 per cent, of all, and this bone is less frequently broken than either the clavicle, radius, or ulna. Different tables of statistics show great variations in the rela- tive frequency of the fractures of the different portions of the bone, some giving the greatest number to the shaft, others to the lower end, but all agree in giving the greatest frequency to the first twenty years of life. The different varieties of fracture may be most conveniently studied by arranging them in three groups : fractures of the upper end, frac- tures of the shaft, and fractures of the lower end, although the first and third groups severally contain varieties which differ materially from one another. For a remarkable case of longitudinal fracture extending the entire length of the bone which cannot be placed in any one of these groups, the reader is referred to page 27. 1. FRACTURES OF THE UPPER END OF THE HUMERUS. The fractures of this region include fissures and chippings of the articular head, fractures of the tuberosities, of the anatomical neck, and along the epiphyseal line, and a group comprising the great majority of fractures in this region in which the line of fracture crosses the bone in a variety of ways between the anatomical neck and the lower bor- der of the surgical neck, which is commonly drawn at the insertions of the teres major and pectoralis, and which includes fractures pro- duced by compression, so-called, cross-strain, and torsion. Above, this group unites with or closely approaches fractures of the anatomical neck, and below with oblique and comminuted fractures of the adjoin- ing portions of the shaft. Its upper limit may be placed at those frac- tures which pass along or very close to the lower (inner and posterior) portion of the anatomical neck and then reach the outer side through the greater tuberosity ; the lower limit may, for clinical reasons, be conveniently placed low enough to include even quite oblique fractures in which one end of the line rises to the surgical neck. Between those at the upper limit and fractures of the anatomical neck are some in which the line is doubled on the outer side — a fracture of the anatomical neck with a second line passing through the tuberosities from about the middle of the first. As these, like pure fractures of the anatomical 224 FRACTURES OF THE HUMERUS 225 neck, are frequently associated with anterior dislocation of the shoulder, and as they lack the clinical characteristics of the lower fractures, I shall describe them in the same section with fractures of the anatomical neck, but under a separate title — -fractures through the tuberosities ; their lower line is the same as that of the highest of the main group (frac- tures of the surgical neck), the distinction lying in the addition of a line along the anatomical neck detaching the head. The lower main group is characterized clinically by the fact that the upper fragment is peculiarly subject to the unopposed action of the scapular muscles ; a separate class is made of separation of the epiphysis in the young, but fractures in the adult which follow in the main the former line of the conjugal cartilage are not separated from the main group. In this section, then, will be considered fractures of the head, of the anatomical neck, through the tuberosities, of the tuberosities, and of the surgical neck, and separation of the epiphysis. A. Fractures of the Head. Simple fissures or partial fractures of the head of the humerus with- out associated fracture of the tuberosities or surgical neck are very rare. To the two instances which Gurlt quotes from Gosselin and Gross l may be added, I think, three others, one described by Malgaigne, 2 the other two by Houel. Houel's first case is a specimen in the Musee Dupuytren ; about one- third of the head of the humerus has been broken off and has reunited. His second case, also in the same museum, is a specimen of fracture through the head separating a thin fragment entirely covered with articular cartilage. The fragment was turned completely over and not united. The patient was an old woman and died seven or eight months after the receipt of the injury. The cases are much more numerous in which the articular surface is fractured in connection with fracture of adjoining parts ; and in ante- rior dislocation of the shoulder (q. v.) deep indentation or bruising of the surface of the head by the edge of the glenoid fossa is apparently not infrequent. B. Fracture of the Anatomical Neck, and Fracture Through the Tuberosities. 3 Fracture of the anatomical neck, without an additional line of frac- ture through the tuberosities, is apparently a very rare, and also a very obscure, injury, except in association with anterior dislocation of the shoulder. Although it is described, and the means of diagnosis given, in all systematic works upon the subject, it must be admitted, 1 think, that our knowledge of it is extremely scanty and uncertain, being limited to a few specimens and to a few cases clinically observed in which the diagnosis remains more or less doubtful. The reported specimens of fresh fracture, without dislocation or additional fracture 1 (h-oss' Surgery, fifth ed., vol. i. p. 5>s.v - Malgaigno's Atlas. Plate iv. Fig. 2. 8 It is to be noted that some "writers include both forms under the title " Fracture of the Anatomical Neck." 15 226 FRACTURES. through the tuberosities, are those of Boyer 1 and Spence ; 2 both patients were aged, and in each the injury was caused by a fall upon the shoul- der. The reported specimens from cases in which the fracture was associated with dislocation are more numerous, but in so many of such cases associated fracture of the tuberosities, generally without displace- ment, is mentioned that it seems probable it may have been overlooked or passed without comment in many of the others. These specimens have been obtained in the course of operations undertaken for the removal of the dislocated head or for the reduction of the dislocation. Usually the head remains attached to the shaft by a strip of perios- teum or capsule, and in three of my own cases the line of fracture diverged from the neck and split off a thin piece of the shaft adjoining the lowest portion of the head. The clinical cases are obscure, even uncertain. A number of sup- posed cases have recently been rej>orted in which the diagnosis rested upon skiagraphic showings, but the skiagrams, as published, leave in my mind much doubt of the accuracy of this diagnosis ; it seems probable that the line in fracture runs in part, at least, through the tuberosities. Kocher 3 reports three cases in which he thought this diagnosis could be made. The first was a man seventy-nine years old who fell from a height upon his side ; the shoulder was swollen ; no deviation of the axis of the arm ; shortening half a centi- metre ; active motion lost, passive motion gave distinct crepitus. The head projected in front below the acromion and could be drawn downward away from it, so that the finger could be passed in beneath the acromion and could there feel be- hind the fulness of the head in the region of the anatomical neck the edge of the lower fragment directed backward In the second case, also a fall upon the side, the patient was nineteen years old, and the edge could be similarly felt ; movements were very painful. The third patient was a woman sixty-one years old ; the cause a fall upon the front of the shoulder. Slight swelling, pain, loss of function, crepitus on rotation of the arm ; displacement of the upper fragment upward could be felt. Figs. 96 and 97 represent his conception of the fracture and the displacements. . I have seen only one case in which the diagnosis seemed probable. The patient, whom I presented to the New York Surgical Society, 4 was a man about thirty-five years old, who had fallen on his back "in front of a horse-car in such a way that, as the car passed over him, the Fig. 96. Fig. 97. Supposed displacement and line of frac- ture of anatomical neck of the humerus. (Kocher.) 1 Boyer: Traite des Maladies Chirurgicales, 1831, vol. iii. p. 199. 2 Spence: Edinburgh Medical Journal, 1860, vol. v. p. 1140. 3 Kocher : Praktisch wichtiger Frakturformen, 1896. * Stimson : New York Medical Journal, March 19, 1891, p. 310. FRACTURES OF THE HUMERUS. 227 edge of the front platform caught against his right elbow and pressed the humerus with great force against the scapula. Swelling and pain at the shoulder, complete loss of function ; the tuberosities rotated with the shaft ; the acromion, coracoid, and neck of the scapula were unin- jured; pressing the arm upward against the acromion gave pain and was accompanied by crepitus. He was treated in the recumbent posi- tion with moderate continuous traction for five weeks, and made a complete recovery. On another occasion I had an opportunity to examine an undoubted case. The patient had suffered the fracture with dislocation, and I was able clearly to recognize the small, movable upper fragment in the axilla. Under anaesthesia I was, fortunately, able to reduce the dis- location, and then, being in presence of a fracture of the anatomical neck without dislocation, I examined it carefully in order to ascertain, if possible, a means of diagnosis ; but I could detect nothing abnormal, no deformity, no crepitus ; after the anaesthesia had ended, pressure upward at the elbow or backward at the front of the shoulder caused pain. This shows that the fracture can exist without other symptom than pain on pressing the fragments together, and that crepitus on moderate movements of the limb may be absent ; which, indeed, is not surprising when it is remembered how easily the head can move in its socket and, consequently, how likely it is to share in the movement of the lower fragment if it is at all closely connected with it by irregularities of the line of fracture. Probably the most that can be said in any case is that there is a fracture above the surgical neck, but whether it is purely of the anatomical neck or combined with frac- ture through the tuberosities or even partly of the neck and partly through the tuberosities is likely to remain uncertain, because the deter- mining fact — the relations of the upper part of the greater tuberosity with the shaft, its move- ment with it or its independence of it — may easily be beyond exact determination. Of fracture through the tuberosities the ex- amples are much more numerous. To a frac- ture of the anatomical neck may be added one or more lines of fracture passing from the first Fig. 98. through the tuberosities, or the ine may pass Fracture of the anatomical neck of the humerus, with slight splintering and frac- ture of both tuberosities. (GtTRLT.) along the lower (posterior and internal) portion of the neck and then diverge through the tuber- osities. The fresh specimens have almost all been obtained from cases of combined fracture and dislocation, and our periodical literature now contains almost every year one or more instances. I have had two such, fracture of the anatomical neck with fissuring of the greater tuberosity, in which I removed the head, and have seen two others under the care of colleagues. The distinction between this variety and the higher form of fractures 228 FRACTURES. of the surgical neck (as I have here defined the latter) is arbitrarily drawn and I doubt, for the reasons given, if it can often be recognized clinically. Because of its mode of production — violence acting directly against the upper end of the bone from the outer side or in front — it is, I think, much more frequently associated with dislocation of the upper fragment than are fractures at a somewhat lower level which seem more commonly to be caused by cross-strain. Independent mo- bility of only the upper part of the tuberosity would at least show that the fracture was high. Two specimens described and pictured by R. W. Smith 1 (Figs. 99 and 100) show healing with marked impaction in one case and with complete reversal of the head in the other. In the one shown in Fig. 100, examined five years after the accident, "the head of the humerus was found to have been drawn into the cancellated tissue of the shaft between the tuberosities so deeply as to be below the summit of the Fig. 99. Fig. 100. Fracture through the tuberosities of the humerus. Reversal of the head. (R. W. Smith.) greater tubercle ; this process had been split off and displaced out- ward ; it formed an obtuse angle with the outer surface of the shaft of the bone." The specimen illustrated in Fig. 1 00 is described by the same author as " impacted fracture of the neck of the humerus, accompanied by fracture of both tubercles. " " The head of the bone was found to have been separated from the shaft by a fracture which traversed the ana- tomical neck of the humerus. It was reversed in the articulation, so that the fractured surface was directed upward toward the glenoid cavity, and the cartilaginous articulating surface thrown downward 1 E. W. Smith : Fractures iu the Vicinity of Joints, 1S54, p. 192. Impaction of the head of the humerus into the shaft, with splitting off of the tuberosi- ties. (R. W. Smith.) FRACTURES OF THE HUMERUS. 229 toward the shaft, and having assumed this position it was driven to a considerable distance into the cancellated structure between the tuber- cles. From this violent impaction of the head of the bone into the lower fragment a second fracture resulted which split off the lesser tubercle along with about two-thirds of the greater, and a small por- tion of the shaft of the humerus, corresponding to the upper part of the bicipital groove." The outer part of the cartilaginous surface of the head was buried to a depth of nearly an inch, but the inner part was free ; the cartilage remained perfect, and was not united to the cancellated tissue of the tubercles; the rest of the fragment was firmly united with the tissue of the tubercles, and their union also was complete. A similar case is reported by Kronlein l and one bv Korte. 2 (See also Gurlt, vol. ii. p. 693.) Doubtless, also, the upper fragment may undergo that displacement inward and downward by the rising of the shaft under the action of the deltoid which was pointed out by Jonathan Hutchinson as occurring in those cases which I here classify as high fractures of the surgical neck, and which at a later period may easily be mistaken for unre- duced dislocation. Repair is largely carried on by the distal portion of the bone, and is marked by an exuberant production of callus and osteophytic growths on the surface and sometimes by ossification of the adjoining portion of the capsule. Of the fate of the small upper fragment after fracture of the anatom- ical neck we have little positive knowledge. Boyer's statement that in his case the fragment had been diminished by absorption has been extensively quoted, but as the patient died only seven days after the injury was received the accuracy of the observation is doubtful. Kocher does not state the result in his cases, but in McBurney's in which the fragment was restored to its place by operation, and in mine in which a presumably similar fragment was restored to its place by manipulation, and in my other in which the fragment was not dislo- cated and the diagnosis is not certain, recovery with good function fol- lowed. Probably the head in most cases retains some vital connection through untorn portions of the capsule, and experience at other joints shows that similar fragments can reunite or can remain as unirritating loose bodies in the joint. Treatment. Treatment is clearly limited to immobilization of the joint, possibly aided by some traction to oppose the tendency of the muscles to draw the shaft upward and thus displace the head. C. Fractures of the Tuberosities. Isolated fracture of either tuberosity is so rare an accident, except in connection with dislocation of the shoulder, that very tew cases are on record, and none that have been verified by direct examination while 1 Kronlein: Deutsche Zeitschrift 1". Chirurgie, 1874, p. 1. a Korte: Langenbeck's Archives, 1882, vol. xxvii. p. 749. 230 FRACTURES. fresh. Partial fracture of the greater tuberosity, that is, the fracture of a larger or smaller portion comprising some or all of the facets to which the supraspinous, infraspinatus, and teres minor muscles are attached, is a not infrequent accompaniment of anterior dislocation of the humerus, 1 and has also been seen by Malgaigne 2 in a case of dislo- cation backward under the acromion. (See Anterior Dislocations of the Shoulder.) Fracture of the lesser tuberosity is much more rare. A number of cases have been reported of fracture of the greater tuberosity with symptoms so closely resembling those of dislocation that the diagnosis of the latter lesion was at first made in each case, and a study of the reports makes it seem probable that this diagnosis was correct, the dislocation having then been unwittingly reduced during the manipulations ; most of the specimens found at autopsies probably belong in the same class. Gurlt quotes a case of supposed fracture of the tuberosity by mus- cular action, in which the symptoms were extreme passive mobility at the shoulder, complete loss of voluntary outward rotation, and partial loss of voluntary elevation of the arm. If the arm was rotated vigor- ously and the ear laid upon the patient's shoulder, crepitus could be heard. Four weeks later the corresponding muscles were still power- less and atrophied. The patient was a muscular youth of twenty years, and the lesion was produced by an effort to throw a snow-ball with force ; something was heard to crack and the arm fell powerless. The only mention of displacement in the case is that the patient's brother, a physician, thought the arm was dislocated and "made a sort of reduction." In 1881 I saw at the Presbyterian Hospital a youth of nineteen years who had been injured the preceding day. He said that while holding the bridle of a horse in his right hand the animal reared, and as he came down his breast struck against the patient's left forearm which was held before his face in protection, and threw him to the ground. The left shoulder was somewhat swollen ; there was an ecchymosis at the lower border of the tendon of the pectoralis major ; voluntary abduction possible ; voluntary external rotation impossible ; firm pressure upward at the elbow painless. The lesser tuberosity moved with the shaft on rotation ; crepitus observed high up in the shoulder when the head of the bone was grasped between the thumb and fingers and they were moved ; pain on pressure upon the greater tuberosity. I inserted an insect-pin in front at the bicipital groove and passed it backward its full length, evidently between two bony surfaces, and by pressing its point against the inner one and rotating the arm the continuity of this surface with the shaft was shown. My diagnosis was fracture of the greater tuberosity by muscular action, by outward rotation of the arm in the effort to ward off the descending body of the horse. I have seen a few cases of pain at the greater tuberosity on pressure and on voluntary outward rotation, but without crepitus or abnormal 1 For a review of a number of cases, see Wohlgemuth, Deutsche Gesellschaft fur Chir., 1900, ii. p. 375. 2 Malgaigne : Atlas, Plate xxii. Figs. 5 and 6. FRACTURES OF THE HUMERUS 231 Fig. 101. mobility, which I have regarded as minor effects of similiar muscular action, the partial rupture or detachment of the tendon or possibly the avulsion of a small piece of the bone ; in one of them the ic-ray showed fracture of the upper portion of the tuberosity. Graessner 1 and Jacob, 2 with the aid of the arrays, have found it frequently after falls upon the shoulder, and think it a frequent cause of the stiffness which follows such blows. Graessner saw 23 examples in three years ; 20 were due to direct violence, 3 to a full upon the out- stretched hand. So many errors of interpretation of a'-ray plates are made that some doubt must remain as to the accuracy of these statements. The line of fracture usually runs along the sulcus making the anatomical neck at the part where it adjoins the tuberosity and down the bicipital groove, sometimes liberating the long tendon of the biceps from its sheath and allowing it to slip in between the fractured sur- faces. If the separation is complete the fragment is drawn upward and backward ; if incomplete, that is, if the periosteum remains untorn on the side of the fragment adjoining the shaft, new bone fills up the lower part of the gap, and the upper part of the fragment stands out from the surface from which it has been torn, as in Fig. 101. When union takes place it is almost always bony. I believe that in all cases in which the fracture is not an incident of a dislocation the cause is the direct action of the at- tached muscles. Some writers ascribe it almost without exception to direct external violence, but I know of no cases to support the opinion except the .T-ray findiugs quoted above. The diagnosis must be made by local- ized pain on pressure and on attempted volun- tary outward rotation of the arm, and by the abnormal mobility of the fragment, possibly with crepitus. Treatment. The treatment is immobiliza- tion with as much outward rotation of the arm as is practicable in order to diminish the pull of the attached muscles. Any ten- dency to inward displacement, such as was noted by Smith, should be opposed by a pad in or below the axilla. Keen in 1907 (personal communication) exposed the fragment and sutured it as nearly in place as he could bring it; and Niehaus 3 says he has done it several times. Wohlgemuth says Schuler in two cases relieved the limitation of abduction caused by contact of the fragment with the acromion by chiselling away a portion of the tuberosity. Fractures of the lesser tuberosity are extremely rare. Guilt collected Fracture of the greater tuberosity of the humerus united. 1 Graessner : Veroff. aus dem Gabiete Militar-Sanitats., lift. 35, p. ISO. 2 Jacob : Gaz. des Hop., 1903, pp. 109, 123. "'Niehaus: Arch, klin Chir., 1904, vol. 73, p. 71. 232 FRACTURES. only three cases, two of them accompanying dislocation of the shoul- der, the third a specimen in the museum at Giessen. In each of the first two a small hard lump could be felt on the inner side of the head of the humerus, not moving with it. A very few other cases, certainly or probably associated with dislocation, have been reported, among them two by Bardenheuer. 1 The only case not so associated and which seems beyond question is that of Lorenz, 2 whose paper may be profitably consulted for an analysis of reported cases. His patient was a man forty-five years old, whose arm was forced into outward rota- tion, with an audible crack. He was treated for a contusion. When seen, three months later, by Lorenz active inward rotation was almost lost, outward rotation increased 40°, and a bony irregularity tender in pressure could be felt at the site of the lesser tuberosity. A slightly movable piece of bone could be indistinctly felt below the coracoid. The outlines of the shoulder were normal. Jossel 3 reports two cases accompanying backward dislocation of the shoulder (q. v.) ; in both the tuberosity remained attached to the sub- scapularis, and in one it was broken into two pieces. Engel 4 reports one. Treatment. The treatment would be immobilization in inward rota- tion, possibly aided by pressure on the outer aspect of the shoulder to oppose a tendency to outward displacement. D. Separation of the Epiphysis. The upper epiphysis of the humerus comprises the head and the tuberosities. The epiphyseal line runs upward and outward along the lower and inner half of the anatomical neck and then transversely under or through the tuberosities to the outer edge, its level rising as the individual grows older, and passing above part of the insertion of the teres minor. Its centre is higher than its edge, so that the shaft terminates in a low cone or wedge, with a corresponding hollow on the under surface of the epiphysis. This cone is very low in early life and its height increases as the individual grows older, until ossi- fication of the conjugal cartilage takes place, usually by the twentieth year, but sometimes as late as the twenty-fifth. This lesion has been observed at all ages between the moment of birth and the age of nineteen years. Jetter, 5 in an account of sixteen cases operated upon by Bruns, mentions two cases aged twenty-three and twenty-four years, but no mention is made of the presence of the conjugal cartilage in either, and in one the line of fracture followed that of the epiphyseal junction for only half an inch. Both, I think, belong in the class of fractures after ossification of the cartilage, and are examples of the rather common high fractures of the surgical neck in Avhich the line of fracture frequently follows the former epiphyseal 1 Bardenheuer : Deutsche Chirursie, Lief 63 a, p. 168. 2 Lorenz : Deutsche Zeitschrift fur Cliir., 1900-01, vol. lviii. p. 593. 3 Jossel : Deutsche Zeitschrift fur Chir., 1874, vol. iv. p. 125. 4 Engel : Arch, fur klin. Chir., 1897, vol. 55, p. 603. 5 Jetter: Beitrage zur klin. Chir., 1892, vol. ix.^p. 361. FRACTURES OF THE HUMERUS. 233 lines quite closely. In 66 eases collected by J. Hutchinson, Jr., 1 (J occurred at birth, 4 during the first year, and 17 at or above the age of fifteen years. In a considerable number of the recorded cases it was produced by the efforts of the midwife or physician to hasten delivery by drawing upon the presenting arm, or with the finger hooked into the axilla, or to bring down the arm from the side of the head when the legs and body were already delivered. In others it has been caused by falls, by forcibly drawing the arm upward and outward, and by a fall upon the elbow when it was held behind the axillary line. See also a paper by Linser. 2 Considering how easily the epiphyses can be separated by the cross-strain produced in forcibly carrying the limb beyond the normal limit of motion in the corresponding joint established by the capsule, ligaments, and muscles attached to it, it seems probable that this is the mechanism in most cases, and in this may probably be included forced rotation of the arm. The opportunities for direct examination of the seat of injury have been largely increased of late by operations undertaken for the correc- tion of the displacement, often while recent. They show that the line of fracture almost always follows the epiphyseal line closely and that the periosteum remains untorn to a considerable extent, especially pos- teriorly, and that where torn its separation often takes place at some Fig. 102. Fig. 103. Separation of the upper epiphysis of the humerus ; dis placement forward of the lower fragment. (Moore.) Upper epiphysis of the humerus at 10 years; separated by maceration. Outer side. (Moore.) distance below the line of fract ure , N the portion between the rent and the line of fracture being stripped from the shaft and remaining attached to the epiphysis as an irregular sleeve. The younger the patient the more marked apparently is this sleeve formation. 1 1. Hutchinson, Jr., British Medical Journal, July S, 1898. 2 Linser: Beitrage zur klin. Chir., 1900-01, vol. xxix. p. 360. 234 FRACTURES. The displacement is habitually of the shaft forward, and some- times to the outer or to the inner side, the posterior portion of the end Fig. 104. Fig. 105. .Separation of upper epiphysis of humerus Fig. 106. Separation of the epiphysis, with an oblique fragment from shaft. Outward displacement ot shaft, (v. Bruns.) of the shaft usually lodging in the saucer-shaped lower surface of the epiphysis, the latter being flexed and abducted (Fig. 102). Excep- FRACTURES OF THE HUMERUS. 235 tionally the displacement inward of the upper end of the shaft may be such as completely to separate the fractured surfaces and lodge the end of the shaft beneath the coracoid process. There is reason to think that in some cases there is no displacement. The upper frag- ment may be rotated outward. Symptoms. The symptoms are so characteristic that it is difficult to understand why the mistake of supposing the injury to be a disloca- tion should have been made so frequently. The anterior edge of the upper end of the shaft can be distinctly felt at the front of the shoulder an inch or more below the acromion, and often so raises the skin that its presence can be seen as well as felt. The arm usually hangs straight with the elbow directed a little backward, or it may be abducted, but the suggestion of a dislocation which the latter attitude gives is at once removed by palpation of the shoulder which shows the head of the humerus to be in its place, and if the head is grasped between the thumb and fingers and the arm gently rotated the inde- pendent mobility of the two will be recognized, perhaps with crepitus. The anterior displacement of the upper end of the shaft is well shown in Fig. 103. Fig. 107. Fig. 108. Union after separation of the upper epiphysis of the humerus with displace- ment. (R. w. Smith.) Separation of upper epiphysis of humerus. Excision of projecting end of shaft. (Kocher.) In cases without displacement the di- agnosis could be made only bv the local- ized pain on pressure, on pressing the on attempting to cial importance here because humerus in length takes place at its upper end. When the displacement persists various results elbow upward, and use the limb. If displacement is absent or has been corrected repair takes place habitually without incident, although occasionally the trauma has led to premature ossifica- tion of the conjugal cartilage and conse- quent arrest of growth, a matter ot' spe- the greater part of the growth o\' the are ible 23(3 FRACTURES. may take place (Fig. 107), and the subsequent range of motion be restricted by the deformity ; as the epiphysis is already flexed and abducted motion of the arm in those directions is restricted, and motion in other directions may be interfered with either by the faulty position in some respects (e. g., inward rotation) of the lower fragment or by the contact of projecting portions with adjoining apophyses. Or suppuration may follow ; in the reported cases it is not entirely clear that the suppuration was not provoked by injudicious attempts to reduce a supposed dislocation, or that it may not have been a sponta- neous osteomyelitis preceding the separation of the epiphysis, the latter being the result, not the cause, of the suppuration. Or, very rarely, reunion may fail. In respect of treatment the first effort must be to correct the dis- placement ; this can sometimes be effected by traction upon the arm aided by direct pressure upon the projecting fragment, but in other cases it is advisable to use the plan suggested by Dr. E. M. Moore, that of forcibly raising the elbow beside the head so as to bring the shaft into a position corresponding with that taken by the epiphysis ; as the latter is prevented by the posterior portion of the capsule from moving further in this direction, the forced movement of the arm throws the upper end of the shaft backward into place. Interposition of the torn and loosened periosteal sleeve may create so serious an obstacle that reduction cannot be effected without the aid of an incision exposing the seat of fracture. In the older cases ossification of the untorn periosteum rapidly produces a bony bridge between the fragments which pre- vents reduction. In two such cases Kocher cut away the projecting portion of the shaft (Fig. 108) and increased the range thereby; others have resected the callus and a portion of the diaphysis and then made reduction. After reduction immobilization of the limb for three or four weeks is necessary. It is only in cases in which reduction is incomplete that measures are required to oppose a tendency to recurrence of the dis- placement. E. Fracture of the Surgical Neck. Under this rubric are here included fractures of the portion of the bone lying between the site of the epiphyseal cartilage and the insertion of the pectoralis and teres major, the great majority of all fractures of the upper end of the bone. The line of fracture in separation of the epiphysis in the young marks the upper limit of this group in adults ; its lower limit is an arbitrary and ill-defined one and, moreover, is not infrequently crossed by fractures which lie partly above and partly below it. The higher fractures of the group are separately described by some as fracture through the tuberosities, fractura pertubereularis, but the distinction does not seem worth preserving. The common cause is external violence, a fall or a blow upon the arm, but occasionally is muscular action. The mode of action is rarely clear in the history of a given case, but experiment has thrown light upon it. The higher fractures may be caused by a blow or fall upon the upper part of the arm or upon the elbow, presumably aided by the w Oh 3 «-. o Z o FRACTURES OF THE HUMERUS. 2:37 resistance of the glenoid fossa or the acromion, the so-called u com- pression " fractures, but much more frequently, I think, by a cross- strain in which the upper end is fixed by the resistance of the capsule and ligaments and possibly the muscles, and either the elbow is forced outward or forward or is fixed in abduction while the blow is received on the outer part of the shoulder, " abduction fractures;" " adduction fractures," by violence acting in the opposite direction, are much rarer, The lower fractures may be caused by violence acting on the side of the shaft at or below the point of fracture, or by cross-strain in a fall on the elbow or hand, or by torsion of the limb. Fig. 109. Fig. 110. Upper and lower limits of fracture of the surgical neck of the humerus ) with spiral fracture of shaft extend- ing into the area. Impacted fracture of the surgical neck of the humerus. (R. W. Smith.) In the higher and some of the lower fractures the line is essentially transverse, usually with splintering or even comminution, sometimes with fissures extending through the head and sometimes with notable impac- tion. Many of the lower fractures are oblique, often markedly so. The upper fragment, since opposition to the action of the muscles attached to it is diminished or annulled by the fracture, often takes the attitude of flexion, abduction, and outward rotation, being sometimes aided therein by the impaction into it of the lower fragment (Plate VI.) ; the latter is usually displaced inward, partly by the momentary con- tinuation of the fracturing force in some cases and partly by the action of the pectoralis and teres major. Exceptionally the displacement is equal to the thickness of the shaft, and may be outward or posterior, as 238 FRACTURES. shown in some of the figures; but in the great majority of cases the displacement is too slight to be clinically recognizable. An important form of impaction is that in which the shaft passes to the front and outer side of the head and the latter is thereby brought to a lower point on its inner side (Fig. 110). It is claimed by Hutch- inson that the rising of the shaft under the pull of the deltoid may press the head so far inward and downward that the final position may resemble that of a dislocation below the coracoid. Fig. 111. Fig. 113. Fig. 114. Figs. 111-114. Forms of fracture at the upper end of the humerus, .r-ray tracings. The tendon of the long head of the biceps may be torn in these extreme displacements. Injury of the axillary vessels and nerves is extremely rare ; thrombosis of the artery in consequence of bruising has been seen, the axillary vein has been torn in a compound fracture, and the musculo-spiral nerve has been so compressed as to cause paral- ysis of motion and sensation in its area of distribution. FRACTURES OF THE HUMERUS. 239 In an oblique fracture the sharp end of the lower fragment may approach or become engaged in or even perforate the skin, usually on the inner side, and even in the higher fractures this has been observed in front close below the acromion. Fig. 115. Fig. 116. Fig. 117. Fig. 118. Figs. 115-118. Forms of fracture at the upper eud of the humerus, .r-ray tracings. For the combination of fracture with dislocation see Dislocation o{ the Shoulder, Chapter XLTV. Symptoms. The symptoms vary with the form of fracture and tlie displacement; usually the arm hangs by the side or the elbow is slightly 240 FRACTURES. abducted, but if the displacement inward of the upper end of the shaft is marked the abduction of the arm resembles that of an anterior dis- location (Fig. 120); the distinction is easily made by recognition of the presence of the head in the glenoid fossa, maintaing the fulness Fig. 119. Fig. 120. Fracture of the surgical neck of the humerus. The dark spot is an ecchy- mosis. Fracture of the surgical neck ; displacement inward of the lower fragment, resembling dis- location. of the shoulder. Loss of function is usually complete, swelling marked, and ecchymoses very extensive, especially in the old, often spreading to the elbow and across the front of the chest. If the elbow is pressed upward pain is felt at the fracture, and dis- tinctly localized pain can often be caused by pressure with the finger along the line of fracture. Then if the upper fragment is grasped between the thumb and fingers in such a way that the notch between the tuberosities at the bicipital groove can be felt, and the elbow is gently rotated, the failure of the former to share in the movement will be recognized and usually crepi- tus will be perceived. In the cases with more marked displacement the relations of the fragments can be determined by palpation if the patient is not too fat or the region too swollen, or by noting the direction of the axis of the shaft. Diagnosis. In the great majority of cases the diagnosis is made upon the localized pain, especially on pressing the elbow upward, and on the FRACTURES OF THE HUMERUS. 241 failure ot the tuberosities to share in slight rotatory movements com- municated to the elbow, for the displacement is usually too slight to be recognized through the swollen tissues. When marked displacement exists the position of the upper end of the lower fragment is indicated by the direction of the axis of the shaft, generally upward and inward, and is demonstrated by abnormal resistance to pressure and pain at the indicated point, usually corresponding to the groove between the pec- toralis and deltoid near the coracoid. Dislocation of the shoulder is excluded by recognition of the head in its place. The lower end of the upper fragment can be traced only in those oblique fractures where the line of fracture descends upon the shaft. Prognosis. When no important displacement persists and no compli- cations are present, the course is uneventful and the result good ; union takes place in from thirty to forty days, and the restoration of function is complete after a few more weeks. Exceptionally, function may be diminished by an associated arthritis, especially in the old, or by exces- sive formation of callus in the higher forms. Failure of union has been noted in only a very few cases with uncorrected displacement; and once or twice the displaced end of the shaft has become firmly adherent to the coracoid process. Treatment. Reduction of the displacement is made by traction upon the arm aided by appropriate pressure on the end of the lower frag- ment. In most cases, because of the usual abduction of the upper fragment, it is necessary to make traction with the arm widely abducted so as to bring the shaft into line with the attitude of the upper frag- ment, and after the displacement has thus been reduced the arm is lowered to the side and there maintained by suitable dressings unless this position too greatly favors recurrence of the displacement, in which case the abducted position must be maintained for a week or two. Exceptionally, another attitude may be made necessary by another form of displacement. The chief disturbing influence which the retentive dressing has to oppose is the action of the muscles, which tends to draw the lower frag- ment upward and inward and to flex, abduct, and sometimes outwardly rotate the upper fragment, and the great difficulties in the preparation of an always effective dressing are to find a fixed support for its upper end which will furnish the counter-extension for traction upon the lower segment and to oppose the tendency to displacement inward with- out making undue pressure upon the vessels and nerves of the axilla and inner aspect of the arm. The upper fragment is too small to be acted upon directly by any splint, and its position and movements can be controlled only through its interlocking with the lower fragment ; in default of such control the lower fragment must be brought into line with the upper in the position given to the latter by its attached mus- cles. Counter-extension against the folds of the axilla is ineffective both because they are yielding and because they rest upon muscles, the pectoralis and latissimus dorsi, which are attached to the humerus below the seat of fracture, so that the force is applied to the two ends of the lower segment and is, therefore, ineffectual to control its rela- 16 242 FRACTURES. tions to the upper one. The desired fixation can be got by a heavv plaster-of-Paris dressing enveloping the chest and shoulder, but this is too irksome to be used except in cases of extreme need. I have used it with advantage in some compound fractures. Fortunately the ten- dency to displacement can usually be controlled by simple measures which are sufficiently effective in practice even if not in theory, but when it is great continuous traction must be used, either by "weight and pulley with the patient in bed, or by a weight attached to the dependent arm when the patient is seated or standing. Lateral displacement inward of the upper end of the shaft can be effectively opposed when the patient is in bed by moderate traction outward applied by a band about the upper part of the arm. No fixed dressing or splint can alone do it, when the tendency is marked, because of the presence of the main vessels and nerves on the inner side of the arm where they might be dangerously compressed between the bone and the upper part of the splint. Fixed dressings consist essentially of a stiff piece on the outer side of the limb, resting against the shoul- der and elbow, to which the arm is made fast by a bandage; this meas- urably controls inward displacement but not shortening. If the latter threatens it must be opposed by traction, although that supplied by the weight of the limb is usually sufficient. Occasionally the fixed dress- ing is a simple support between the arm and the body, by which the limb is immobilized in abduction ; and not infrequently it is sufficient simply to bind the arm to the side of the body. Continuous traction by weight and pulley is made through a cord attached to the arm above the elbow by two strips of adhesive plaster bound to it by a roller bandage as in the similar treatment of fractures of the thigh (page 97). The hand and forearm should be bandaged to prevent swelling. The patient should be in bed, the arm somewhat abducted and resting on pillows or a sliding support; weight about five pounds. It is rarely necessary to maintain it for more than two weeks. Traction with the patient out of bed can be made by a weight simi- larly attached to the arm or hanging from a plaster-of-Paris dressing as described below ; the elbow is flexed at a right angle, and the fore- arm supported at the wrist by a sling. The common shoulder-cap of leather or cardboard, capping the shoul- der and covering the outer aspect of the arm, or even extending to the elbow, is wholly inefficient against inward displacement or overriding and serves only to give support and to protect against chance violence. It must be combined with an internal lateral splint to give it more control over the lower fragment and with traction to prevent over- riding. A similar dressing of plaster of Paris enveloping the arm and fore- arm and overlapping the shoulder has the same defects, although they are diminished by the better control of the limb and by the weight of the dressings which makes efficient traction when the patient is erect. It can safely be used when the tendency to displacement is slight, especially after the second week. It can be readily made as shown in Fig. 126 or with the usual plaster roller-bandage, applied FRACTURES OF THE HUMERUS. 243 lightly over the forearm and more thickly on the arm as high as the axilla, and combined with a cap over the shoulder made by carrying the bandage up and down over it from the outer side of the arm. Overriding taking place under it can be detected by noticing that the cap rises above the shoulder, admitting the finger, or even two, beneath it ; this must be met by attaching a weight to the elbow, and in all cases the forearm should be supported across the chest, only at the wrist, in order that the weight of the arm may constantly draw the lower fragment down when the patient is erect. A tri- angular cushion extending from the axilla to the elbow between the arm and the chest secures slight abduction if needed and may add to the comfort (Fig. 128). Fig. 121. Fig. 122. r\ Hennequin's plaster splint for fracture of the humerus. A convenient method of making a similar plaster dressing is that devised by Hennequin : l a dozen thicknesses of crinoline, or "three or four of muslin or canton-flannel, cut as shown in Fig. 121, the width being equal to the circumference of the arm, and the length of the central portion equal to the distance from the fold of the axilla to the elbow, are soaked in plaster cream and applied as shown in Fio<. 122, the limb having previously been bandaged from the wrist to the elbow to prevent swelling. If overriding is present or anticipated traction must be made while the plaster is hardening, either by the hands or by a weight made fast at the elbow by a bandage under the splint. Hen- nequin makes temporary counter-extension bv a bandage under the axilla, but I doubt its value or safety ; it seems liable to lead to making 1 Hennequin : Revue de Chirurgie, L887, 244 FRACTURES. the splint too high on the inner side and thus chafing the axillary folds. For cases in which the attitude and fixation of the upper fragment are such that the limb must be kept abducted so as to be in line with it, and in which confinement to bed must be avoided, a' support braced against the body may be used. Middeldorpf s triangle (Fig. 1 23) is a type of such dressing ; the objection to it is in the in- ternal rotation which it gives to the arm and which may not coin- cide w r ith the position of the upper fragment. A lighter pattern is made of a bent rod or piece of stout leather strapped to the arm and trunk. The choice of these different methods in varying cases may be summarized as follows : In the high fractures with little displace- ment or tendency thereto moderate immobilization, support, and pro- tection are sufficient, and these may often be got by binding the arm to the side, especially if the patient is fat. If the patient is robust, and especially if the fracture is oblique, so that shortening by the traction of the muscles is prob- able, a plaster-of- Paris dressing with traction by a weight at the elbow is required. If the upper fragment is abducted and its position can- not be controlled by interlocking of the broken surfaces, the abducted position of the arm is necessary, and the patient should be treated in bed with traction in that position for a fortnight, when the upper frag- ment will generally be found to accompany the lower one when it is adducted, or out of bed with a dressing like the Middeldorpf triangle. Cases with marked tendency to displacement inward of the upper end of the lower fragment should be treated in bed with traction in abduction aided by moderate outward traction upon the upper part of the lower fragment. Compound fractures which suppurate need a strong fixed support which can be maintained during the changes of dressing, such as a plaster-of-Paris jacket with iron braces extending across to a plaster case enveloping the lower two-thirds of the arm or with a strong broad plaster bridge uniting the two over the top and outer aspect of the shoulder. In compound fractures with splintering of the upper frag- ment and implication of the joint, usually gunshot, excision of the head favors repair and the subsequent usefulness of the limb. In all cases the patient should be directed to move his wrist and fingers freely ; and fixed dressings should be removed as early as pos- Middeldorpf s triangle for fracture of the humerus. FRACTURES OF THE HUMERUS. 245 sible, and the limb supported only in a sling and protected by a removable shoulder-cap extending to the elbow, in order that massage may be used to hasten the restora- Fig. 124. tion of function. For the treatment of fracture combined with dislo- cation see Dislocation of the Shoulder. 2. FRACTURES OF THE SHAFT OF THE HUMERUS. The region is that included between the insertion of the pectoralis major and the upper portion of the supracondyloid ridges. All the varieties of fracture which may occur in long bones are contained among those of the shaft of the humerus. A remarkable and unique example of longi- tudinal fracture extending the entire length of the bone is quoted in Chapter II. (p. 27), and Gurlt gives two of exceptionally long fissures, beginning in the one case at the condyles and ending at the insertion of the deltoid, and extending in the other from the upper border of the greater tuberosity to the lower fourth of the shaft. Incomplete or partial fractures are ex- tremely rare. All the forms of displacement common to fractures of the long bones are also found here, and no one deserves mention as of exceptional frequency and importance. The character of the primary displacement depends largely upon the fracturing force ; that of later displacement upon the unsupported weight of the limb and upon muscular action. Double fractures of the same bone are very rare. Simultaneous frac- ture of both humeri has been caused by epileptic convulsions and by external violence. Among the injuries which may be associated with the fracture are dislocation of the shoulder, laceration of the soft parts, and contusion or rupture of bloodvessels or nerves. The latter deserve special atten- tion because of the gangrene of the limb or the paralysis which may result and may be attributed to negligence in the treatment. The brachial artery or vein may be so crushed or bruised by direct violence that a thrombus forms within it and arrests the circulation ; or, more rarely, it may be torn by the sharp edge of a displaced fragment, or the vessel may be stretched across the fragment in such a way as to be occluded by pressure. Occasionally the injury to the artery has resulted in the formation of an aneurism. The museulo-spiral nerve is par- ticularly exposed to injury because of its close relations to the bone throughout so large a part of its course. (See p. 7(3.) Causes. The causes of fracture are external violence and muscular action ; the latter causes fracture in the humerus more frequently than in any other bone, and the causative effort has not always been very Longitudinal frac- ture of the humerus. (Gurlt.) 24(3 FRACTURES. great. The two most common efforts which have caused it are throw- ing a stone and that trial of strength in which two men clasp hands with elbows resting on a table and strive each to force the other's hand aside ; the latter produces a spiral fracture. Compound fractures have no anatomical peculiarities that require mention. Gurlt collected five cases of almost complete severance of the arm by a blow with an axe or sabre, all of which recovered with preservation of the limb ; in all the wound was on the outer and ante- rior aspect of the limb. Symptoms. The symptoms are the usual ones : abnormal mobility, crepitus, loss of function, pain, and more or less deformity. Impor- tant complications, such as dislocation of the shoulder or injury of the artery or a nerve, have their special symptoms; the principal danger is that they may be overlooked because the attention is concentrated on the fracture. Injury to the artery is indicated by absence or weakness of the radial pulse, either immediately or after the lapse of a few hours ; sometimes the symptoms have appeared gradually, the pulse becoming weak, and finally disappearing, the hand numb and cold, the surface bluish, and after death or amputation a clot, sometimes firm, pale, and adherent, sometimes dark and soft, has been found in the artery. Injury of a nerve, usually the musculo-spiral, is shown by paralysis and loss of sensation or hyperesthesia in the region supplied by it ; paralysis or loss of sensation indicates division or destruction of the nerve ; hyperesthesia indicates irritation, usually by pressure. Paralysis of motion is often overlooked at first. A simple fracture in an adult, running its course without complica- tions, will be solidly united in from four to six weeks, and in three or four weeks in children. The possible complications are inflammation and delayed union ; the former is sometimes quite marked, and the latter is of more frequent occurrence in the humerus than in any other bone. The general and local causes which lead to delay in or failure of union have been discussed in Chapter VIII. It has been thought that the special cause in the case of the humerus is defective immobilization of the fragments, for when the elbow is kept at a right angle any vertical movement of the hand or forearm is likely to cause horizontal movement of the lower fragment on the upper one, and lateral splints cannot be fitted accurately or snugly enough to prevent it. It has been proposed, therefore, to treat the fracture with the elbow in full extension, but this position is very irksome and equal immobili- zation can be obtained by the use of a posterior splint the upper end of which overlaps and is secured to the shoulder. The supposed inter- position of muscle which lias been so frequentlv alleged as the cause has existed in none of the cases upon which I have operated because of failure of union. Treatment. Reduction is made by traction upon the condyles or the flexed forearm. The treatment in fractures of the upper third is essen- tially the same as in fractures of the surgical neck ; rest in bed, with continuous traction and the limb supported upon cushions, may be required at first. For the lower fractures abduction of the limb is not so often needed. The plaster-of-Paris bandage is in common use, is FRACTURES OF THE HUMERUS. 247 more .secure than lateral splints, and gives good results, but it needs careful watching at first, both to detect displacement and to prevent Fig. 1H5. Fig. 126. Plaster-of-Paris splints for fracture of the shaft of the humerus. strangulation of the limb. It should be carried from the wrist to the shoulder, and may include a few spiea turns over the shoulder and about the chest to aid immobilization and oppose overriding. The fore- arm should be flexed and supported by a sling at the wrist. Snug support under the elbow in low fractures can produce an angular deviation inward of the lower fragment (Fig. 125), which greatly dis- . figures the limb, especially when the forearm is tion of shaft; angular extended ; this deformity is considered in detail in displacement; cubitus the subsequent section on Supra-condyloid Fractures. A posterior moulded plaster or wire splint, extend- ing under the forearm and over the back of the shoulder (Fig. 126), is convenient and efficient. A weight attached to the elbow is sometimes useful to prevent shortening or to overcome that which is already pres- ent ; it will lengthen a limb even after the lapse of two or three weeks. I have found it advantageous in eases o( tract lire by direct violence, especially in women and the alcoholic, to keep the patient in bed for about a week, or until the danger oi' acute inflammatory complications 248 FRACTURES. Fig. 127. Stromeyer's cushion applied. had passed. Stromeyer's cushion, designed particularly for the treat- ment of compound fractures, is useful as a support. It has the form of a triangular pyramid (Fig. 127), the long lines of which are twelve or. fifteen inches long. It should be firm enough to keep its shape uuder pressure, and its upper end should be blunter than shown in the figure. It is secured in place by tying the upper pair of straps about the opposite shoulder and the lower pair about the waist. A similar but smaller cushion (Fig. 128) is sometimes used in connection with an ambulatory dressing like the preceding. In the treatment of compound fractures the general principles laid down in Chapter VII. are to be followed. I habitually treat them in bed for the first fortnight with the limb on a pillow, trusting to Fig. 128. the position and the support of a bulky dressing of the wound for the desired immobilization. If prompt union of the wound is not obtained moulded splints can be applied outside the dress- ing. Resection of the ends of the fragments or their direct suturing is rarely indicated. When there is reason to fear serious injury to bloodvessels or nerves fixed dressings and band- ages should be avoided until after the extent of the injury shall have become apparent. Reduction should be made as completely as possible and the limb supported upon cushions. If there is reason to believe that the musculo-spiral nerve has been ruptured, it should be sought in the groove between the supinator and brachialis anti- cus and traced to the point of injury, and sutured. Or the operation may be delayed two or three weeks in order that repair may be well advanced and the dangers of infection thereby lessened. If the paralysis appears only after the lapse of a few weeks it is probably due to inclusion of this nerve in callus or cicatrical tissue, which must then be relieved by open opera- tion. (See Chapter VI., p. 76.) Small Stromeyer cushion for ambulatory treatment. FRACTURES OF THE HUMERUS. 249 3. FRACTURES OF THE LOWER END OF THE HUMERUS. This group, like that of fractures at the upper end of the humerus, includes a number of varieties differing materially in character and importance, and having in common only their position near the elbow, and the frequent necessity and difficulty of making a differential diag- nosis between each and the others and dislocation. A certain lack of agreement among writers, as to the sense in which some of the distin- guishing terms are used, makes it desirable to define those that are to be here employed at the same time that the limits of the divisons of the main group are traced. These divisions are : A. Fractures Above the Condyles ; Supracondyloid. The line of fracture crosses the expanded part of the bone above the articular sur- face transversely or obliquely, and may or may not open the articulation. B. Fractures of the Internal Epicondyle or Epitrochlea. The line of fracture is entirely extra-articular, and the piece broken off consists of the whole or part of the epicondyle. And by the internal epicon- dyle or epitrochlea is meant the whole of the projecting tuberosity that lies above and on the inner side of the trochlea, and part of which is developed about a separate centre of ossification. C. Fractures of the External Epicondyle. The line of fracture is probably extra-articular; the fragment is very small, consisting of the epicondyle proper, either alone or with some of the adjoining bone. D. Fractures of the Internal Condyle. In these the line of fracture passes from a point on the inner border of the bone above the tip of the epicondyle obliquely downward and outward to the articular surface. E. Fractures of the External Condyle. Similar to the preceding variety, except that the line of fracture begins upon the outer side and passes downward and inward. F. Intercondyloid or T-shaped Fractures. These are a combination of the first, fourth, and fifth, the extremity being separated from the shaft and split into two or more pieces. G. Separation of the Epiphysis. The fracture follows the line of the conjugal cartilage. H. Fracture of the Articular Process. In this more or less of the portion of bone covered by articular cartilage is broken off; the most common form is fracture of the capitellum. These fractures are much more common than those of either the upper end or shaft. The relative frequency of the varieties mentioned in the preceding list has not been satisfactorily determined; published statistics differ quite widely, and the differential diagnosis is often so difficult (partly because of the extreme youth of many of the patients) that doubt must sometimes remain whether a case has been properly assigned to its class. In the Out-patient Department of the House of Relief in about six years, ending in 1904, 97 of these fractures, excluding the epicondyle, were received, as follows : External condyle 45, supracondyloid 26, intercondyloid 9, internal condyle 15, separa- tion of epiphysis 1, edge of trochlea l. 1 Examination of the record suggests that some of those classed as fracture* of the internal condyle were supracondyloid. Sixty-two of the patients were under eleven years of age, and IS others were loss than twenty years old; 15 were more than twenty years old. For other statistics, see Stolle, Deutsche Zeitschrift fur Chir.. vol. lxxiv. p, 65 250 FKACTUBES. The great relative frequency of these fractures in children makes necessary a brief account of the somewhat complex development of this end of the bone. According to Henle, the epiphysis at birth is wholly cartilaginous below a transverse line passing through the lower part of the olecranon fossa ; in a month or two this line descends centrally to the lower edge of the fossa, becoming convex, and during the first Fig. 129. Fig. 130. Twelfth to fifteenth year. Eighth to twelfth year. First to second year. Ossification of the lower epiphysis of the humerus. or second year a centre of ossification appears in the capitellum. Between the eighth and twelfth years this nodule enlarges, nearly or quite reaching the trochlear groove, a nodule appears in each epicondyle, and the diaphy- sis sends a prolongation down into the inner portion of the trochlea. Between the twelfth and fifteenth years the nodule of the capi- tellum unites with that of its epicondyle, and after that the final point of ossification, that of the trochlea, appears ; it is a thin concave cap or shell, closely applied to the downward projection of the corresponding portion of the diaphysis, and unites with the nodule of the capitellum about the fif- teenth year ; soon afterward the nodule formed by the union of the trochlea, capi- tellum, and external epicondyle unites with the diaphysis, and subsequently the nodule of the internal epicondyle unites. Kocher's statement, following Farabeuf, that the trochlear nodule is the first to unite with the diaphysis seems to be an error due to misinterpretation of the peculiar descent of the diaphysis into the trochlea, probably through ignorance of the late appearance of the trochlear nodule. It thus appears that the epiphysis after about the fifth year is an irregular strip of cartilage containing one, or two, bony nodules in its thicker outer portion, and none in its thin saucer-like trochlear portion, which latter is continuous by a sort of neck with the cartilaginous and bony internal epicondyle. My own specimens and skiagrams indicate that the end of the diaphysis after the sixth year is much more directly transverse, descends lower on the outer side, than is shown in Fig. 129. Possibly the difference in ap- Supracondyloid fracture of the humerus. FRACTURES OF THE HUMERUS. 251 pearance depends upon the direction of the line of section, Henle carry- ing it further forward on the outer side so as to include more of the projecting capitellum. A. Fractures Above the Condyles — Supracondyloid. The line of fracture may be transverse or oblique, and oblique either from side to side or from before backward, and it may open the joint by crossing the olecranon or coronoid fossa or by the extension into it of a fissure between the condyles. It may lie above both epicondyles, or above one and below the other, and, at least at an early age, may coincide in whole or in part with the epiphyseal line. The cause is violence acting upon the front or back of the lower end of the bone, usually through the bones of the forearm, as in a fall upon the outstretched hand, or, as indicated by KocheFs experiments, by torsion. The commonest cause appears to be a fall upon the hand in which the end of the humerus is pressed backward (" extension fracture ") either directly by the partly flexed forearm or possibly by hyperextension of the joint. In this case the line of fracture is oblique from behind downward and forward, the lower end of the upper fragment often ending in a sharp point on its anterior aspect. Fig. 131. Fig. 132. " Extension" and " flexion " fractures of lower end of the humerus. When the force acts in the opposite direction, against the back of the elbow, a much more rare occurrence, and the lower end of the humerus is forced forward (" flexion fracture "), the line of fracture runs from in front downward and backward, and the sharp point is found at the upper end of the lower fragment in front (Figs. 131 and 182). Figs. 133 and 184 represent a specimen of this kind which 1 obtained from a patient who died of delirium tremens shortly after the accident. While carrying a flagstone he fell upon the elbow, flexed at a right angle, with the edge of the stone resting in the flexure of the joint ; the fracture was almost exactly in the frontal plane, as it' the condyles had been cut oil' by an axe descending along the anterior surface of 252 FRACTURES. the humerus. Iu both forms the higher the fracture the less, appa- rently, is the obliquity. An adduction fracture in the young may be Fig. 133. Fig. 134. Supracondyloid fracture. A. Front. B. Rear view. classed as a low form of this ; the fracture starts close above the exter- nal epicoudyle and runs along or close above the epiphyseal line toward or to the epitrochlea or diverges downward through the trochlea into the Fig. 135. joint (Fig. 135) ; the displacement is angu- lar, pivoting on the inner side, and if it remains uncorrected or recurs, marked cubitus varus results. The character and extent of displace- ment vary with the direction of the line of fracture ; as the latter is so often oblique downward and forward, the lower frag- ment is commonly displaced backward and upward, and not infrequently the sharp end of the upper fragment is forced through the overlying muscles and even the skin on the antero-internal aspect. In one case, seen six months after the accident, I found on operation the musculospiral nerve ruptured at the edge of the upper fragment. To this displacement backward may be added, or for it may be substituted, an angular displacement, the apex directed forward, which accentuates the promi- nence of the back of the elbow. In the less common cases in which the obliquity is downward and backward the displacement of the fragment is for- ward and upward, but is much less marked than in the other form, although occasionally the upper fragment has been forced through the triceps and the skin. If displacement persists the range of motion in Experimental adduction fracture in a child. FRACTURES OF THE HUMERUS. 253 the elbow may be restrieted by direct bony contact or by fibrous bands attaching the torn and bruised muscles to the bone. In the low fractures in children, where the line apparently often coincides more or less with the epiphyseal junction, the lower frag- ment may be displaced inward, or less frequently outward, and with the inward displacement usually coexists an angular displacement by which the outer portion of the lower fragment is lowered, and some- times a backward displacement of its outer portion. The result of this displacement, if uncorrected, is the angular lateral deviation of the lower fragment with the apex directly outward, which is shown in Fig. 136. Fig. 137. Supracondyloid fracture with angular di placement ; marked cubitus varus. Supracondyloid fracture with angular displace- ment ; marked cubitus varus. Front view. Figs. 136 and 137 and in Plates VIII and XII. The deformity of the elbow, cubitus varus, which results is very noticeable in extension and has usually been attributed solely to the ascent of the internal con- dyle after its fracture ; but the almost total absence of such specimens, the possession of others showing descent of the external condyle, and the findings in several operations undertaken to correct the deformity have convinced me 1 that, when marked, it is habitually the result of a 1 Stjnison : Cubitus varus, Annals .if Surg., Sept., L900, 254 FRACTURES. complete or partial supracondyloid fracture followed by this angular displacement, and that this is practically the only form of fracture after which it is at all likely to occur to any extent. A number of speci- mens have been described and I possess three (Figs. 125, 136 and 137, and Plate VIII.) ; those represented in Fig. 137 and Plate VIII. correspond almost exactly with the condition of the bones shown in the skiagram (Plate XII., Fig. 1) of a limb very like Fig. 138. Two frontal sections of the specimens shown in Plate VIII. show no trace of fracture, no change in the cortex of the juxta-epiphysary region, and the outline of the inner supracondyloid ridge is unbroken, but more sharply curved. The appearance is that of elongation on the outer side, and of shortening on the inner, and suggests a frac- Fig. 138. Cubitus varus. ture along or close above the epiphysary line, incomplete on the inner side, with angular displacement upon the inner portion of the internal condyle as a centre. Presumably the mass between the outer condyle and the shaft is new bone formed by the untorn periosteum. Ex- periment on the cadaver shows that the posterior part of the periosteum may remain untorn even when the displacement downward of the outer part of the fragment is considerable, and its preservation is even greater when the fracture is along or close to the epiphyseal line. The artery or the median or musculo-spiral nerve may be torn or compressed, but this injury is much less frequent than might be antici- PLATE VII Fig. 1.— Skiagram of Normal Elbow at age of Five Years. Fig. 2. — Normal Epiphysis of Humerus at age of Eight Years. PLATE VIII FIG. 1 FIG. 2 FIG. 3 Cubitus Varus after Low Partial Supracondyloid Fracture in Youth. or Separation of Epiphysis. Fig. 1, front. Fig. 2, rear. Fig. 3. sections, ending above on posterior surface. PLATE IX Ficr. 1.— Fracture of the Lower End of the Humerus. Fig. 2. — Supracondy loid Fracture of the H PLATE XI Fig. l.-Supraeondyloid Fracture of Humerus by Extension in a Young Child. Fig. 2. — Supracondy loid Fracture at Eight Years. PLATE XII Fig. 1.— Old. Supraeondyloid Fracture of trie Humerus, Cubitus Varus, 2.— Cubitus Varus; Three Years after a Low Supraeondyloid Fracture. The lower part of the Supinator Ridge ha* been cut awa\ FRACTURES OF THE HUMERUS. 255 pated from the extent and direction of the displacement. In one case six months old I found the mnsculospiral nerve ruptured at the dia- physeal edge of the fracture, and sutured it. The ultimate result is not known. In two cases of inward displacement of the low form in the young I have seen late sloughing of the skin by pressure against the outer angle of the upper fragment. Savariaud l reports four cases of appa- rent injurv to the median and ulnar nerves ; one recovered spontane- ously, one after operation, and in two operation failed to relieve. Symptoms. The symptoms are deformity, loss of function, abnormal mobility, and pain. The deformity may be marked or slight, the former especially when the line of fracture is oblique from behind downward and forward and the lower fragment is displaced and tilted backward ; this causes a prominence of the back of the elbow which in some stages resembles that of a dislocation, but is readily distin- guished from it by noting that the relations of the olecranon and epi- condvles are normal and that the head of the radius is in place. In the young, when the line of fracture passes below the internal epicon- dyle and the lower fragment is displaced inward, the appearance on the inner side is that of an internal lateral dislocation, and the true nature of the injury must be determined by the relations of the head of the radius and the capital 1 urn. The easy reduction of the backward displacement by drawing the flexed forearm forward, and its easy reproduction by pressing the forearm backward has led even expe- rienced surgeons into error, and emphasizes the necessity of accu- rately determining the relations of the head of the radius and the capitellum. The determination of these relations is the first step to be taken in the examination of most injuries of the elbow ; it is conveniently done by placing the tips of the thumb and middle finger on the two epicon- dyles respectively and that of the index-finger upon the point of the olecranon, and noting their correspondence or lack of correspondence with the normal in the positions of extension and of flexion at a right angle, ordinarily using the other elbow in comparison. The head of the radius can be felt from one-half to three-fourths of an inch distant from the external epicondyle in the direction of the wrist. Swelling is marked and uniform ; eeehymosis is usually present after a few hours; voluntary motion is inhibited by pain, passive motion restricted. Abnormal lateral mobility — adduction and abduction of the forearm — exists and is most surely recognized if the test is made while the elbow is extended. If the condyles are firmly grasped with one hand and the shaft with the other, free mobility of one upon the other, usually with crepitus, is found. Pressure upward with the hand under the flexed elbow causes pain. Pressing the condyles together does not cause pain unless the line of fracture also runs between them (T-fracture), nor can the condyles be moved independently of each other. Pressure with the tip of the finger along the supracondyloid ridges may detect irregularity and cause pain at the point of fracture if the displacement is slight ; if it is marked the lower end of the 1 Savariaud: Arch. gen. de mod., 1903, No. 2. 256 FRACTURES. upper fragment can be readily recognized, usually in front, at or close above the flexure of the elbow. Kocher, analyzing five personal cases of what he terms fr actum diacondylica, which corresponds to that described here as the low form in the young, speaks of pain on pressing the extended or flexed forearm against the arm. Treatment. In view of the proximity of the joint the important indi- cation is to secure repair without displacement ; and the displacements which threaten are the primary overriding in the higher fractures in adults and the late lateral angular deviation in the low ones in children (Fig. 136). The overriding can be corrected by traction, preferably with the elbow at a right angle, and its recurrence effectively opposed by anterior and posterior moulded splints, or a plaster encasement, aided sometimes by a weight attached to the forearm close by the elbow, with the wrist supported by a sling. In the low form in children, which is, I believe, practically the only form of fracture at the elbow in which the dreaded deformity, cubitus varus, is liable to ensue, the principal factor in its production, after reduction of the primary displacement, is, I think, the action of gravity when the forearm is supported across the front of the body. In experiments upon the cadaver and in operations to correct the deform- ity I have repeatedly seen the displacement appear when the limb was placed in this position, and I have seen one patient in whom it seemed probable that it took place within a plaster encasement, although it is not certain that reduction was made and maintained during the application of the dressing. Recumbency, with the elbow at a right angle and the forearm vertical, has always, in my experience, prevented it, with the aid of a thick enveloping dressing of gauze rollers. The confinement to bed need not last more than a week. Full 'flexion of the elbow, which of late has been urged in a some- what exaggerated and uncritical way as the proper treatment for all fractures at the elbow, undoubtedly holds the fragments, in this form of fracture, more firmly together, apparently by the tension of the triceps thus produced, or, as emphasized by Lusk, 1 by the untorn periosteum on the back of the bone, but it can itself produce an angular displace- ment (apex backward), as shown in Plate XVI., and of course it is valueless unless antecedent reduction is made. The frequency with which some deformity persists after this fracture has led some surgeons to maintain that in it, more perhaps than in any other simple fracture of a long bone, a primary operation for adjust- ment and fixation is justifiable or even requisite, but Konig 2 has shown by several skiagrams taken at intervals of two or three years that even very marked deformity disappears rapidly in the young by absorption of projecting bone and the filling up of hollows, and that functional limitations are rarely caused by it. In compound fractures I always use vertical suspension of the limb for about a fortnight, unless the wound heals sooner. It is of great value in controlling reaction as well as preventing gross displacements ; 1 Lusk : Annals of Surgery, 1908, vol. 48, p. 432. 2 Konig : Arch, fur Klin Chir., vol. 85, p. 187. FRACTURES OF THE HUMERUS. 257 minor adjustments can still be made after the wound has healed or lias become unimportant. In several cases of low fracture in the young, after the lapse of from four weeks to six months, I have exposed the region through an exter- nal lateral incision, cut away all new bone, freed the lower fragment, and brought it back into place with full restoration of form and func- tion. Occasionally a second incision on the inner side is needed. In some old cases the deformity has been relieved by excision of a wedge- shaped piece from the outer side of the humerus just above the epicondyle, thus bringing the lower fragment into line with the shaft. The same could be done in case of angular displacement, apex forward, and thereby the hand would be brought nearer the shoulder in full flexion of the joint. B. Fractures of the Internal Epicondyle (Epitrochlea). By the epitrochlea is meant the projecting spur of bone on the side of the trochlea ; its lower limit is sharply defined, but above it is con- tinuous with the condyloid ridge. The first author who called attention to this fracture was Granger, 1 in 1818. It is more common in children than in adults ; often cases, not associated with dislocation of the elbow, treated in the House of Relief in two and a half years, the ages were one, five, ten, ten, four- teen, seventeen, twenty-eight, thirty-four, and forty-three years. The fracture frequently accompanies dislocation of the elbow, being pro- duced, I think, by the pull of the flexor muscles of the forearm which are attached to it and which are put upon the stretch by the forcible abduction of the form which is so common a first step in the production of a backward or outward dislocation. In FlG cases not thus complicated the cause appears commonly to be external violence acting directly upon the back of the epitrochlea. Symptoms. The symptoms vary somewhat with the size of the fragment, for when the latter is small it is held in place by the untorn portion of the muscular attach- ments upon it and the adjoining bone, but when it is large enough to include the greater part of the attachment dis- placement takes place downward and forward in the direc- tion of the muscles. If the swelling is not too great the fragment can be seized between the thumb and finger and moved, usually with crepitus. Ecchymosis is common, and the functions of the joint may be diminished bv pain Fracture of the or the fear of it. Pain is felt on forcible contraction of intenml epicon " ,1 m i" ,i i i dvleoi the hume- the flexors of the hand. rus (epitrochlea). In a few cases the ulnar nerve has been injured bv the (Gtolt.) original violence or irritated by pressure of the displaced fragment or a portion of callus. In three of Granger's cases there was partial paralysis of motion and sensation in the region supplied by the ^ 3 Granger: Edinburgh Medical and Surgical Journal, vol. xiv. p. 196, 258 FRACTURES. ulnar nerve, and repeated crops of vesicles formed upon the correspond- ing part of the hand during the two or three months following the injury. All the symptoms disappeared after a time. Richet 1 observed a case of fracture of the epitrochlea with dislocation of the elbow in- ward due to a fall upon the ice. After reduction of the dislocation the ulnar nerve was found to be completely paralyzed. A month later the little finger was so insensitive that the patient amused himself and amazed his play-fellows by holding it more than a minute in the flame of a candle. The deep burn which was the result took several weeks to heal; afterward sensibility returned gradually and became complete. Denuce 2 was consulted by a man suffering with an intense neuralgia of the ulnar nerve following a fall upon the elbow three months before. He recognized deformity of the epitrochlea, made an incision, and found the nerve hypertrophied and resting upon a bony prominence formed by the epitrochlea displaced and united in its false position. The projecting part of the bone was excised, and the neuralgia ceased. Treatment. The treatment is simple : immobilization of the elbow in the flexed position so as to relax the muscles that arise from the epi- trochlea and thus diminish the force that tends to draw it forward and downward. It is futile to attempt to keep the fragment in place by pressure upon it from the outside. Even if it remains displaced down- ward and forward the deformity is slight and entails no loss of function. Immobilization should be maintained until consolidation has taken place, the length of time necessary for which varies with the age of the patient and the extent of the unreduced displacement. In children, and without displacement, union is sufficiently firm at the end of ten days or a fortnight to allow splints to be laid aside and the arm to be carried in a sling, and in three Aveeks the arm may be left unsupported and free. In a few cases the fragment has been excised because of pain or tear lest it should interfere with function ; it has also Fig. 140. been proposed to secure it in place by transfixion with a pin or by incision and suture, but the meas- ure seems wholly unnecessary. C. Fractures of the External Epicondyle. This is a much rarer accident than the preceding, and as the fragment that is broken off is small, and as the cause appears to be always direct violence, which is usually accompanied by bruising and swelling, the exact nature of the injury may easily pass unrecognized. An anatomical demonstration of the fracture has never been made, except in con- Fracture of the external nec ti n with more extensive fractures of the elbow. epicondyle of the hume- T ,, , . , , . , -, ,, rus. (Gurlt.) I n the sense in which the term is here used the epicondyle is the small prominence above and on the outer side of the capitellum, composed in part of bone formed about 1 Richet : Anatomie Medico-Chirurgicale, 4th ed., p. 672, note. 2 Denuce : Diet, de M£d. et (Jhir. Pratiques, art. Coude, p. 721. FRACTURES OF THE HUMERUS. 259 a separate centre of ossification, and in part of the projecting portion of the shaft or condyle itself. To it are attached the external lateral ligament of the joint and part of the extensor muscles of the forearm. Most surgeons deny the possibility of an extra-articular fracture of this part, and group all fractures of the region as of the external coudyle. Anatomically speaking it is certainly possible for such a fracture to in occur; the epicondyle, though small, is still large enough to be broken in such a way that the line of fracture may lie entirely outside the joint. Gurlt describes as extra-articular fractures of the external epicon- dyle two specimens preserved, the one at Giessen, the other at Berlin. In each the fracture has united with considerable displacement down- ward of the fragment, which appears in the description and figure (Fig. 140) too large to have been entirely extra-articular. Still, his personal examination of the specimens was more likely to lead to a correct opinion of them than a verbal description or a figure is. There is little to be added. The cause must be direct violence, or possibly forcible adduction of the forearm acting through the lateral ligament ; the displacement must be slight and unimportant ; the treatment, rest. D. Fractures of the Internal Condyle. The line of fracture runs from a point on the inner border of the epitrochlea or of the ridge above it downward and outward, ending on the outer half of the lower part of the trochlea or at, or even a little beyond, its junction with the capitellum (Fig. 141). The common cause appears to be violence acting from below upward upon the trochlea, as in a fall upon the flexed elbow or by forced adduc- tion or abduction of the forearm, turning upon the head of the radius as a centre, and Fig. 141. breaking off the condyle by forcing it up- ward or backward or drawing it downward or forward. The fragment may be displaced in any of these directions, and may also be rotated. As the ulna remains attached to the frag- ment and is itself held in place by its attach- ments to the radius, the displacement of the fragment cannot be great unless there is associated dislocation of the radius from the capitellum, as occasionally observed. A late displacement, similar in effect to that observed after supracondyloid fracture, may occur here also; pressure upward against the flexed elbow, as by a snug sling, is transmitted through the olecranon to the fragment and raises it above its proper place, thus changing the direc- tion of the transverse axis of the joint and substituting abduction of the forearm — cubitus varus — for the slight normal abduction. Possibly Upper and lower limits of fracture of the internal condyle. 260 FRACTURES. the contraction of the triceps and brachialis anticns may aid in pro- ducing this result, I believe, however, this is a much less frequent cause of the deformity than displacement after supracondyloid fracture. The swelling, as in most of these fractures at the elbow, is uniform, rarely more marked on the side of the injury except at first; loss of function is marked, the arm generally being held at an angle of about 125 degrees, and the range even of passive motion without anaesthesia is restricted. The characteristic symptoms are independent mobility of the condyle, usually with crepitus, pain on pressing the condyles together and on pressure with the tip of the finger at the point where the line of fracture crosses the supracondyloid ridge, and sometimes an irregularity in the line of the ridge at that point. The independent mobility is recognized by grasping the fragment between the thumb and fingers and moving it slightly backward and forward while the other condyle and the shaft are held with the other hand. Pain can also be caused by pressure upward against the olecranon or backward through the forearm while the elbow is partly flexed. If the limb can be fully extended abnormal lateral mobility of the forearm — adduction and abduction — is found, especially abduction. The same mobility exists when the joint is more or less flexed, but the observation cannot be safely made, at least in the young, because of the difficulty of dis- tinguishing between it and rotation of the humerus ; full extension is necessary for the test, and this can rarely be had except with the aid of general anaesthesia. The relations of the epitrochlea and tip of the olecranon are preserved, and their elevation or displacement backward with reference to the external epicondyle is generally too slight to be recognized through the swelling. Associated dislocation of the radius from the capitellum is recognized by the presence of its head below and behind the outer condyle and by the marked displacement backward of the internal condyle, and olecra- non which leaves the outer condyle and lower end of the shaft as an easily recognizable prominence in the flexure of the joint. The main point to be considered in the treatment is the correction or prevention of such displacement as would seriously interfere with the functions of the joint or the appearance of the limb, notably the ascent of the condyle by which the axis of the forearm would be directed inward (adduction). The fragment is too small to be acted upon directly by any dressing, and its position must, therefore, be controlled through the ulna to which it is attached. Ordinarily this can be satis- factorily done by a fixed dressing with the elbow at a right angle, either a tin posterior splint or, preferably, a moulded one or a plaster encase- ment. The essential points are that the fragment should be kept well down in place while the dressing is hardening, if a moulded one is used, and that it should not be pressed upward during repair by the bandage which supports the forearm ; this should lie near the wrist, not under the elbow. Full flexion and full extension of the joint, which meas- urably control the position of the fragment by the tension of the pos- terior and anterior portions of the capsule respectively, have been recommended ; in each position tilting of the fragment sometimes PLATE XIII Fracture of Internal Condyle of the Humerus in an Adult. > > — I X w < Ph PLATE XV Fracture of External Condyle; Patient Eighteen Years Old. PLATE XVI FIG. 1 Angular Displacement Produced by Flexion. FIG. 2 Discondyloid Fracture, Three Weeks Old. Reduced by operation. FRACTURES OF THE HUMERUS. 261 Fig. 142. occurs. Full flexion is a much more convenient attitude than full extension, unless the patient is kept in bed; but it is no more con- venient than rectangular flexion and, I think, gives no more security against displacement. It is usually desirable in fracture complicated by dislocation of the radius, in order to oppose recurrence. If the fragment is rotated or tilted and cannot otherwise be brought into place, it should be exposed by an incision ; advantage may be taken of this to fix the fragment in place by periosteal sutures or even by transfixion with a pin. Immobilization is required for about three weeks, a sling for another week, and then the limb abandoned to natu- ral use without forced passive motion; the latter, for reasons given in Chapter VII., is more likely to do harm than good, for it may increase the irritation which provokes overgrowth of callus. Even with satisfac- tory reduction the range of motion may be diminished by callus obstructing the olecra- non or coronoid fossa, and even with con- siderable permanent displacement the range of motion may be only slightly restricted. E. Fractures of the External Condyle. These are much more common than frac- tures of the internal condyle, and much more frequent in the young than in adults. The cause is a fall upon the hand while the elbow is flexed or upon the inner and pos- terior portion of the flexed elbow, or forcible adduction of forearm ; in the first the force is transmitted through the radius to the capitellum in a backward or backward and upward direc- tion, in the second through the olecranon upward and outward against the outer slope of the trochlea, and in the third it acts by avulsion through the external lateral ligament and the muscles attached to the condyle. I have found it easy to produce the fracture by adduction of the extended forearm in bodies of the young, or by a blow upon the palm with the elbow flexed at a right angle (Fig. 143). In one or two cases I have thought the cause was a blow upon the back of the condyle. The line of fracture runs obliquely from the outer ridge of the humerus above the epicondyle downward and inward into the joint, ending usually in the groove of the trochlea, coinciding in part at least with the epiphyseal line so that the fragment comprises the capitellum, the outer portion of the trochlea, and perhaps the epicondyle. In the adult the line seems usually to extend somewhat higher. As the fragment remains attached to the radius and ulna by the lateral ligament and capsule, the displacement is usually slight when the forearm is Lines of fracture of external condyle 262 FRACTURES. Fig. 143. Experimental fracture of external con- dyle by a blow on tbe palm of the hand, elbow flexed at right angle. Swelling appears first on the outer side and then be- comes uniform; ecchymosis appears below the condyle, or on the inner side if the patient has remained in bed with the arm abduct- ed. Loss of function is not so marked as in frac- ture of the internal con- dyle ; pain is felt on press- ing the broken condyle against the shaft, inward, upward, or forward; also on pressure with the tip of the finger on the ridge close above the epicondyle. Ab- normal mobility appears as adduction of the fore- arm (also painful), with less or no abduction, and can sometimes be recognized by grasping the fragment between the thumb and finger and moving it back- ward and forward while the shaft; is firmly held ; crepi- m its proper position, but there is tend- ency to tilting (flexion) of the fragment, and sometimes it is markedly rotated about one or another axis, so far in one of Kocher's cases and one of mine that the fractured surface looked outward, and in two of mine upward. If the forearm is abducted the fragment is displaced back- ward or upward and outward ; if adducted, forward or doAvnward. If the elbow is simultaneously dislocated backward or outward the fragment accompanies the radius. A late condition, sometimes found, such as that shown in Fig. 145, and usually attributed to a primary displacement left uncorrected, appears to me to be due more probably to arrest of development at the base of the capitellum. This condition leads to marked abduction of the forearm cubitus valgus. Fig. 141. A Old fracture of external condyle of humerus with displace- ment downward and inward and incomplete dislocation inward of ulna. FRACTURES OF THE HUMERUS. 263 tus may be perceived at the same time. If the fragment is notably displaced the irregularity may be recognized by palpation ; and if the ulna is at the same time dislocated backward from the trochlea the con- dition is recognized by noting the common signs of dislocation on the inner side — backward projection of the olecranon, prominence of the trochlea in the flexure of the elbow — and the position of the fragment Fig. 145. Fracture of external condyle ; late result. Cubitus valgus. (Helferich.) in close relations with the head of the radius behind and above its proper position. The much rarer dislocation outward could be recog- nized in like manner. The difficulty in treatment lies more in the reduction of displacement, if it is marked, than in the maintenance of the proper position if that is secured. In most cases, those without much displacement, immobil- ization for three weeks at a right angle by a posterior moulded splint is sufficient, although, of course, pains must be taken to make reduc- tion as complete as possible. When the fragment has suffered one of the rarer displacements by rotation it is generally impossible to restore it to place without an operation. In three such cases I opened the joint by an incision on the outer side and, with considerable difficulty in two, turned the fragment back into place and obtained a good result. Kocher twice excised the fragment under such circumstances, and reports a satisfactory result ; both were old cases, and one of mine was two months old. In two old cases, one of them with displacement o\' the fragment downward and inward and partial dislocation of the ulna inward, the other with displacement upward and backward, I detached the frag- 264 FRACTURES. merit with a chisel and brought it back into place. Primary union ; considerable improvement in function. F. Intercondyloid, T-shaped, or Y-shaped Fractures. These fractures are commonly caused by great violence, and conse- quently are often compound, either by the direct action of the violence upon the skin or from within outward by the sharp end of one of the fragments. In many the main line of fracture is the same as in supracondyloid fracture, with an additional line passing down into the joint between the condyles ; in the others the variations in the form and extent of the Fig. 146. Fig. 147. Intercondyloid fracture of the humerus. (Gurlt.) Intercondyloid fracture of the humerus. Front view. (Gurlt.) fracture and the degree of displacement are very great, the essential features being the separation of both condyles from the shaft and from each other, the variations appearing in the number and position of the fragments and lines of fracture. When the fracture between the con- dyles is a mere fissure the condyles remain together, and the displace- ments are those of supracondyloid fracture ; in the other cases the displacements are too varied and irregular for classification and the condyles may be widely separated from each other, the olecranon pass- ing up between them. Occasionally the nerves or vessels crossing the front of the joint are torn or compressed. Symptoms. The symptoms in many cases are those of supracondy- loid fracture with, in addition, independent mobility of the condyles upon each other and pain when they are pressed together. In cases with the more varied displacements the deformity is great and the inde- pendent mobility of the condyles upon each other and the shaft is readily recognized if they can be grasped through the swollen tissues. FRACTURES OF THE HUMERUS. 205 In respect of treatment much that lias been said of that of supra- condyloid fracture can be repeated. Cases with comminution and much displacement are quite certain to result in marked limitation of motion in the joint. Reduction by manipulation through the unbroken skin is largely problematical, and the limb should, therefore, be kept in the attitude which will be most useful if stiffness results. In maintaining reduction I have been best satisfied with plaster splints, anterior and posterior, held snugly at and above the condyles while they were hard- ening. Vertical suspension occasionally does well, especially in com- pound fractures, but I have never continued its use for more than about ten days, resorting then to moulded splints with the elbow flexed, and with fresh reduction if necessary. There is of late a distinct tendency toward operation in such cases with the object of suturing or pinning the fragments in place, but it must be remembered that an ideal restora- tion is far from always producing a similar restoration of function. In compound fractures it may sometimes be advisable to remove some of the smaller fragments or cut off sharp ends ; and in one case in which the fragments could not otherwise be held together I transfixed them with a long drill which was left in place for a fortnight. Kocher recommends the removal of the external condyle, on the ground that it facilitates drainage and ensures a greater range of motion without seri- ously diminishing the stability of the joint. Occasionally it has seemed advisable to remove both condyles ; the resulting joint is likely to be troublesomely loose, although not so much so as when the olecranon also has been removed. G. Separation of the Epiphysis. To the account of the development of the epiphysis previously given (p. 250) must be added that the views of others differ therefrom in some important details, and that some of the appearances shown on section can be explained only on the supposition that the development (especially of the trochlea) differs widely in individuals, or (which seems to me more probable) that the sections have been made in different planes. The accounts which seem most trustworthy represent the trochlear portion of the epiphysis as remaining wholly cartilaginous much longer than the other portions, and as having a concave upper surface which steadily deepens so that before its union with the diaph- ysis it has become a relatively thin saucer-like scale capping a project- ing portion of the shaft, and is connected with the capitellum on one side and with the epitrochlea on the other only by a thin neck. This seems to make the separation of the entire epiphysis, with or without the epitrochlea, in one piece from the shaft very improbable except at an early age ; that it has thus been separated is demonstrated by a few specimens, but the diagnosis in the great majority of supposed cases rests only upon doubtful clinical evidence. Moreover, some writers and reporters of cases describe under this title fractures in which the line diverges widely into the shaft on the inner side, and 1 believe that all the eases are essentially the same as those described above as low supracondyloid fractures in the young. 266 FRACTURES. Among the specimens described are Lange's, 1 two of Bardenheuer's, 2 and two figured and described by Poland 3 from the museums of St. Mary's and St. Thomas's hospitals ; in Lange's the patient was ten years old, the separation (compound) was wholly through cartilage, and the epicondyles Avere separated from the fragment and also from the shaft ; the fragment w r as widely displaced from the shaft and the bones of the forearm, but was still attached to the shaft by the loosened periosteum. In one of Bardenheuer's the separation appears to have been below both epicondyles, and the fragment was displaced back- ward and inward with the forearm ; in the second the fragment, which is not described in detail, was displaced backward, also preserving its relations with the bones of the forearm. In both of Poland's the separa- tion was wholly along cartilage, the epicondyles remaining attached to the trochlea and capitellum. A specimen apparently of pure cartilag- inous separation was in the Bellevue Hospital Museum, but has now been lost. The cause appears usually to have been a fall upon the elbow or the outstretched hand ; in Lange's the elbow was caught between an elevator and a beam, and in one of Poland's it was "jammed in a gate." The displacement in all the certain cases has been great, and in all but Bardenheuer's the injury was compound. In the alleged cases diagnosticated without direct examination of the fragment the displace- ment has been sometimes marked, sometimes slight, the diagnosis in the former being made by palpation of the fragment, in the others upon the abnormal lateral and antero-posterior mobility of the upper end of the forearm with fine crepitus and on the exclusion of other forms of fracture. Schuller and Bruns think the injury more frequent than the paucity of reported cases indicates, an opinion which must be correct if the low supracondyloid fractures iu the young are included. The symptoms and diagnosis are essentially those of low supracon- dyloid fracture in the young. The line of separation may pass above or below the epicondyles ; the essential diagnostic feature (from dislo- cation) is the maintenance of the relations of the small lower fragment with the radius and ulna ; and the position of the line of separation along the epiphyseal junction may be indicated by cartilaginous crep- itus on manipulation. The treatment is reduction of the displacement and immobilization, with special precautions against displacement inward, as in low supra- condyloid fracture (q. v.). H. Fractures of the Articular Process, in Whole or in Part. These include fractures of the whole or part of the capitellum, of the inner portion of the trochlea, and of the capitellum and trochlea together. A few specimens of fracture in adults passing wholly or mainly below the epicondyles are known, and Kocher, who includes them with 1 Lange : Medical Eecord, July, 1880, p. 48. 2 Bardenheuer : Deutsche Cliirurgie, Lief. 63a. p. 736. 3 Poland: "Traumatic Separation of the Epiphyses," London, 1898. FRACTURES OF THE HUMERUS. ( 2()7 separation of the epiphysis under the title " fractura diacondylica," found that the lesion could be produced experimentally by a blow upon the lower surface of the bone in the direction of its long axis ; as the trochlea and capitellum project in front of the line of the shaft they can thus be broken off and pressed upward. (Compare Fig. 133.) In the alleged cases in the young the diagnosis must remain in doubt, for the cartilaginous element makes the arrays ineffective, and palpation is necessarily uncertain. The direction and character of the violence apparently concerned in the production of these fractures suggest a well-marked displacement of the fragment forward and upward in combination with the radius and ulna which probably could be recognized by palpation and the abnormal mobility. The indications for treatment would be to press the fragment downward and backward into place and keep it there by pressure or traction upon the upper part of the forearm. The prog- nosis, in respect of the preservation of function, seems bad because of the intra-articular position of the line of fracture. Fracture of the capitellum alone, in whole or in part, has been ob- served in a number of cases. Hahn 1 reports an old specimen in which the capitellum had united with the front of the humerus after displacement upward and rotation. Kocher figures four specimens representing larger or smaller portions of the capitellum removed by operation in fresh cases; Figs 149 and 150 represent the largest and smallest. Steinthal 2 reports a case similiar to Hahn\s. The capitellum was removed by operation, with improvement of function. In two of Kocher' s cases the cause was violence exerted through the radius, the elbow being flexed, once in a fall upon the palm of the hand, and once by pressure against the Fig. 148. palm while the back of the elbow rested against a wall ; in the other two the injury was received in an effort to raise or hold a heavy object, apparently with the elbow partly flexed. The mechanism in the latter cases seems to me to be pressure by the head of the radius upward against the lower anterior portion of the capitellum under the pull of the biceps. In a personal case the capitellum was broken off' and the upper posterior angle of the olecranon broken (extra-articular) by the fall of a heavy stone. The capitellum. injury was compound and the skin so contused that it sloughed ; the ensuing suppuration led to later excision of the end of the humerus. Recovery with preservation of rotation of the forearm. In another the lower two-thirds of the capitellum was broken off, but remained attached posteriorly (Fig. 148). The arm had boon caught between a tugboat and a float. There was a largo hematoma and a small wound of the skin. I exposed the fracture and fas- tened the fragment in place with periosteal sutures. Good result. 1 Hahn: Quoted by Gurlet, loo. cit., p. SOI. 2 Steinthal : Centralb. f. Chir., 1S9S, p. 17. 268 FRACTURES. In a third case the line of fracture was nearly parallel to the long axis of the humerus, in a frontal plane, and the fragment had been displaced upward and had united with the humerus. I removed it. In a case similar to this last one Dr. Carleton Flint (oral communica- tion) found the fragment united with the humerus in such a way that the lower part of its surface of fracture rested against the side of the head Fig. 149. Fig. 150- Fracture of inner rim of trochlea. (Tracing from an imperfect skiagram.) Fracture oi.capitellum. of the radius and had become eburnated. Rotation was preserved ; flexion and extension almost entirely lost. Removal of the fragment restored motion between the angles of 45° and 165°. The local reaction, as evidenced by pain, swelling, and loss of func- tion, is comparatively slight or tardy in appearing ; in four of eight reported cases the fragment was displaced upward within the capsule of the joint, in three (all Kocher's) backward, lying between the head of the radius and the olecranon, where it could be easily felt, in one (Flint) outward and downward. Kocher removed the fragment in all his cases and secured a good result. Lorenz 1 reports 2 cases success- fully treated by excision of the fragment, and quotes 2 others (Hahn, Steinthal) in which the fragment was displaced upward beyond the head of the radius. 1 Lorenz : Deutsche Zeitschrift fur Chir., vol. 78, p. 531. FRACTURES OF THE HUMERUS. 261) Fracture of the trochlea alone is very rare. Laugier first called at- tention to it in 1853 in a report of a case in which the diagnosis rested only on scanty clinical evidence. I have had a case in which a frag- ment of the lower part of the inner rim of the trochlea, about three- fourths of an inch long, had been broken off and could be easily felt beneath the epitrochlea. The displacement was slight, so I did not excise the fragment, but simply immobilized the joint. The result was good. In another case, Fig. 151 with a larger fragment, the same plan was followed with a similar result. Diagnosis. There is so much in common in these injuries of the lower end of the humerus that it is w T ell to summarize the methods of examination and the principles of treatment. In most cases of injury the diagnosis at first sight rests between frac- ture, dislocation, and sprain ; the first two have positive signs by which they can be affirmatively recognized, the latter has its own signs, but its diagnosis must be confirmed by exclusion of the other injuries. If the case is seen early the absence of swelling greatly facilitates examination ; if excessive swelling is present it may be diminished by vertical suspension of the limb or by the use of the elastic bandage, and the fluoroscope or the skiagram may give information that cannot be got at the time by palpation. The region in which swelling begins, or to which it remains limited, is the one which specially requires close examination. After the history of the accident has been obtained — usually too vague or uncertain to be of much value — and in the absence of indi- cations pointing clearly to one or another portion of the bone or one or another kind of injury, the surgeon seeks to place the ends of his thumb, index-, and middle finger on the two epicondyles and the tip of the olecranon in order to determine their relative positions and to note if their relations are normal in such attitudes as he can give to the joint. This examination, if it can be satisfactorily made, should at once determine the presence or absence of a dislocation of the ulna, and of the radius if the head of that bone is next found. If dislocation has thus been excluded and if the patient is not too young, he next seeks the indications given by pain, grasping the elbow with one hand and the shaft of the humerus with the other and press- ing the two together and then sideways, with thumb and fingers on the epicondyles, determining also by the latter movement the presence or absence of abnormal mobility of the lower end upon the shaft ; if the results suggest supracondyloid fracture confirmation is sought by exploration of the condyloid ridge for points of pain and irregularity of outline, and the shaft is traced downward to determine its relations to the condyles. The condyles are also pressed together to note the pain of a fissure running down between them, or each is grasped between the thumb and fingers and the effort made to move them on each other. The positive sign of fracture of either condyle is its independent mobility, recognized by grasping it between the thumb and lingers and 270 FRACTURES. moving it backward and forward. Corroborative evidence, or evidence that may be deemed sufficient in absence of independent mobility, is pain on point pressure on the condyloid ridge and abnormal abduction or adduction of the forearm, adduction in fracture of the external, adduction in that of the internal condyle, and pain, especially on^move- ment in the opposite direction. Fracture of the internal epicondyle is shown by its abnormal mobility. The positive evidence in every case is the independent mobility of the fragment, usually with crepitus, and only when that is unrecog- nizable because of the impossibility of properly grasping the fragment should the surgeon rest his diagnosis upon other symptoms. If this rule and that of always determining the relative positions of the ends of the bone constituting the joint were followed, the disastrous con- founding of fractures and dislocations would be much less frequent. Anaesthesia is indispensable in many cases for a complete examination. Treatment. The tendency to displacement except by the unsupported or im- properly supported weight of the limb is so slight that if reduction can be made a satisfactory result should be obtained in most cases, the exceptions being those in which the functions of the joint are dimin- ished by obstructive callus or by peri-articular thickening. Consequently every effort should be made to effect complete reduction, especially when the fracture extends into the joint, even, if necessary, by exposure through an incision, and then to prevent its recurrence by so support- ing the limb that this cause of displacement may not become operative. In the great majority of cases efficient immobilization and protection are afforded by moulded anterior and posterior plaster splints, the elbow being flexed at a right angle and the limb supported at the wrist by a sling. But in the low supracondylar fractures in children this attitude exposes to lateral displacement by gravity and consequent marked cubitus varus, and should be guarded against as above described. If the sling is broader and so placed as snugly to support the limb at the elbow, it may easily produce a slighter form of cubitus varus in frac- ture of the internal condyle or in the higher supracondyloid fractures, by pressing the internal condyle or the inner portion of the lower frag- ment respectively upward. The stiffness which is found when the splints are removed will ordi- narily disappear promptly under natural use. The period can be short- ened by systematic daily massage, begun at about the end of the second week. Bony anchylosis is extremely rare. For the details of special cases which cannot well be summarized the reader is referred to the preceding sections, and for fracture of the adjoining portions of the radius and ulna, to the following chapter, CHAPTER XX. FRACTURES OF THE BONES OF THE FOREARM. In the Vicinity of the Elbow-joint : Olecranon, coronoid process, head and neck of radius — Fractures of the Shaft : Both bones, ulna, radius — In the Vicin- ity of the Wrist : Of the radius, Colles's, other than Colles's. 1. IN THE VICINITY OF THE ELBOW- JOINT. A. Fractures of the Olecranon. The frequency of fractures of the olecranon has been very differently estimated by different writers, Malgaigne placing it among the rarest, only nine cases in a total of more than 2300 fractures treated during eleven years at the Hotel-Dieu. The table in Chapter I. gives 118 cases in a total of 14,566 (0.8 per cent.). The line of fracture may lie at any point above the base of the coronoid process, crossing the bone transversely or obliquely or along a V-shaped line corresponding somewhat to the borders of the trian- gular subcutaneous surface of the olecranon.*- In rare cases it is comminuted, and sometimes is compound. In a very few cases the epiphysis has been broken off along the line of the conjugal cartilage. The commonest cause by far — 36 out of 45 cases collected by one writer — is thought to be a fall upon the elbow. The mechanism, however, is apparently not simply that of fracture, by direct violence, the bone is not broken solely by a force acting directly upon the end of the apophysis, but the contraction of the triceps must play an important part in it. Among the reasons for this belief are the usual absence of the signs of direct violence upon the surface of the region sufficient to have caused the fracture, and the impossibility of producing similar fractures upon the cadaver by this means. When the fracture is produced experi- mentally by direct violence, by a blow with a blunt object, the bone is not broken cleanly and transversely at its narrowest part, as is the case in most fractures observed clinically, but it is crushed and split into several pieces. The explanation that seems most plausible is that a sudden change is effected in the position of the forearm by the fall when the muscles are all tense. The man falls with his elbow partly bent, and all his muscles rigid with the effort to save himself; his out- stretched hand or the back of his forearm encounters some solid object, and the flexion of the limb is suddenly and violently increased, while the olecranon is held immovable by the triceps. The consequence is that the ulna is bent about the elbow, and breaks at the weakest part of the olecranon if the violence is received near the elbow, or. perhaps, at some part of its much thinner shaft if the violence is received upon the hand. 271 272 FRACTURES. Occasionally the olecranon has been broken in an attempt to reduce an old dislocation or to mobilize a stiff elbow ; and it has been alleged that a blow upon the back of the ulna near the elbow can break or crack the olecranon from the articular surface outward. Muscular action, contraction of the triceps, appears to be an occa- sional cause, as in throwing a ball or vigorously pushing with the' elbow partly flexed. In such fractures the fragment torn off is small, little more than the cortical layer of the summit of the process to which the triceps is principally attached ; in other cases the line of fracture lies usually at the narrowest part of the process, directly under the centre of the sigmoid fossa, that which is called by some the centre, by others the base, of the olecranon. Fig. 152. Fracture of olecranon, x-ray tracing. Fig. 153. Fracture of olecranon, x-ray tracing. Another variety of fracture, partial or complete, and produced from within outward, has been spoken of by different writers as theoretically possible, but has only recently been observed and described clinically. Pingaud l produced it experimentally in the effort to dislocate the ulna backward by over-extension (extension beyond the straight line) of the forearm. The end of the olecranon is pressed againt the humerus, the lateral ligaments resist the movement, and the prolongation of the effort results in fracture of the olecranon or, much more commonly, of the thinner and weaker shaft of the ulna. Quintin 2 reports three cases of incomplete fracture of the olecranon ; the surface articulating with the humerus was broken, the dorsal portion was unbroken ; in all 1 Pingaud: Diet. Encylopedique, art. Coude, pp. 517 and 631. 2 Quintin : Beitrag zur Lehre von den Bruchen des Olekranon, Bonn, 1881, Abstract in Centralblatt fur Chirurgie, 1881, p. 763. FRACTURES OF THE BONES OF THE FOREARM. 273 the swelling was moderate, the pain severe, flexion and extension com- plete but slow. In the first case, seen a week after the accident, a small prominence could be felt on the side of the olecranon, and behind it was a notch ; the upper end could be sprung back a little. In the second case a short shallow groove could be felt on the outer side of the olecranon, at its base ; and in the third the olecranon could also be sprung. Quin tin thinks this fracture is frequently overlooked and treated as a simple contusion. The symptoms in the three cases described will, perhaps, hardly be considered entirely demonstrative, in the absence of corroborative testimony of direct examination, of a recent fracture ; and, indeed, it is only by admitting that the injury is a common one and has heretofore always been overlooked that its occurrence three times during a short period in the experience of one observer can seem probable. Symptoms. The symptoms of the fracture are pain, swelling, dis- placement, and mobility of the upper fragment, sometimes crepitus, and loss of power, especially of active extension. As the result, apparently, of theoretical considerations, and of what has been observed in exceptional cases, the tendency to displacement upward of the fragment by the contraction of the triceps has been somewhat overstated. This action of the muscle is greatly restricted by the lateral aponeurotic attachments and ligaments, and by the exten- sion of the insertion of the triceps along the lateral and posterior aspects of the olecranon, all of which must be ruptured before the fragments can be widely separated and the upper one drawn high up. In a dis- cussion in the Societe de Chirurgie which followed the presentation by Bardinet of a paper upon this subject, Robert, Richert, and Gosselin testified to the usual absence of separation in their experience, and similar testimony has since been furnished in abundance. If the thick periosteum and tendinous attachments on the sides and back of the olecranon are torn, nothing remains to hold the fragments together, and separation may be effected either by the contraction of the triceps, drawing the upper fragment away from the shaft of the bone, or by flexion of the forearm, drawing the bone away from the fragment. In either case coaptation is effected by extending, straight- ening, the forearm upon the arm, because the triceps cannot draw the fragment above the position which it takes in complete extension unless the ligaments which bind it to the humerus are torn, and this is a complication which apparently happens very rarely. In old ununited cases the gradual retraction of the triceps draws the fragment upward, but not even in such has it risen above the ole- cranon fossa. Another displacement, one that is important because of the danger that the skin may be broken by the pressure to which it leads, is an angular one observed in a few cases when the line of fracture has been near the base of the coronoid process, and especially when its direction has been obliquely downward and backward and the upper fragment has ended in a sharp lower edge or point. Coincident dislocation of the radius and ulna forward is occasionally seen. (See Chapter XLV., and Plate XV I ['.), 18 274 FRACTURES. Mobility of the fragment is recognized by grasping it between the thumb and finger and moving it laterally, or by flexing the forearm gently while the finger is pressed against the groove or crack left by the separation when it is slight. If the fragments are brought together by extending the forearm or drawing the upper fragment down, crepi- tus can be felt. If the swelling is sufficient to prevent recognition of these objective signs, the fracture may be suspected from the history of the case and the loss or marked diminution of the power of active extension. Repair. It is very important, with reference both to the treatment and prognosis, that the character and extent of the displacement should be known. As a rule, union takes place, but it is fibrous, not bony ; and the restoration of function depends in a measure upon the length of the fibrous band. I say "in a measure," for experience has shown in not a few cases that there may be excellent control over the limb even with a long fibrous band between the two fragments. The disability sometimes observed under the opposing conditions, limitation of motion when the band is short, is due to adhesions between the fragment and the humerus, or to change in the flexibility and length of the capsular bands. The process of repair involves two dangers : defective union or failure of union between the fragments, and the formation of the intra-articular bands or changes in the artic- ular and peri-articular tissues. Instances of bony union do exist. Malgaigne figures and describes one in his Atlas (Plate XXIV., fig. 2), which, however, differs notably from the ordinary fracture, the line having run so obliquely as to bring away with the olecranon a lateral half of the coronoid pro- cess. Many instances of union with very slight separation, if any, and apparently bony, have been reported, but in only a few has the character of the union been established by autopsy. Gurlt l describes and pictures two : one, a fracture half an inch from the apex of the process, united with slight displacement of the fragment upward and only a small amount of callus on the outer side ; the line of fracture is partly visible upon the surface Fig. 154. of section, and complete extension of the joint is prevented by an over- growth of bone at the apex. The other is an oblique fracture (Fig. 154), and has united so completely that the onlv siarn of it is "a shal- low groove on the under surface of Fracture of olecranon ; bony union. (Gurlt.) the olecranon running obliquely backward from the radial to the ulnar side. The articular cartilage is lacking in part, and the callus consequently visible." Apparently bony union is more probable when the fracture is oblique. The length of the fibrous band varies within very wide limits. Fig. 155, taken from Malgaigne, represents a comparatively short band and one that presents another peculiarity in that it consists of two 1 Gurlt : Loc. cit. ; vol. i. p. 41, Fig. 9, and p. 310, Fig. 121. PLATE XVII Fig. 1. Fracture of Olecranon ; Dislocation forward of Radius and Remainder of Ulna. I ' Fig. 2 — Fracture of Forearm ; Angular Displacement. FRACTURES OF THE BONES OF THE FOREARM. 275 lateral bands with a central interval or gap. This is by far the most common mode of reunion, and although several cases have been reported in which the patient appeared to have regained full use of the Fig. 155. Fracture of the olecranon ; fibrous union. (Malgaigne. arm, notwithstanding fibrous union with separation to the extent of half an inch more, yet actual deficiency in the power of active exten- sion of the forearm is to be regarded as a frequent result of fibrous union, and its degree will vary directly with the length of the band. The disability may be unnoticed by others, and its consequences may be avoided or diminished by care in the use of the arm, by avoidance of positions and movements which require the especial action of the Fig. 156. Ununited fracture of the olecranon, a, the upper fragment ; b, the external condyle. triceps, but it exists and can be readily demonstrated. Malgaigne describes a case in which the fragment apparently had not reunited with the shaft, and yet the patient could use the limb actively, and even handle a sword or a foil. On examination it was found, how- ever, that the vigor and strength of the arm depended largely upon its position, being greatest when the hand was supinated and the arm dependent, and disappearing almost entirely when the arm was raised above the horizontal line. Failure of union, as in the case just mentioned, is not very uncom- mon ; the upper fragment may remain freely movable, or it may become adherent to the humerus. In a case of the latter condition which came 276 FRACTURES. under my observation thirty-five years after the accident (Fig. 156) the forearm could be completely flexed and could be extended to 135 degrees, the force of extension being very feeble. In the majority of cases union takes place with but little separation and with full restoration of function, so far at least as power is con- cerned, although extension is often incomplete. A still more unfortunate result, anchylosis of the joint, has followed in a small number of cases. Malgaigne quotes from Camper and Trioen an anatomical specimen of bony fusion, and although it is not specifically asserted that the union was between the ulna and the humerus, this seems probable from the context. Thierry, according to Pingaud, reported two cases of articular rigidity that had lasted, the one for six months, the other for a year, in spite of the most persistent efforts to overcome it. I have seen a case in which the joint was stiff in full extension after wiring of the fragments, although the operation- wound had healed without suppuration. The course of the fracture is ordinarily very simple aud uncompli- cated ; the swelling subsides promptly and union takes place in from three to four weeks. Treatment. Discussion concerning the proper treatment of fracture of the olecranon has turned mainly upon the position to be given to the limb, some favoring the extended position in order to secure closer union of the ligaments, others recommending flexion, either because they did not fear separation of the fragments and sought the position that could be kept with the least discomfort, or because they feared anchylosis and wished to have the limb in the most favorable position if it should occur. It is evident from the facts that have been already stated that neither the first nor the third reason is sufficient to establish a rule of practice to be followed in all cases. The probability of the occurrence of anchylosis after simple fracture is very small, so small that it ought not to be w r eighed against that of non-union when the fragments are separated rather widely. On the other hand, the sepa- ration at first is so slight in many cases and the extended position so unnecessary to overcome it that if partial flexion is more comfortable to the patient, if it makes the restraint less irksome, it should not be denied him. Furthermore, there appears to be danger of two displace- ments in complete extension : if the fracture is at or near the base of the process the ulna can be readily dislocated forward ; and secondly, effusion into the joint or swelling of the capsule may prevent the tip of the olecranon from sinking into the olecranon fossa to the usual depth, and under such circumstances complete extension of the forearm would cause a tilting, an angular displacement of this fragment. This latter point has been made by several writers upon theoretical grounds alone, but, although it seems plausible, no confirmatory observation has been made, so far as I know. The aim of treatment should be to secure bony union if possible, and, failing that, close fibrous union, and this consideration will regulate the position to be given to the arm. If there is wide separation which increases as the elbow is flexed, if the fragments cannot be brought well together except by extending the forearm, that position must FRACTURES OF THE BONES OF THE FOREARM. 277 be taken and kept until consolidation is well advanced. If, on the other hand, the separation is slight and the upper fragment follows the movements of the lower, if they can be easily brought to- gether and kept so by moderate traction upon the upper one, the patient may be safely allowed the comfort of the partly flexed posi- tion. Apparently it is not often necessary to take especial measures to draw the upper fragment down to the lower one, and even when there is con- siderable separation between them in the flexed position it is usually sufficient simply to extend the elbow. Some methods of treatment, however, have been designed with the especial intention of drawing the fragment down, and it has been sought to accomplish this by figure- of-eight bandages passing above and below the fragment and crossing in front of the elbow, or by circular bands about the arm drawn together by longitudinal ones. In others, strips of adhesive plaster have been applied to the skin above the olecranon, drawn down snugly, and fast- ened to the skin of the forearm or to the splints ; sometimes the plaster is cut in the form of a U, the olecranon lying in the angle and the two sides passing along the forearm. Metal hooks similar to those used in fracture of the patella have also been used here successfully, although not frequently. I do not know when or by whom they were first employed, but Busch recom- mended them in 1864, and Pingaud 1 speaks of the use of a similar method a a very long time ago" by Prof. Rigaud, of Strasburg. It is sufficient that the hook should have but a single point at the upper end, and at the other end should be made fast to a gypsum bandage covering the arm and forearm and provided with a large fenestra behind the elbow. The best splint is an anterior one made fast to the limb by a roller bandage or a fenestrated gypsum bandage. It is not worth while, I think, to try to force the upper fragment down by turns of a roller bandage, because this can be done much more effectively when necessary by adhesive plaster or hooks. In short, the treatment to be recom- mended is as follows : If the separation is slight and is not increased by the flexed position it is only necessary to immobilize the limb with the forearm slightly flexed, about midway between complete extension and flexion at a right angle, and for this purpose an anterior splint of wood or of plaster of Paris is sufficient and convenient. If the frag- ment shows any tendency to be drawn up it should be secured with adhesive plaster. If, on the other hand, there is notable separation, and if the separation is increased by flexion of the forearm, the exten- sion should be complete enough to bring the fragments together, and it should be aided by adhesive plaster or hooks. The fenestrated gypsum bandage seems to be the one best fitted for this purpose, and the fenes- tra should be large enough and so placed as to permit inspection of the seat of fracture. If Malgaigne's hooks are used in connection with it one hook or pair of hooks should be forced through the tendon ot^ the triceps down to the bone, and the other pair fixed to the gypsum bandage below the fenestra. In one of three cases recorded by Quin- 1 Pingaud : Diet. Encyclope'dique, art. Coude, j>. 639 (1878), 278 FRACTURES. tin, 1 the hooks remained in place four weeks without causing any inflam ma tor v symptoms. If the patient is rheumatic, or if the reaction has been severe and prolonged and anchylosis is feared, it is well to change the degree of flexion slightly from.time to time after the pain and inflammation have disappeared ; and if the tendency to separation is slight this change of position may be begun quite early. It must be done very gently and cautiously, and the upper fragment must be supported by the finger in order that the adhesions may not be ruptured. In a case reported by Pingaud, 2 the callus was broken by this attempt at passive motion ; and as the surgeon did not dare to immobilize the joint again for three or four weeks he applied a plaster bandage to the forearm, and used it as the support for a pair of Malgaigne's hooks by which he was enabled to keep the fragment perfectly in place, and at the same time to move the elbow as much as he wished. Lauenstein 3 used in one case a method of preliminary treatment recommended by Volkmann in fracture of the patella : aspiration of the joint to remove the blood and synovia. There was separation to the extent of half an inch and the joint w T as distended ; he removed 50 c.c. (about 1J ounces), dressed the limb in the extended position upon an anterior splint, and drew down the fragment by means of longitu- dinal strips of adhesive plaster renewed about once a week. Recovery followed without displacement and with full use of the joint. Another case is reported in the Centralblatt fur Chirurgie, 1885, p. 570. In a few cases the fragments have been wired together ; when resort to such a measure was deemed necessary I have preferred sutures through the fibro-periosteum adjoining the fracture, or a suture through the tendon of the triceps and a hole drilled transversely in the ulna below the fracture. In a few cases of fibrous union with much separation and consequent disability operative measures, according to some of the various plans mentioned in Chapter VIII., have been undertaken to obtain closer union ; and some surgeons have obtained good results by excising the fibrous band and wiring the fragments together. B. Fractures of the Coronoid Process. 4 This fracture, the frequency of w T hich has been much disputed, is unquestionably very rare except as a complication of dislocation of the ulna backward. So far as can be inferred from the few detailed descriptions of speci- mens the line of fracture crosses the process transversely or somewhat 1 Quintin: Centralblatt fur Chirurgie, 1881, p. 764. 2 Pingaud : Gazette Hebdomadaire, May 21, 1875. 3 Lauenstein : Ceutralblatt fur Chirurgie, 1881, p. 172. 4 The references to the specimens in the first edition are: Cooper, Fractures and Dis- locations, p. 411 ; S. Cooper and Gibson, quoted by Hamilton ; Velpeau, Annales de la Chir., 1843, vol. ix. p. 98; Berard, Diet, de Med., en 30 vols., art. Coude, p. 228; Gurlt, vol. i. p. 41 ; Bryant's Surg., 3d Am. ed., vol. i. p. 837; two in Holmes's System, Am. ed., vol. i. pp. 859, 860; Annandale, Medical Times and Gazette, 1875, vol. i. p. 576, and Edinburgh Medical Journal, February, 1885, p. 681. For a personal case seethe following section, Fractures of the Head and Neck of the Eadius. FRACTURES OF THE BONES OF THE FOREARM. 279 obliquely at about one-fourth of an inch below its apex, and may reunite with a close bony union or by a fibrous band. When the union is close and bony there may be a somewhat exuberant callus upon the anterior aspect of the process, due probably to the stripping up of the periosteum or tendon. The mechanism in the great majority of cases is by indirect violence exerted in such a way as to cause dislocation of the joint backward and to break off the point of the process as it is forced past the trochlea, Fig. 157. Fracture of the coronoid process of the right ulna. United with exuberant callus on the anterior surface, line of fracture still visible on the articular surface. a, a small fragment broken from the articular border of the olecranon and reunited. (Gurlt.) Fig. 158. Fracture of the coronoid process and the head of the radius. (Bryant.) and in such cases there is also sometimes fracture of the anterior por- tion of the head of the radius. In one case mentioned by Lotzbeck l the process appeared to have been broken off by direct violence ; a soldier was struck in the elbow by a piece of a shell which caused a severe contusion but no open wound. Two months afterward the coro- noid process could be felt as a movable body, and by pressing it down it could be made to rub against the ulna with a creaking sound. Acu- puncture proved the supposed fragment to be a hard solid body. In another case, that of a boy fourteen years old, the process was broken off by extreme flexion of the elbow. A somewhat similar personal expe- rience may be mentioned as corroborative of this mechanism to a cer- tain extent. I excised an elbow for suppurative disease of the joint, using Oilier' s postero-lateral incision. In order to facilitate the clean- ing of the external condyle, and before the olecranon had been touched, I asked the assistant to flex the elbow ; he did so with some force, and felt something snap. About half an inch of the coronoid process was found to have been broken off. It seemed, however, to be unusually long and prominent, possibly by ossification of the attached capsule in consequence of the prolonged inflammation. As regards experiment upon the cadaver we have the assertion ot y Malgaigne, 2 that in producing dislocations backward he broke off the end of the coronoid process quite frequently, and the more detailed results of Lotzbeck who fixed the elbow in a slightly flexed position by means of a gypsum bandage and then by striking upon the palm of the hand broke the coronoid process five times in ten attempts. 1 Lotzbeck : Schmidt's Jahrbuch, 1S66, vol. exxix. p. 134. 2 Malgaigne : Luxations, p. ('34. 280 FBACTUBES. Schwenk (ZUblattf. Chir., 1908, p. 976) reports a similar case without dislocation, confirmed by the .v-rays. The mechanism of this production and the anatomical relations of the process explain the union with slight displacement shown in some of the specimens and the difficulty of diagnosis during life. The ten- don of the brachialis anticus is inserted not upon the top of the process but upon its anterior aspect and base, and the articular capsule is attached all along its edge. When it is broken off by being forced backward against the trochlea its connection with the ulna is preserved in front by the tough attachments of the tendon, and therefore instead of being displaced bodily along the anterior aspect of the bone it is probably only tilted forward. Its vitality is assured in any case by its connection with the capsule, and when the dislocation is reduced the fragment is held exactly in place by the tendon of the brachialis anticus in front and the humerus behind. The symptoms and the means of diagnosis, in view of the uncer- tainty of the diagnosis in the supposed cases, cannot be positively described ; those which have been deemed sufficient are : dislocation backward, easy reduction, great tendency to recurrence, possibly crepi- tus, and the presence of a hard movable body in front of the elbow in the line of the tendon of the brachialis anticus. In a personal case the supposed fragment could be readily grasped between the thumb and finger and moved freely to and fro. Treatment. The treatment consists in immobilization of the joint flexed to a right angle or beyond. The degree of flexion and the com- pleteness of the immobilization may vary with the tendency to dis- placement. If the latter is great, experience has shown that it is best opposed by increasing the flexion ; and, of course, complete immobil- ization gives additional security. The immobilization should be main- tained as long as the tendency to dislocation exists ; when that ceases the splint becomes unnecessary, and the only indication then is to main- tain sufficient flexion to favor prompt and close union. C. Fractures of the Head of the Radius. Our knowledge of this variety of fracture is drawn from about a score of specimens, old or recent, and a constantly increasing number of clinical cases supported by skiagrams. It has recently been studied by Thomas l in a paper admirable alike for its thoroughness of research and its soberness of judgment. Apparently the injury occurs quite frequently ; Thomas collected 48 cases and found evidence of 55 others in skiagrams taken in Philadelphia. The line of fracture may sepa- rate a small portion of the head, about one-third, or a much larger portion passing down through the neck, or may split the head into two or more pieces and separate all of them from the shaft. Usually the fragments retain connection with the periosteum of the neck. Cause. The cause may be a blow upon the head of the bone (Stim- son, Cheyne, Delorme), or a wrench of the forearm, probably forced abduction (Stimson), or a fall on the palm, or the injury may occur as 1 Thomas : Univ. of Perm. Med. Bull., vol. 18, p. 184. FRACTURES OF THE BONES OF THE FOREARM. 281 an incident of a backward dislocation of both bones of the forearm or of the head of the radius. The form of the fracture varies with the cause : fracture of a small portion of the head is the form seen in dis- location and in fracture by direct violence ; the more extensive frac- tures — splitting of the head and complete separation from the shaft — are seen when the limb has been violently wrenched. I have seen five of the former — four in dislocation and one by direct violence — and five of the latter verified by arthrotomy and four'probable cases observed clinically. In the cases accompanying dislocation a small piece, comprising about one-third of the periphery, is broken off, probably the portion that is anterior when the head is forced past the capitellum. I have found it lying, after reduction of the dislocation, beneath the external epicondyle between the radius and the olecranon, and the portion of the head of the radius accessible to palpation did not comprise the gap left by the fracture. In one case the fragment had been displaced downward along the neck and had become attached, limiting rotation ; I cut it away and covered the raw surfaces with silver foil, getting a good functional result. In a case of fracture by direct violence (kick by a horse) Cheyne found the fragment in the same place and removed it, as he did also in another supposed to be by direct violence ; in another Delorme recog- nized abnormal mobility of the'undisplaced fragment and treated it by immobilization, obtaining complete restoration of function. In mine the patient did not come under observation until after suppuration of the joint had occurred ; resection was done. Fig. 159. A B Fracture of head and neck of radius, a, first case : b, second case : c, third case ; the portion corresponding to the gap was crushed. My five certain cases of fracture by violence acting through the forearm resemble one another closely. In each the cause was a fall from a height, the arm being caught under the body. I imagine that the immediate cause was violent abduction of the forearm. Fig. 159 shows the lines of fracture. In the first, one of the two smaller frag- ments was displaced outward and backward, and a primary excision of the head and neck was done, with a good functional result. It was thought that the coronoid process also was broken. In the second there w T as no recognizable displacement at first, and I was not entirely certain of the character of the injury ; after immobilization for four weeks the functional result seemed so likely to be bad that I opened the joint and removed the head and neck, finding the larger fragment 282 FRACTURES. displaced angularly outward aud backward aud reunited with the .shaft. In the third case there were two large pieces and a crush of the inter- mediate portion, also fracture of the coronoid process and slight dis- placement backward of the ulna. I saw the patient a month after the accident and removed the head of the radius. The cases are .reported in detail in the references given above. In the fourth case the head and neck were split and broken off, and in the fifth the fragment com- prising about one-third of the head, antero-external, was detached and displaced downward and inward. In one case observed clinically (details in first edition) reunion followed, with a good functional result, notwithstanding a notable enlargement of the upper end of the radius ; in the other rotation of the forearm was lost. I haye also had a case in which the head of the radius was broken by a pistol-bullet entering from the outer side and above. I excised the head, and the functional result was good. Two of Mutter's specimens and Helferich's show a small portion of the head broken off and reunited with displacement. In Pinner's the small fragment was eburnated but not reunited, and in Delorme's the fragment reunited with conseryation of function. These cases show that union is possible, even probable, after fracture of the neck or of the head ; in my case in which suppuration followed the patient was a delicate strumous lad in whom any serious joint lesion would have been likely to have that result. Diagnosis. The diagnosis after fracture of a small portion accom- panying a dislocation or by direct violence is easy if the fragment is displaced to the position beside the olecranon which it has occupied in most of the reported cases, for it can then be readily palpated. Its removal is easy, and its loss appears to entail no disability. The loss of rotation obseryed in one case after removal was probably due to adhesions between the surface of fracture and the capsule. In the cases of more extensive breaking the diagnosis is easy if there is enough displacement of the head to be recognized by palpation and if its separation from the shaft is shown by its failure to share in rota- tory movements of the forearm. In my second case the head rotated with the shaft, and the only sign pointing to its fracture Avas an occa- sional click perceived during rotation of the forearm ; there was also marked abnormal lateral mobility, especially adduction of the forearm, and sharp pain on abduction. If it cannot be felt, the diagnosis must be made by local tenderness on pressure, but probably the a-rays are needed for a positive recognition. The proper treatment of this condition is not so clear ; one of my cases regained good use of the joint without operation ; another did the same after a primary excision ; the others had all lost more or less rotation when first seen some weeks after the accident, and some of them much of flexion and extension ; the removal of the fragment or of the entire head improved the condition. The results recently obtained by massage and immobilization in cases in which an early diagnosis was made are encouraging, but I doubt if small completely detached portions of the head should be left in ; their reunion is not to be expected and their presence is always a danger. Of 18 cases of PLATE XV 11 Fig. 1.— Fracture of Head of the Radius. Fig. 2 — Fracture of Neck of the Radius. FRACTURES OF THE BONES OF TIFF FOREARM. 283 Thomas's collection in which the result is known there was good union without deformity in 3, with deformity in 5, non-union in 8, 1 bony and 1 fibrous ankylosis, and 2 with greatly impaired function. D. Fractures of the Neck of the Radius. This injury appears to be much less frequent than fracture of the head, although Mouchet 1 saw 11 cases in the course of two or three vears, all in children under thirteen years of age. The known speci- mens are one of Mutter's, united with displacement, one each removed by Annandale, Douglas, Mouchet, Fig. 160. and myself, and one found by Moullin on amputa- tion. Moullin's 2 was a separation of the epiphysis. In several other cases the line of fracture has been shown by the *T-rays (Plate XVIII. ). Mouchet's is shown in Fig. 160. Mutter's specimen of fracture of the neck alone is without history of the cause or symptoms ; in Annandale's the patient, a man forty years old, received a severe jar of the elbow by striking his wrist against his knee while shovelling. He did „ P , , , ., . it, a n, Fracture of neck of ra- not seek treatment until six weeks later. Alter a dius. (mouchet.) month's immobilization the joint was opened ; the head was found loose and the neck atrophied. Dr. Richard Douglas, of Nashville, reported to me a case of fracture of the neck by a blow on the inner side of the forearm, verified by a late arthrotomy. A prominent feature was marked flattening of the inner side of the elbow, with extensive ecchymosis, which I attributed to avulsion of the flexor museles in forced abduction of the forearm. In November, 1902, I saw at the Hudson Street Hospital a man whose right elbow had been dislocated (and reduced) two days previ- ously. The flexed forearm could be moved slightly backward and forward upon the arm, there was a gap below the capitellum, and the head of the radius could be plainly felt in the flexure of the joint. I exposed the joint by an external incision and removed the head of the radius, which had been broken off by a fracture through the neck. The coronoid was broken at its base. Bolton, at the New York Hospital in 1907, found the head inclined outward, forced it back into place, and got a good result. The line is transverse or somewhat oblique, and the proximal frag- ment usually has an angular displacement, the angle opening outward and backward. The mode of production has varied greatly — a fall on the hand, a blow on either side of the forearm, a wrench of the forearm, a crush of the elbow in a machine. Definite diagnostic features are not known beyond pain at the site of fracture and especially on attempting supination (Mouchet). Here, too, the .r-rays will probably be the final arbiter in doubtful cases. 1 Mouchet : Revue de Chir., vol. 21, p. 596. 2 Moullin: Trans. Path. Soc. London, vol. 39, p. 242. 284 FRACTURES, Mouchet\s 9 fresh cases recovered with good function after treat- ment by massage and mobilization. Adults have not done so well, and late excision may be required to improve function. 2. FRACTURES OF THE SHAFT. A. Fractures of the Shafts of Both Bones. The relative frequency of fracture of both bones may be seen by reference to the table in Chapter I. It occurs rarely in the upper third and with about equal frequency in the middle and lower thirds. Usu- ally the radius is broken nearer the elbow than the ulna. Cause. The cause may be direct or indirect violence or muscular action, a fall upon the hand, or the bending of the forearm across some object, or by a transverse blow. Only a few instances of fracture by muscular action have been recorded, and even in those there was a contributing external force, such as shovelling or rising upon the hand in bed. Partial or incomplete fractures — " green-stick fractures" — are, according to Malgaigne, more common in the forearm than elsewhere, and are usually due to a fall upon the hand. Displacements. The displacements are of the usual kinds : overrid- ing in oblique fractures, lateral with or without overriding in the transverse fractures, and angular displacement of one or both bones in both forms. Rotatory displacement of the radius alone, especially when it is broken above the insertion of the pronator teres, was first pointed out apparently by Lonsdale. He suggested that the upper fragment might be strongly supinated by the biceps, while the lower fragment was kept in the usual semi-prone position, and he thought this might be a cause of the inability to supinate the hand completely sometimes observed after fracture. Flower and Hulke l say they have found proof of the correctness of this conjecture in the examination of numerous specimens of united fracture of the radius, " in a great number of which the lower fragment was much less supinated than the upper," and Agnew says there are similar specimens in the collec- tions of the College of Physicians and the University of Pennsylva- nia. Mr. Callender 2 examined eighteen specimens of united fracture of the shaft of the radius in the London museums, and found in fifteen of them rotatory displacement averaging 36 degrees, the extremes being 6 degrees and 64 degrees. The displacement in every case was that pointed out by Lonsdale, supination of the upper fragment. The agency of this rotatory displacement — supination of the upper frag- ment — in preventing full supination of the lower segment after heal- ing appears much more likely to be efficient in fractures below the insertion of the pronator radii teres, for that muscle is the main oppo- nent of the exaggerated supination of the upper fragment which would then be necessary to the full supination of the lower. In angular displacement one bone may be bent while the other remains nearly straight, possibly with overriding, or the fragments of 1 Hulke : Holmes's System of Surgery, Am. ed., vol. i. p. 860. 2 Callender : St. Bartholomew's Hospital Reports, vol. i., 1865, p. 297. FRACTURES OF THE BONES OF THE FOREARM. 285 both bones may be inclined in the same direction, forward, backward, or to either side, or there may be lateral inclination in opposite direc- tions, each bone being inclined toward the other ; and if the fractures are at the same level the four ends may thus be brought into contact, and the possibility created of a union that will abolish the power of rotation of the limb. Such faulty union of the two bones is, however, very rare. Overriding of the fragments has been observed to a dis- tance of more than three inches (eight centimetres). Symptoms. The symptoms are the usual ones of fracture : pain, deformity, abnormal mobility, crepitus, and loss of power. The course is usually simple and the prognosis favorable, but both may be gravely modified by laceration or bruising of the soft parts or by the occurrence of acute inflammatory reaction or of gangrene, and in addition the prognosis may be made unfavorable by an irreducible displacement or comminution or loss of substance of one of the bones. Displacement affects the prognosis when it increases the chances that union may take place between the two bones, and comminution or loss of substance by favoring the occurrence of pseudarthrosis. In simple cases without marked displacement or complication com- plete union may be expected in a month, but in no other limb do inflammatory complications and gangrene occur so frequently, even under prudent treatment. The gangrene may be limited to points where the splints have made pressure or to portions of the hand and fingers, but it is very likely to involve the entire member if it is over- looked at the beginning or not effectively combated. Diffuse phleg- monous inflammation of the forearm may follow severe bruising of the soft parts or may even take its rise in the fracture. Its importance lies in the danger to the life and limb which follows the burrowing of the pus, the opening which it necessitates, and the matting together of the tendons and their sheaths. Ischsemic contraction of the muscles (p. 70) is of especial import- ance because of its marked interference with the usefulness of the hand. The cause of gangrene in many cases and of ischemic contraction has been pressure exerted by splints or bandages, and the necessity for caution and watchfulness to avoid this accident cannot be urged too strongly. The practice of applying a roller bandage to the limb under the splints is extremely dangerous, and so also is the use of splints of soft material, pasteboard and the like, which take the shape of the limb and are fastened to it with a roller bandage. There is the same compression, the same chance of strangulation in this case as when the roller is applied directly to the skin. It is not safe to depend upon the sensations of the patient, upon pain, to give warning of threatening strangulation ; cases, in both old and young, have been reported in which total gangrene of the distal portion of the limb has occurred without attracting the attention of the patient or his attend- ants by any symptoms except the final change in the color of the exposed fingers. The persistence of angular displacement of both bones, or, to a less degree, of the radius alone, affects the prognosis by its inter- ference with rotation. In rotation only the radius moves, and its 286 FRACTURES. movement is about an axis running from its upper end to the lower end of the ulna, so that in full pronation the radius crosses the ulna obliquely, and in supination is parallel to it and at its maximum dis- tance from it at the centre. If now the bones are bent, say in the middle third, the radius of rotation of the radius at the apex of the angle is correspondingly increased, and this angle must, therefore, move to a greater distance from the ulna than normal in supination ; such a movement is prevented by the interosseous membrane, and rota- tion is correspondingly diminished. This is the most frequent cause of diminution or loss of rotation after fracture. The marked dis- Fig. 161. Fig. 162. Fracture of the forearm, angular displacement, and union between the bones. Fracture of the forearm, with formation of a lateral joint. placement of the radius in the case represented in Plate XX V fig. 1, caused the loss of only half of the rotation. The possibility of union between the bones as well as the fragments, though rare, should also be borne in mind. Its occurrence is more likely when the natural interval between them is destroyed or dimin- ished by displacement, but this approximation is not essential. Excess- ive formation of callus, in consequence of laceration of the intermediate tissues and irritation, especially of the interosseous membrane, is suffi- cient in itself to produce this result so destructive of the usefulness of the limb. The occurrence is favored also by correspondence in the position of the fractures, for the fragments are more likely to fall into abnormal contact with each other, and the granulations which form the callus about each fracture may easily unite if each spreads over only half the intermediate space (Fig. 161). It has occasionally happened PLATE XIX Fig. 1.— Fracture of Humerus by Small B ullet. Fig. 2 — Fracture of Forearm. FRACTURES OF THE BONES OF THE FOREARM. 287 that the two calluses have come into contact and formed a lateral joint (Fig. 162), instead of uniting. Slight inclination of the hand to one side or the other is a not infrequent result and may be due to the posi- tion of the sling in which the arm is supported ; thus, if the weight of the arm is borne upon the sling at or above the point of fracture the unsupported hand drops downward and the lower fragment deviates toward the ulnar side, as in the figures ; while if the sling passes under the hand or wrist and leaves the forearm unsupported the latter sinks down between the wrist and elbow and the lower fragment deviates in the opposite direction toward the radial side. Fig. 163. ' " C - : ^'^Si IL^B H§L ■L^ ¥■ - .ftS Fracture of the forearm ; union with angular displacement. No union between the two bones, Delay or failure of union of either or both bones is not very uncom- mon, especially of the radius, and cases are reported in which the union of one of the bones has been delayed four or five months, and has then taken place without operative aid. Treatment. Reduction must be effected, when necessary, by exten- sion and counter-extension aided by cautious pressure upon the bones near the seat of fracture. The importance of reduction is exception- ally great, because of the special function of rotation of the forearm which may be so easily destroyed by displacement or failure of union. I have once or twice found it necessary to cut down upon the fracture because I could not otherwise correct the displacement, the fragments being so placed after oblique fracture that the surfaces of fracture were separated from each other by the entire thickness of the bone and the fragments were in contact only by surfaces covered with periosteum. Overriding is to be overcome by traction ; the forearm and fingers are flexed, counter-extension is made by an assistant who grasps the arm close above the elbow, and traction by the surgeon himself or another assistant grasping the hand. If there is angular displacement the traction should be first made in the direction of the lower fragment, and when this is thought to be sufficient, and while it is still main- tained, the lower segment of the limb is brought into line with the upper one, the latter being steadied by the hand oii the surgeon or pivs>- 288 FRACTURES. lire being made upon the projecting angle with the thumbs. This pressure may be safely made if the angle is directed forward or back- ward, but it must be used with great caution when the angle is lateral, for there is danger that it may force the bone upon which it is made too near its fellow, and that when the manoeuvre is completed the posi- tion of the fragments may resemble that of the arms of an X, each pair being displaced angularly toward the other. To avoid this result the hand should be supinated while the reduction is making, because in this position the interval between the bones at the centre of the limb is greatest and most accessible, and the surgeon should seek to force or keep the fragments apart by pressing his thumbs in between them in front and his fingers behind. The position in which the forearm is usually kept during treatment is that which is midway between pronation and supination. It is the one which the limb naturally assumes when it is suspended beside the body with the elbow bent at a right angle and is the one which is borne with the least fatigue and discomfort. But while this position meets the indications sufficiently in the simple and, indeed, in most cases, it was long since recognized by some surgeons that the bones of the forearm are normally separated most widely from each other at the centre when the limb is supinated, and that consequently this position is the one in which the arm should be kept whenever there appears to be danger of the bones uniting with each other. According to Mal- gaigne, fractures of the forearm were treated in the supine position by the contemporaries of Hippocrates, but the practice was condemned by that writer ; it was reinvented by Pare, and abandoned by him when he learned that Hippocrates had disapproved of it, a yielding to authority that seems to have been unusual with that vigorous-minded surgeon, and again reinvented by Malgaigne, who afterward learned that Lonsdale had preceded him by a few years. Lonsdale l recom- mended the position for a reason mentioned above, the difference between the degree of supination of the upper fragment of the radius and that of its lower fragment ; Malgaigne recommended it because of the greater distance between the centres of the bones when they are in this position. The difficulty which Lonsdale sought to avoid, supination of the upper fragment, appears not to have much importance when the frac- ture of the radius is above the insertion of the pronator radii teres and to be rare when it is below it ; that which Malgaigne had in mind — possible union of the two bones— is rare even when the two bones are broken at the same level. The principal faults to be avoided are angu- lar displacement and overriding, and so far as these are concerned the attitude of pronation or supination seems to be indifferent. The objec- tion to the attitude of supination is its greater constraint and incon- venience ; if the attitude is desirable the discomfort can be avoided by confinement to bed with the arm abducted and the elbow flexed at a right angle, in which position the forearm rests easily in full supination. A common method of treatment is to fix the limb between two light 1 Lonsdale : London Medical Gazette, 1832, vol. ix. p. 910. FRACTURES OF THE BONES OF THE FOREARM. 289 wooden splints broad enough to overlap it slightly when applied to the palmar and dorsal surfaces. The palmar splint should extend from the fold of the elbow to the roots of the fingers, the dorsal one should be shorter and not reach beyond the wrist. Each splint should be padded with cotton, and patients usually find it agreeable to have the end corresponding to the palm of the hand very thickly padded, or a small Moulded plaster splint for fracture of forearm. roll of bandage fastened obliquely to it so that the fingers can close easily over it. In simple cases uncomplicated by threatening displacement, the splints are applied to the semi-pronated limb and fastened by two strips of adhesive plaster wrapped about them, one near the elbow, the other at the wrist, the hand is made fast to the palmar splint by a few turns of a bandage, and the limb is placed in a sling that supports both the elbow and hand. The limb should be frequently inspected at first in order to guard against excessive pressure either by bandages too tightly applied at first, or made too tight by the swelling of the parts, and the splints should be removed in the second week to detect and remed v any new displacement. 19 • 290 FRACTURES. A roller bandage should not be applied to the limb under the splints ; it exposes to displacement by pressing the bones toward each other, and to gangrene or ischemic contraction by constriction. The com- plete plaster-of-Paris dressing is objectionable for the same reasons during the first few days, but it or moulded plaster splints including the lower portion of the arm may be used after the first week if care is taken not to make lateral pressure. Anterior and posterior splints immobilize the limb sufficiently to meet every indication except that of opposing the tonicity of the mus- cles and the occurrence of overriding. When the lines of fracture are transverse or toothed the bones themselves afford sufficient protection, and in any case flexion of the elbow relaxes many of the muscles and diminishes the risk, which, moreover, is not a great one. A moulded plaster-of-Paris splint dressing, much used at the Hudson Street Hospital, especially in the young, is shown in Fig. 164. As it extends above the elbow it efficiently opposes shortening if traction is maintained while the plaster hardens. In compound fractures great caution should be used in removing fragments or excising portions of bone, lest failure of union should follow. If the extent and position of the wound are such that efficient splints cannot be used at first, the patient should be kept in bed with the arm abducted and the elbow flexed, and traction, elastic or by weight, made by means of adhesive plaster attached to the hand and wrist. Counter-extension can be made from the lower part of the arm by a broad bandage, the limb being meanwhile supported upon cushions or suspended, and preferably steadied by a splint placed outside the dressings of the wound. B. Fracture of the Shaft of the Ulna. Fractures of the shaft of the ulna alone are almost invariably the result of direct violence, of a blow received upon the arm while it is raised to protect the head, or of a fall upon the ulnar side of the fore- arm. Displacement. Displacement may be entirely absent, and when pres- ent may be in any direction. Its extent and direction seem to depend almost entirely upon the fracturing force. Most recent writers, follow- ing the example of Pouteau, 1 have alleged that the broad articulation of the ulna with the humerus prevented lateral displacement of the upper fragment, and that the lower fragment was therefore the only one that could be displaced toward the radius. Even if the articula- tion was absolutely free from lateral mobility, the inference that has been thus drawn would not be correct, because the radius can be moved toward the ulna after fracture of the latter and thus the exact equivalent of the displacement of the ulna toward the radius produced. The only muscle which acts directly upon the lower fragment is the pronator quadratus, the tendency of which is to draw it toward the radius. Symptoms. The symptoms may be limited to pain and swelling at the seat of fracture, and if their significance should be rendered obscure by the history and the effect upon the soft parts of the direct violence 1 Pouteau : GEuvres posthumes, 1783, vol. ii. p. 258. FRACTURES OF THE BONES OF THE FOREARM. 291 which has caused the fracture, the doubt can be removed by noting that pain at that point is aroused by the effort actively to extend the elbow against opposition. If the radius remains entire and is not dislo- cated at either end, there can be no shortening of the limb, no over- riding of the fragments, and displacement, if present, must be recog- nized by following the outline of the bone with the finger. Crepitus and abnormal mobility may be obtained by grasping the limb above and below the fracture and making pressure alternately upon the frag- ments with the fingers, or by seizing the fragments between the thumb and fingers and moving them forward and backward upon each other. An important and not infrequent complication is dislocation of the head of the radius forward ; it should always be suspected when there is marked displacement of the fragments of the ulna or unusual swell- ing at the elbow. Fig. 165. Fracture of ulna, with dislocation of head of radius forward. The prognosis is good as regards repair and preservation of function. Reduction. Reduction can be made only by appropriate pressure upon the displaced fragments, traction being practically without value. The displacement which it is most important to overcome is the lateral one toward the radius, and that should be met in the same way as after fracture of both bones, that is, by pressing the thumb and fingers in between the bones. As the radius acts as a splint to prevent overriding of the fragments the surgeon's chief care is to secure immobility and prevent lateral or angular displacement. This can be done by the anterior and posterior splints used in fracture of both bones, or by a rectangular splint fast- ened against the inner side of the arm and semi-pronated forearm, or by a moulded plaster splint. In some cases it may be necessary to keep the forearm supinated, and in others the bruising of the soft parts 292 FRACTURES. may be so severe as to forbid the use of splints at first. The arm should be kept in a sling and the same precautions should be taken to avoid undue pressure by the sling upon the ulna as when both bones have been broken. A pasteboard, felt, or plaster gutter may be used to avoid this danger. C. Fracture of the Shaft of the Radius. As far as can be judged from general impressions and statistics that are somewhat scanty, isolated fracture of the shaft of the radius is less frequent than that of the ulna, and appears also to be generally caused by direct violence, sometimes by a fall upon the hand. In three cases reported by Falkson ? fracture in the middle third with angular dis- placement forward was caused by pressure along its longitudinal axis, the palm of the hand in dorsal flexion and the back of the elbow having been caught between heavy objects which were approaching each other. Occasionally it has been broken by muscular action — forcible rotation. Displacements. The displacements vary somewhat with the seat of fracture, the causes being the fracturing force and the action of the biceps and pronator muscles. The more common displacement appears to be an angular one, the apex of the angle directed forward and inward. Plate XX. represents an extreme form. The possible loss of supination in consequence of union with a rota- tory displacement, the upper fragment being completely supinated by the biceps while the lower is kept partly pronated by the dressings, which was pointed out by Lonsdale, and has been spoken of in the sec- tion on fracture of both bones, is also to be borne in mind after frac- ture of the radius alone, especially if the seat of fracture is above the insertion of the pronator teres, and is to be met, if at all, in the same manner, that is, by keeping the forearm supinated, but it does not appear to interfere noticeably with function. If the fracture is at or below the middle of the bone the tendency of the biceps and pronator teres is to draw the lower end of the upper fragment forward and inward, and that of the pronator quadratus and supinator longus is to draw the upper end of the lower fragment toward the ulna. Overriding has been observed only when dislocation of the lower end of the ulna was associated with the fracture. Diagnosis. The diagnosis is made by recognition of the displacement, if it exists, of crepitus and abnormal mobility obtained by grasping the fragments with either hand and moving them upon each other or by placing a thumb upon the head of the radius and rotating the wrist gently. Treatment. The indications for treatment are the same as after frac- ture of both bones, except so far as the uninjured ulna may be utilized as a splint or as its dislocation may require more or less prolonged traction. If displacement exists the fragments should be pressed back into place as before described, and if the fracture is low down and the lower fragment is inclined toward the ulna it will perhaps be 1 Falkson : Centralblatt fur Chirurgie, 1885, p. 913. PLATE XX Fig. l.-Fraeture of Radius; Marked Angular Displacement. Fig. 2 .-Recent Colles's Fracture in a Boy Twelve Years Old showing Epiphyses. FRACTURES OF THE BONES OF THE FOREARM. 29:5 found easier to bring it back into line by drawing the hand forcibly downward and toward the ulnar side than by pressing the fingers in between the bones. Traction at the wrist and elbow may be required to overcome dislocation of the lower fragment upward from the ulna. The arm should be secured upon well-padded anterior and posterior wooden or moulded splints in the semi-pronated position. Dislocation at the lower radio-ulnar articulation or change in the direction of the lower articular surface of the radius may make it desirable to use a moulded splint that will include the hand and perhaps the lower part of the arm, or a long rectangular one for the purpose of extension and counter-extension, or to keep the hand inclined toward the ulnar side. 3. FRACTURES IN THE VICINITY OF THE WRIST. A. Fractures of the Radius. Colles's Fracture. Under this term are included fractures of the radius near the wrist, which, while differing from each other in many respects, have in com- mon a characteristic deformity, and often a certain difficulty in making reduction. Next after the ribs the lower end of the radius is the part of the skeleton most frequently broken. While the fracture occurs at all ages, it is most frequent in the elderly. It is very remarkable, and worthy of mention as a proof of the difficulty of diagnosis in fractures near a joint, as well as of the force of authority and tradition, that the real nature of this common injury which comes so frequently under the notice of all surgeons should not have been recognized, and that it should have been taken almost always for a dislocation of the wrist backward, until about one hundred years ago. The first mention of the injury as a fracture is generally attributed to J. L. Petit, but, I think, incorrectly, for I find no reference to it in his chapter on frac tures, while the chapter on dislocation of the wrist contains a very good clinical description of it. Pouteau 1 is the first author to describe it as a fracture and to point out the previous universal error in diagnosis. He describes its pathol- ogy, attributes its production to the violent contraction of the prona- tors, and gives its symptoms and treatment, adding that there is, per- haps, no fracture so easy to recognize at a glance. The fact that he includes in his description fractures of both bones does not, I think, diminish the credit due him for his recognition of the error of his pred- ecessors and contemporaries. His view of the subject does not appear to have commended itself to his immediate successors, and, during the thirty years following its publication, only an occasional mention is made of even the possibility of such a lesion, and the common injury was still deemed a dislocation. The next writer upon the subject failed in like manner to impress his opinion upon his immediate contemporaries, and although justice was ultimately done him, and the fracture is now known widely by his name, the recognition did not come until after his death. Mr. Colics 1 Pouteau : CEuvres postliumes, 1783, vol. ii. \>. 251. 294 FRACTURES. published his brief but accurate account of the fracture in 1814/ but Dr. R. W. Smith, writing in 1847, 2 says: " Subsequent authors have repeated what Mr. Colles had said upward of thirty years since, but no writer (as far as I have been able to ascertain), not even the distin- guished author of the Surgical Dictionary, has alluded to his account of the injury." Sir Astley Cooper, in the second edition of his Dislocations and Frac- tures of the Joints, published in 1823, describes fracture of the lower end of the radius, and adds that he had seen this injury frequently, but did not understand its nature until taught by dissection ; but he describes at the same time dislocation of the wrist, and evidently did not appreciate the full character and frequency of the fracture. In a subsequent edition he describes experiments made by himself upon the cadaver in 1833, in which he produced the fracture by hyperextension (extreme dorsal flexion) of the hand. The same failure to appreciate the character of the common injury which was coming so frequently under the care of every surgeon persisted, notwithstanding the publi- cations of Pouteau and Colles, that of the former being entirely over- looked apparently, and that of the latter remembered only by the Dublin surgeons, who believed in the fracture and gave his name to it. But the misapprehension was not destined to last long ; the great change which took place in the science of medicine at the beginning of the present century under the inspiration and guidance of the French physicians, the substitution of objective knowledge for dogma, of clinical and dead-house observation for pure speculation, made short work of this error. Dupuytren was the first to call attention to it and to impress it upon the profession ; a post-mortem examination in 1820 showed him the real character of the injury, and his hospital service gave him the clinical opportunities that were needed for study and demon- stration. A short period of doubt followed, and then, about 1830, the fact was universally accepted, and the second stage — that of dis- cussion of details, which has lasted until the present time— was entered upon. Mr. Colles, who had never had an opportunity to dissect a specimen of the fracture, speaks only of the symptoms and treatment. His only statement concerning the fracture itself is an incorrect one: "This fracture takes place at about an inch and a half above the carpal extremity of the radius." We now know that, while the line of frac- ture may lie at the point he mentioned, it is usually much lower, and is often associated with comminution of the lower fragment. The aver- age distance is differently estimated, possibly because some have meas- ured from the articular edge of the bone and others from the styloid process; but the weight of testimony places it at from one-third to three-fourths of an inch above the articular border. In the young it sometimes follows the epiphyseal line. Its direction is usually trans- verse, but it may be oblique laterally or antero-posteriorly, and the lower fragment is often comminuted. The lower fragment is some- times displaced bodily backward without crushing, as in Figs. 166 and 1 Colles : Edinburgh Med. and Sur°r. Journal, April. 1814, vol. x. p. 182. a K. W. Smith: " Fractures in the Vicinity of Joints," Am. ed.. p. 129. FRACTURES OF THE BOXES OF THE FOREARM. 296 167, but the displacement appears more often to be almost entirely angular, the lower fragment turning upon its anterior edge as upon a Fig. 166. Fig. 167. Fig. 168. Fracture of the lower end of the radius. Displacement backward. (R. W. Smith.) Fracture of the lower end of the radius. Displacement of lower fragment backward. (R. W. Smith.) Fracture of the lower end of the radius. Angu- lar displacement of the lower fragment back- ward with impaction. (R. W. Smith.) hinge, crushing or penetration with impaction taking place posteriorly and outwardly, and the articulating surface looking downward and backward instead of downward and forward as it does normally ; at the same time the styloid process rises to a higher level. An extreme example of this displacement, with union, is shown in Fig. 168. Sometimes the styloid process of the ulna is broken off, apparently by avulsion through the lateral ligament or possibly the fibro-cartilage. Some authors have noted this complication in more than half of their cases ; it has appeared in less than 10 per cent, of my skiagrams. Specimens of recent fracture are not very common, and many of those we possess are open to the objection that the fractures have been caused by violence far in excess of that which causes the great majority of the fractures met with clinically, the patients having falling from a considerable height, and having received other injuries that caused death within a short time thereafter. Others are obtained from elderly patients who have received the fracture in the usual manner, that is, by a fall upon the ground while walking, and have then died in a few days of an intercurrent affection, usually pneumonia. The lioutgen rays have recently added to our knowledge ot' the details, showing that the surface of fracture is rarely flat and trans- verse, that comminution or splitting of the lower fragment is frequent even in early adult life, and that the displacement backward of the fragment is not commonly so marked as has been supposed from the appearance of the limb. They confirm the opinion that the radial side 206 FRACTURES. of the bone is shortened and show that the carpus preserves its relations with the articular surface of the radius, passing slightly upward toward the radial side of the ulna and thus making the latter prominent. In marked backward displacement the ulna accompanies the fragment. The figures of Plates XX.-XXYI. show the different levels at which the fracture occurs, the frequency and character of the comminu- tion, the difference in dorsal displacement, and the marked dorsal pro- jection of the first row of the carpus in one. Plate XXVII., fig. 1, shows arrest of growth after fracture at the age of twelve years, the patient being nineteen years old when the picture was taken. Plate XXVIII. shows the normal wrist in the adult male and female ; the notably lower position of the articular surface of the radius as compared Fig. 169. Fig. 170. United fracture of the radius. Smith.) (R. W. Recently united fracture of the lowei end of the radius. (R.W.Smith.) with that of the ulna in the female was found in most of the female cases examined. In specimens obtained after repair has taken place without reduction of the displacement the penetration of the posterior portion appears very marked (Fig. 169), often more so than it really is. The appearance is due in part to the formation of callus upon the posterior face of the upper fragment under the periosteum which is stripped up, the " peri- osteal bridge/' which is so often found at one side of a fracture, and in part to condensation of the spongy tissues during repair. Among the lesions that may be associated with the principal fracture are fracture of the ulna near its lower end, fracture of the styloid process of the ulna, rupture of the radio-ulnar and intra-articular liga- ments, and perforation of the skin by the ulna. The first is rare, and all the others are the consequence of the momentary prolongation of the action or variation in the degree of the fracturing force. The Rbntgen rays show the fracture only occasionally, and then only as the breaking off of the tip of the process, so that I think it probable that the more extensive injuries heretofore noted were in cases charac- PLATE XXI Fig. 1— Recent Colles's Fracture; Male, Twenty-two Years. Same as Plate XXV, Fig. 1. Fig. 2.— Old Colles's Fracture. PLATE XXII Fig. 1.— Recent Colles's Fracture; Comminution; Male, Forty-five Years. Fig. 2.- ■Reeent Colles's Fracture; Comminution See also Plate XXV. Fia. 2. Male. Fonv Years PLATE XXIII Fig. 1.— Recent Colles's Fracture; Male, Twenty-six "Years. from a height of four feet. Fall Fig. 2.— Same as Fig. 1. Side view. PLATE XXIV Fig. 1. — Same as Plate XXIII. After reduction. Fig. 2.— Recent Colles's Fracture; Male, Fifty-six Years Fall from a height. PLATE XXV Fig. 1.— Recent Colles's Fracture; Male, Twenty-two Years. Same as Plate XXI, Fig. 1. Fig. 2.- ■Reeent Colles's Fracture. Male. Forts Years. Same as Plate XXII. Pig. 2. PLATE XXVI Comminuted Colles's Fracture. PLATE XXVII Fig. 1.— Arrest of Growth of Radius after Colles's Fracture at age of Twelve Years. Present age, nineteen years. Fig. 2.— Separation of Radial Epiphysis; Boy. Fifteen Year?. PLATE XXVIII Fig. 1. — Normal "Wrist; Adult Male. Fig. 2.— Normal Wrist; Adult Female. Fracture of Third Metacarpal. FRACTURES OF THE BONES OF THE FOREARM. 207 terized by greater causative violence and wider displacement. The mechanism appears to be avulsion through the cord-like lateral liga- ment which is attached to its tip. Concerning the condition of the intra-articular fibro-cartilage I can find but little that is positive, since the only sources of information are the autopsies of recent fractures. The Rontgen rays give no direct information on this point, for the cartilage is transparent to them ; its avulsion from the ulna or- radius seems inevitable when the lower end of the radius is markedly displaced. Although much stress has been laid by some upon the supposed rupture of the internal lateral ligament, fresh specimens and experiment upon the cadaver give no ground for the belief that it occurs except in cases with marked displacement. The fact that the end of the ulna is prominent and that the finger can be pressed in on the side below it much more deeply than in a normal joint can be explained by the ascent of the carpus, which would draw the ligament to a more trans- verse position. I believe that in the severer cases the tendon of the extensor carpi ulnaris is torn out of its sheath and displaced outwardly from the ulna, for I have noted in such cases the absence of the resistance which the tendon normally offers to the finger close below the joint. I have not met with the record of any case in which the radius pro- jected through the skin, except after separation of the epiphysis, but I have seen fractures compound on the radial side. Associated fracture of the scaphoid has been observed in a number of clinical and experimental cases, and that of the semilunar (Hunt) and dislocation of the semilunar (Cameron) have been reported. (See Fractures of the Carpus.) Also injury of the median nerve by stretch- ing across the edge of the upper fragment, of which Blecher 1 collected nine cases. The symptoms usually appeared after an interval. Cause. The cause of Colles's fracture is usually a fall upon the palm of the hand, and in the great majority of cases the fall is only to the ground while walking. This is true of almost all cases in which the patients are somewhat advanced in life ; in the younger ones the vio- lence is usually greater, as a fall from a height. The mechanism by which the fracture is produced has been the subject of much discussion. Three theories have been advanced : 1. Fracture by splitting or crushing; the cancellous tissue is crushed or comminuted between the carpus and the diaphysis. 2. Fracture as in other bones by decomposition of the force and yielding at the weakest point. 3. Fracture by cross-strain exerted through the anterior liga- ment in exaggerated and forced dorsal flexion (hyperextension) of the hand. I believe that almost all these fractures are produced accord- ing to one or the other of the first two ways, and that the third is rarely seen. In the first the weight of the body is received upon the ball oli the hand — the carpus — directly in the line of the long axis of the radius. and the inner end of the scaphoid or the semilunar splits the end o\' 1 Blecher: Deutsche Zeitscrift fur Chir., vol. 93, p. 34. 298 FRACTURES. the radius like a wedge. This is shown by many specimens and appears to be especially frequent in the elderly. In the second the line of the force is slightly inclined from the long axis of the radius, making an angle open anteriorly. The arm is out- stretched and not directly in the line of the fall. The force is decom- posed as usual, part being taken up by the resistance of the shaft in the long axis, and part acting transversely to break the bone. The back- ward displacement and tilting of the lower fragment indicate the direc- tion of this component. According to the third theory a cross-strain is exerted upon the end of the bone through the anterior ligament of the wrist ; the force is thought to be received upon the palm of the extended hand at a point that lies posterior to the posterior border of the end of the radius, the hand is bent back, the ligament is put upon the stretch, and the bone is broken by avulsion. The theory seems to have originated in experi- ments upon the cadaver. The earliest recorded experiments in this direction were those already alluded to which were made by Sir Astley Cooper in 1833, but not published until several years afterward ; the earliest publication appears to have been by Bouchet 1 in 1834. The experiment may produce a transverse fracture within a short distance of the articular surface of the radius, but quite as often it causes rupture of the anterior ligament and even dislocation or fracture of one or more of the carpal bones. There is no doubt, therefore, that the frac- ture can be produced in this way, and there are a few clinical cases in which this was apparently the mode of production. But, with the exception of these few cases, in which the mode of action of the vio- lence was distinctly exceptional, there is nothing but the experiments to support the theory. In other clinical cases the same movement has produced dislocation of the semilunar or fracture of the scaphoid or semilunar. (See also Poulsen, Arch. kiln. Chir., vol. 80, p. 902, and Cartruccio, Bdtrage zur Min. Chir., vol. 53, p. 66.) The violence in a fall is not usually received at a point on the palm of the hand posterior to the line of the radius so as to bend the hand backward ; it is received at the base of the thumb, at a point corre- sponding to the trapezium, or along the carpus, and is transmitted directly to the radius as above described. Moreover, the theory fails to explain the comminution so frequently seen and fractures above the conjugal cartilage in the young. Symptoms. The symptoms are marked and characteristic, but crep- itus and abnormal mobility, so common in other fractures, are not always easily recognizable in this. The most striking features of the deformity are the prominence of the dorsum over the lower* fragment and that of the end of the ulna. The former so changes the outline of the forearm and wrist that when viewed from the radial side its appearance is like that represented in Fig. 171, and was aptly com- pared by Velpeau to the outline of a silver fork, a comparison which has survived in the name "silver-fork fracture," by which it is some- times known. The cause of this change in the outline, so far as it is 1 Bouchet : These sur les Luxations du Poignet. Quoted by Malgaigne FRACTURES OF THE BONES OF THE FOREARM. 209 due to the position of the fragments, is shown in some of the radio- graphs ; swelling of the soft parts and even projection of the first row of the carpus accounts for some of it ; that of the palmar aspect is due mainly to swelling of the soft parts. The radiographs show that the characteristic deformity is present even when the displacement of the fragment is slight, and that in Fig. 171. Deformity in Colles's fracture. general this displacement is much less than has heretofore been sup- posed. The prominence of the end of the ulna appears to be due to the displacement of the carpus and the fragment of the radius upward and somewhat to the radial side, aided sometimes by avulsion of the styloid process of the ulna, or, possibly, the equivalent rupture of the internal lateral ligament. That ascent of the end of the radius is sufficient to produce this prominence is shown by its gradual appear- ance in cases of arrest of growth at the lower end of that bone. (See Plate XX^V II.) If the surgeon marks the positions of the styloid processes by press- ing the end of a finger into the side of the joint below and against the end of each, he will see that that of the radius has risen, so that instead of being about a quarter of an inch lower (nearer the hand) than that of the ulna, as it usually is, it has risen to the same level, or even above it. The swelling upon the anterior surface of the forearm is quite marked, and is sharply rounded off .toward the wrist with deepening of the transverse creases. Crepitus and abnormal mobility can sometimes be obtained by grasping the lower fragment between the thumb and fingers and mov- ing it backward and forward while the forearm is steadied by the other hand. Pressure along the line of fracture on the dorsum of the radius or of the hand upward against the forearm is painful. Diagnosis. The diagnosis is made by recognition oi" the above signs 300 FRACTURES. and symptoms. In difficult cases, fat people and children without displacement, it may be made upon the existence of a well-defined transverse line of tenderness on pressure on the dorsum of the radius, pain at the same point when the hand is pressed upward against the radius, deepening of the transverse folds on the palmar aspect of the wrist, loss of power in the limb, and history of the case. Care should be taken not to confound it with or overlook coincident fracture of the scaphoid. A sprain or contusion may be mistaken for a fracture if the limb has been broken previously and has united with deformity, for it will present some of the physical and functional signs. The question therefore should always be asked whether the wrist has suffered a pre- vious injury. Course and Prognosis. Firm union between the fragments may be expected within a month. The prognosis with reference to deformity depends, of course, upon the completeness of the reduction and reten- tion. As a rule, permanent deformity after fracture in youth is slight or entirely absent ; but in adults the case is different, either because the original displacement is greater, or because crushing and comminu- tion make complete reduction and retention practically impossible. The prognosis with reference to function is somewhat better, since the persistence of even marked displacement does not necessarily entail disability. The range of motion at the wrist may be somewhat restricted, and yet may be wide enough to answer all purposes, and a change in the direction of the articular surface is still compatible with free and painless motion. Restriction of supination is common for some time after recovery, presumably because of infiltration of the pronator quadratus. Rigidity of the wrist and fingers usually persists for some weeks, or even months, and in exceptional cases, in the old and rheumatic and in those where there has been much inflammation of the sheaths of the tendons and of the wrist-joint, it may persist for years. Our recently gained knowledge of fracture of the scaphoid suggests that the disability in some of these reported cases has been due to the co-existence of that injury. I have seen two cases in which the hand was practically useless a year or two after the receipt of the injury. There was much deformity in one of them. This rigidity of the fingers is due in part to their prolonged immobilization and in part possibly to inflammation within the sheaths of their tendons in the forearm. The possible arrest of the growth of the bone after separation of the epiphysis in the young deserves mention, although it is an exceptional consequence of the injury. I have seen two such cases. (Plate XXVII), Treatment. Complete reduction of the displacement is, of course, essential to prevent permanent deformity. The ease a\ ith which it can be accomplished varies greatly in different cases. Traction upon the hand with direct pressure upon the fragment is sometimes sufficient to correct the dorsal displacement; in other cases forcible pressure must be made, the forearm is grasped with the fingers upon the palmar prominence and the thumbs upon the dorsal one, and the pieces pressed into line. Occasionally an anaesthetic must be given and the fragment FRACTURES OF THE BONES OF THE FOREARM. 301 mobilized by moving it forcibly backward and forward and then press- ing it into place. In order to meet the two indications — the prevention of posterior displacement of the lower fragment and of projection of the end of the ulna — a. great variety of splints have been devised, most of them upon the theory that the position of the fragment can be controlled by the attitude given to the hand. Thus, palmar flexion of the wrist has been employed to prevent backward displacement of the fragment of the radius, and ulnar flexion to prevent the prominence of the ulna. The theory is wrong and the results have disappointed. If the dorsal displacement has been corrected it has little tendency to recur, and the attitude of the hand is without influence upon it ; the projection of the end of the ulna cannot be prevented by ulnar flexion of the wrist, for this movement does not bring back the carpus and the radial fragment to their normal positions. The facts to be borne in mind are : 1. That dorsal prominence of the fragment is to be prevented by correction of the displacement before the application of a dressing, and its recurrence prevented by direct action upon the fragment, not by indirect action through the hand. 2. That some permanent shortening of the radius, especially on its outer side, if its cancellous tissue has been crushed, as is the rule in the old and frequent in others, is inevitable. 3. That the prominence of the ulna can be prevented only by bringing the fragment of the radius (and thus the carpus) fully back to its normal position — a prac- tical impossibility in many cases. Direct lateral pressure upon the sides of the wrist may diminish the prominence in some cases. 4. That the fingers must be left free in order to avoid the stiffening caused by their confinement. A suitable dressing, therefore, is one which immobilizes the fragment and the carpus in the position given to them and leaves the fingers free to be flexed and extended at will ; and as the tendency to recurrence of the dorsal displacement is slight special precautions against it are rarely needed. Such a dressing may be made of plaster-of-Paris or wooden splints. The most convenient attitude is that of partial pronation with the wrist in slight dorsal flexion and the fingers flexed. There should be two splints, palmar and dorsal, the former extending from a little below the elbow to the metacarpo-phalangeal joints, the latter from the same height to the carpo-metacarpal joints. Wooden splints (Fig. 172) should be three inches broad and padded, the padding being a little thicker on the palmar splint at the point cor- responding to the lower end of the upper fragment, and on the dorsal splint at the point corresponding to the lower fragment. A roller- bandage placed obliquely at the lower end of the palmar splint makes a convenient rest for the hand, maintains dorsal flexion of the wrist, and permits the fingers to be clasped over it. The splints are secured in place by two adhesive bands, one at each end, and by a roller- bandage. Plaster-of-Paris splints (Fig. 173) should be wide enough to cover in the wrist, and the lower end of the palmar one may bo conveniently 302 FRACTURES. made into a roll to fill the palm of the hand. The dorsal one may extend upon the back of the hand. They should be secured in place by a roller-bandage, and while the plaster is setting it may be held snugly against the sides of the wrist so as to keep the ends of the radius and ulna close together. They are especially advantageous in per- Fig. 172. Wooden splints for Colles's fracture. mitting daily massage of the parts : the dorsal splint is removed and massage made on the uncovered portion from the beginning, and the palmar one can be removed for the same purpose (the dorsal one being kept in place) after the first week. The patient must be instructed to keep the fingers flexed when at rest, and to move them frequently. It is well also to keep the thumb abducted. Fig. 173. Plaster-of-Paris splints for Colles's fracture. The question sometimes arises whether the deformity, persisting for some time after the injury and the result of an error in diagnosis or of failure of treatment, can be corrected. Among Dupuytren's earliest cases were three of this kind, and he succeeded in overcoming the deformity by steady forcible traction and pressure upon the fragments on the twentieth, twenty-ninth, and thirtieth days after the receipt of the injury, the patients being respectively sixty-nine, ten, and thirteen years old. A few cases have been treated by refracture or by incision and osteotomy. • I doubt if anything more than an improvement in appearance can be gained thereby ; the causes of loss of function can-, not be thus removed. B. Fractures at the Wrist Other than Colles's. Dr. Rhea Barton, 1 of Philadelphia, described clinically a fracture which he said was very common, and which he supposed to be the detachment of the posterior border of the articular surface of the radius. It does not appear from his paper that he had ever had an 1 Barton : Medical Examiner, 1838, p. 365. FRACTURES OF THE BONES OF THE FOREARM. 303 opportunity to verify the diagnosis by examination. A few specimens of such a fracture, most of them, I believe, found in the dissecting- room and without history, are in existence, and the injury is known in America as Barton's fracture. Dr. Agnew l figures a specimen in which the fragment is much larger. It is perhaps hardly worth while to try now to change this name, but there are three good reasons why the injury should not be known as Barton's fracture : 1st, as a reference to the original article shows, the injury which Barton described clinically was not what he supposed it to be anatomically, but was the ordinary Colles's- fracture ; 2d, the lesion as he supposed it to be, had been observed some years before his paper was published, and the specimen was presented by Lenoir 2 to one of the Paris societies; and, 3d, it deserves to be classed not as a variety of fracture, but as a complica- tion of dislocation of the carpus backward. In Lenoir's case, which is described as a dislocation by Voillemier and Maigaigne, a narrow frag- ment of the posterior articular border had been broken off, remained attached to the capsule, and was displaced backward with the bones of the wrist. I have seen two such cases. An analogous case, dislocation of the carpus forward with detachment of the anterior border of the articular end of the radius and fracture of the styloid process, was reported, with the specimen, to the Societe Anatomique, by Letenneur. 3 The patient was brought to the Hotel- Dieu May 7, 1838, having received this injury and also a fracture of the scaphoid bone of the other wrist, by falling into a ditch while intoxicated. Mr. Callender 4 refers to a somewhat similar specimen, but one in which the fragment is much larger, in the following words : " The line of fracture is four-tenths of an inch from the end of the radius on the palmar surface, but on the dorsal passed into — along the edge of — the articular facets." A case demonstrated by the .r-ray is reported by Shoemaker. 5 Other infrequent fractures of the region may be conveniently men- tioned here : A condition in which, the line of fracture being the same as in Col- les's fracture, the lower fragment is displaced toward the palmar side, and the crushing is also on that side. Mr. Callender 6 reports such a case caused by forced flexion of the hand in a fall upon it ; there was a well-marked prominence on the dorsum of the forearm about three-fourths of an inch above the wrist-joint, and opposite it on the palmar surface was a considerable depression. The lower frag- ment of the radius was inclined at an oblique angle to the palmar sur- face, and projected at the wrist. No crepitus. Reduction could not be effected. Ten months later the deformity persisted, with good rota- 1 Agnew : Loc. cit., vol. i. p. 905. 2 Lenoir: This fact is mentioned by Voillemier, in the Archives Generates de MMecine, 1839, vol. vi. p. 402, and by Maigaigne. The Society referred to is probably the Societe Anatomique, but I have failed to find mention of the specimen in its Bulletins. 3 Letenneur : Bulletins, vol. xiv. p. 162. 4 Callender : Loc. cit., p. 291. 5 Shoemaker : Annals of Surgery, August, 1904, p. 2S4. <'> Callender: Loc. cit., p. 289. 304 FRACTURES. tion, exaggerated flexion, and inability to extend the hand beyond a straight line with the forearm. Callender mentions also two specimens, one in the museum of West- minster Hospital, the other at St. Bartholomew's, which show the cor- responding displacement with union. In one the styloid proeess of the ulna was broken and the lower fragment of the radius displaced forward and outward, especially in the latter direction, with penetra- tion on the palmar surface, to the depth of more than three-tenths of an inch. In the other the line of fracture is rather more than an inch above the end of the bone ; there is a prominent angle on the dorsal aspect in the line of the fracture and an elevation of new bone on the corresponding part of the palmar surface ; the triangular fibro-cartilage was almost completely separated from the radius. R. W. Smith l describes and figures a similar case, in which also the fracture was caused by a fall upon the back of the hand, and I know of one seen by Dr. Keyes. The diagnosis is made by attention to the position of the styloid process with reference to the carpus and the ulna and by recognition of the line of limited tenderness if mobility and crepitus cannot be obtained. The treatment should be the same as in Coiles's fracture, except that the position of the pads should be changed to meet the different displacements. The subject has been treated in detail by Dr. J. B. Roberts in Annals of Surgery, January, 1897 ; see also Idem., September, 1904, p. 423, for two cases seen by him and one by Stewart. An oblique fracture running downward and inward and detaching the styloid, process of the radius with more or less of the articular por- tion ; the larger the fragment the more closely will the symptoms resemble those of Colles's fracture. The injury is rare. In the few cases I have seen and in those reported the fragment has been quite large. Usually the displacement is slight, but in one case the fragment was drawn upward one and a half inches. Immobilization of the wrist appears to be all that is needed. Longitudinal fracture or fissure of the end of the bone. Dr. Bigelow 2 reported one case and referred to a second. There was a star-shaped crack on the articular surface without displacement and slight corre- sponding cracks in the shaft for more than an inch above. At first there was only lameness at the wrist, but after several days there were swelling and tenderness, the persistence of which led Dr. Bigelow to make the diagnosis. He had had a similar case two years before, with the same symptoms, but less extensive injury to the bone. I have seen one, shown by skiagram. It is clearly an incomplete Colles's ; if the violence had been greater the fracture would have been the usual one. Fracture of the styloid process of the ulna is sometimes observed sepa- rately as the result of direct violence. In addition to the usual symp- toms of pain and swelling, mobility of the process could probably be recognized by direct manipulation or by abduction of the hand. Dr. Agnew says some deformity is likely to remain, and that in the only 1 E. W. Smith : Loc. cit., p. 162. 2 Bigelow : Boston Med. and Surg. Journal, 1858, vol. lviii, p. 99. FRACTURES OF THE BONES OF THE FOREARM. 305 case he had seen the union was fibrous. He advises treatment upon an anterior splint with the hand inclined toward the ulnar side and in dorsal flexion, so as to relax the extensor carpi ulnaris. Fracture of both bones near the wrist is occasionally seen. The diag- nosis is made by recognition of the abnormal mobility of the fragments. Treatment as in Colles's fracture. In compound fractures every effort should be made to avoid ampu- tation. Good results have been obtained even by excision of the lower end of the ulna alone or of both bones. 20 CHAPTER XXI. FRACTUEES OF THE CARPUS AND HAND. Fractures of the Carpus., of the Metacarpal Bones, and of the Phlanges. 1. FRACTURES OF THE CARPAL BONES. 1 (See Plates XXIX-XXXII). The findings of the a'-rays in the last decade and the clinical obser- vations which they have stimulated and made possible have brought to our knowledge in detail many lesions of the carpus which were hereto- fore unknown or known only incompletely and as of rare occurrence. The anatomical and physiological complexity of the carpus leads to a corresponding complexity of the traumatic lesions which occur in it and of the combinations which may be produced in accordance with the many variations in the direction, extent, and prolongation of the force which produces them. Fractures and dislocations of the different bones which compose the carpus may occur singly or in various com- binations, and while some of the single injuries and some of the combi- nations occur frequently and regularly enough to justify systematic description, others are so few or so variable and so dependent upon varying mechanical conditions that they defy analysis and classification and must be recorded only as isolated facts. The two most frequent lesions are fracture of the scaphoid and dis- location of the semilunar. Of each of these many clear uncomplicated instances have been observed, and yet the two are not infrequently combined, and often in association with various derangements of the mutual relations of the other bones, in such a way as to lead some in- vestigators to believe that this combination should be regarded as the type, and the frequent lesser individual injuries as minor forms of or deviations from it. Thus, a frequent combination is fracture of the scaphoid with dislocation forward of the proximal fragment together with the semilunar and a displacement backward of the os magnum 1 Bibliography.— Letenneur, Bull de la Soc. Anat., 1839, vol. xiv. p. 162; Guibout ibid., vol. xxii. p. 27- Flower, Holmes's Syst. of Surg., Am. ed., vol. i. p. 867* Fortu- net, Lyon Med., July 1, 1888; Rutherford, Glasgow Med. Jour., 1891, p. 312; Stimson, N. Y. Med. Jour., May 21, 1892; Auvray, Gaz. des H6p., 1898, p. 377 ; Sir Wm. Stokes, British Med. Jour., 1900, i. p. 1075; Hofiiger, Corresp.-blatt. fur Schweiz. Aerzte, 1901, p. 297; Kaufman, Ibid., 1902, p. 257; Stimson, Annals of Surg., May, 1902; Pagen- stecher, Munch. Med. Wochenschrift, 1903, p. 1916 ; Wolff, Deutsche Zeitschrift fur Chir., 1903, vol. lxix. p. 401; Blau, Ibid., vol. lxxii. p. 445; Lilienfeld, Arch, fur klin. Chir., 1903; vol. lxix. p. 1158; Vialle, Arch, de Med. and Phar. Med., Oct., 1904; Russ. Annals of Surg., Feb., 1905; Codman and Chase, Annals of Surg., March and June, 1905, an elaborate paper; Karrer, Inaug. Diss., Kiel, 1905, abst. in Zentralblatt fur Chir. 1906, p. 811; Ehebald, Arch, fur Orthopa>die, Mechanother. und Unfallchir., 1906, p. 276, with bibliography; Hirsh, Ztlblatt fur Chir., 1906, p. 1289; Cartruccio> Beitrage zur klin. Chir., Feb. 1907, p. 66; De Quervain, Monatschrift fur Unfallheil- kunde, 1902, vol. 9, p. 65 ; Ebermayer, Fortschritte aus dem Geb. Roentgenstrahlen, 1908, vol. 12; Shoch. Deut. Ztschrift, fur Chir., 1907-8, vol. 91, p. 53; Delbet, Bull, et Mem. de la Soc. de Chir., 1908 ; vol. 34, p. 377; Downes, Annals of Surg., Jan., 1908; Ely. Med. Record, May, 1908. 306 PLATE XXIX Fracture of Scaphoid and possibly of Radius. PLATE XXX Fracture of the Scaphoid, with Displacement of Proximal Fragment. PLATE XXXI Fracture of Scaphoid. Profile view of Plate XXX PLATE XXXII Fig. 1. — Fracture of Carpal Scaphoid.. 1 Fig. 2. -Separation of Lower Epiphysis of Femur; Displacement forward -with Rotation about the Transverse Axis. FRACTURES OF THE CARPUS A XL) HAM). 307 either from its fellows of the second row of the carpus or with them from the remaining bones of the first row. Delbet l in an elaborate, pathological, clinical and experimental study of the subject, proposes that this injury should be termed "dislocation of the os magnum," with sub-titles indicating the varieties. The name " dislocation-frac- ture of the carpal bones," or "of the intercarpal joint" was suggested by De Quervain.' 2 While the existence of this complex type, and even its comparative frequency, cannot be questioned, yet I am convinced that both fracture of the scaphoid and dislocation of the semilunar occur without complications, or, in the case of the semilunar, with only slight ones, and that the comprehension of the subject and the readiness of recognition of the injury will be promoted by separate descriptions. The complex form will be considered in Chapter XLVIII, " Mid carpal fracture-dislocation. " Scaphoid. — Until within a few years the injury was deemed very rare and was known only by a few reported cases and fresh specimens obtained at autopsy or by operation, and a few museum specimens of old fractures obtained by chance, of some of which it. was claimed that they might be examples of a rare developmental variation, the " navicu- lar bipartitum." After the existence of the fresh fracture had been shown by the x-rays and the clinical recognition had become easy the number of reported cases rapidly increased and its frequency is now Avell established. Doubtless cases were previously thought to be sprains or occasionally Colles's fracture, or were overlooked when they co-ex- isted with the latter injury. The injury is most frequent in males between the ages of twenty and forty years. The common cause is violence received upon the ball of the thumb, while the wrist is in dorsal flexion, by which the scaphoid is pressed directly against the radius. Usually it is by a fall upon the outstretched hand, but in a few cases the violence has been received in a manner which is identical with that in which the lesion has been often produced in experiments, namely, a blow or forcible pressure against the ball of the hand in the direction of the long axis of the forearm while the back of the elbow rests against solid resistance. The few reported cases in which the scaphoid has been broken in forced flexion of the wrist apparently belong in the complex form, the " frac- ture-dislocation." The character of the violence is so similar to that which produces Colles's fracture that the two may probably be deemed alternative lesions, the scaphoid breaking in some, the radius in others, especially the old whose epiphyses are thinned. This is further con- firmed by the fact that occasionally the two fractures co-exist. The mechanism of the fracture is not clear. Various explanations have been offered, some of which can be true only of the complex eases and will not here be considered. Of the others, two seem possible : pressure by the head of the os magnum against the proximal halt' of the scaphoid, and pressure by the external object against the projecting 1 Delbet : Bull, et Mem. de la Soc. de Ckir., 190S, vol. 34, p. 877. 2 De Quervain: Monatschft fur Unfallkeilkunde, 1002, vol. 0. p. 65, 308 FRACTURES. poles of the curved bone, as a curved rod is broken by straightening it. The latter seems the probable cause in cases in which the fracture is in the distal two-thirds of the bone and the displacement slight, In the cases in which the proximal fragment is dislocated forward, pressure by the head of the os magnum is apparently the only agency by which the displacement could be effected, and it is probable that it would have a part in producing the fracture. Unquestionably in these cases with dislocation of the fragment there must have been at the moment of dislocation some shift in the relations of some of the other carpal bones to one another, a fact which, strictly speaking, would bring them within the complex class, but the shift is either temporary or so slight as to be unrecognizable either clinically or by the a--rays, and I therefore prefer to group them with the pure fractures. It seems probable that the issue of the production of a Colles's frac- ture, a fracture of the scaphoid, or a "fracture-dislocation " is determined by the direction in which the force is applied to the limb and the posi- sition of the hand. If the hand is bent backward but little beyond straight extension, as is common in a fall upon it, the force acts obliquely to the line of the radius and breaks it across — Colles's ; if the hand is thrown further back and the force is more in the line of the forearm, the lower end of the radius is crushed — another form of Colles's — or the scaphoid is broken ; if the force is received a little further out on the palm of the hand and exaggerates its dorsal flexion, the head of the os magnum, which has moved around to the back of the semilunar, forces the latter out of place, taking with it generally a part of the scaphoid, and permanently changes the relations of other bones — " fracture-dislocation." The line of fracture is transverse and generally nearer the proximal than the distal end of the bone, within the area of articulation with the os magnum ; very rarely are there more than two pieces. The separa- tion of the fragments is shown by the a-rays to be increased by ulnar flexion and diminished by radial flexion of the hand. Failure of union is frequent and is probably constant in fracture near the proximal end where the line of fracture is wholly or mainly intracapsular ; in the distal portion the fracture may leave the blood supply sufficient for repair. In the cases in which union is thought to have occurred the opinion has been based on the relief of symptoms and the a?-ray find- ings, neither of which is entirely sufficient. The associated lesions that have been observed are Colles's fracture of the radius, fracture of the styloid process of the radius, and forward dislocation of the proximal fragment of the scaphoid. The characteristic symptom, upon which the diagnosis can be made with great certainty, is sharp pain on pressure in the depression between the extensors of the thumb, the " anatomical snuffbox." There is no definite deformity except swelling ; function is lost or much impaired because of pain. If the proximal fragment is displaced forward it can be plainly felt in the palmar aspect of the wrist at about the level of the styloid process of the radius. FRACTURES OF THE CARPUS AND HAND. 300 As time passes, with or without treatment, the pain diminishes, but only to return sharply after some unguarded forcible movement. These recidives are thought by some to be characteristic of the injury. The diagnosis in fresh cases is made by the history, loss of function, and pain in the tabatiere ; in older cases by the same local pain, the long persistence of disability, and the absence of characteristic signs of other injury or disease. Confirmation by the a>rays is desirable. The prognosis is rather unfavorable. At the best there is likely to remain some loss of flexion and extension in the wrist, and sometimes motion is almost wholly lost. There is reason to hope that with earlier recognition and suitable treatment this may be improved, for the limi- tation is clearly the result of periarticular retraction due to the arthritis set up by the trauma and maintained by the presence of the movable and poorly nourished fragment. Many of the observations upon which our knowledge of the subject is based have been made in Zander or mechanico-therapy establishments to which the patients have gone for treatment of the late disability, and a number of the specimens have been obtained by the late removal by operation in the hope of relieving the stiffness. The treatment in the fresh simple cases without displacement which at present offers the best prospect is immediate immobilization for about a month. A number of successful results in which this means has apparently been effective have been published, while those in which passive motion and mechanico-therapy have been employed have not done well. If the proximal fragment has been dislocated forward it should be removed through a palmar incision. Several such cases with a good result have been reported. I have had one. In the old cases, with stiffness, even if pain is absent, both fragments should be removed, and possibly the entire first row. Vallas 1 recom- mends total excision of the carpus, because in two cases in which he left only the trapezium and trapezoid the joint remained stiff. In a personal case in which the injury was eight years old and the joint quite stiff I first removed both fragments ; no improvement following, I removed the semilunar and cuneiform. On removal of the dressings the gain was slight, but increased under baking and use. The patient was then lost sight of. For this excision of the scaphoid alone a dorsal incision just inside of the long extensor of the thumb is convenient. The semilunar has been found broken in a few cases on examination through an open wound or at autopsy, under great violence and with associated injuries of the region. Under the .r-rays it has been found to present in a number of cases appearances which were thought to indicate recent or remote fracture. Ebermayer 2 gives five such, in only one of which the diagnosis seems to me to be beyond serious ques- tion. Finsterer 3 reports four personal and thirteen reported eases, but i Vallas: Bull, de la Soc. de Chir., 1908, vol. 34, p. 118. 2 Ebermayer : Fortschritte ans dem Geb. de Roentgnstrahlen, 190S, vol. 12, p. 1. a Finsterer: Ztlblatt fur Chir., 1908, p. 1473. 310 FRACTURES. thus far only an abstract of his paper has been published. He gives as symptoms shortening of the distance between the base of the third metacarpal and the edge of the radius (a difficult measurement) and pain on pressing the metacarpal bone upward. He says the prognosis is unfavorable in respect of function, and advises extirpation of the bone to diminish the later arthritis and stiffening. The cuneiform has been occasionally broken in connection with other injuries. The os magnum has been reported broken at the neck in three cases observed clinically, and of course some doubt must remain of the accu- racy of the diagnosis. The first case was that of Robert, quoted as doubtful in the Traits de Chirurgie of Le Dentu and Delbet from the Ann. de Therapeutique de Rognetta, 1845, p. 146. The others are those of Moty ( Gaz. des Hop., 1890, p. 634). which seems accurate and of Guermonprez, very briefly abstracted in the Rev. de Chir., 1882, p. 81. I have seen one case in which the possibility of fracture was suggested by pain on pressure over the neck of the bone. Harrigan 1 reports a case confirmed by the rc-rays, and two cases have been reported in which the x-rays have shown the fracture associated with that of other carpal bones. Ebermayer gives x-yslj pictures of a transverse fracture of the unciform, and of avulsion of a small piece of the trapezium. The pisiform has been reported broken, apparently by forcible con- traction of the flexor carpi ulnaris, by Alsberg 2 . The surface of frac- ture was parallel to the palmar surface, dividing the bone into a small superficial and a larger deep fragment, which corresponds to the in- clusion of the superficial portion in the tendon of the flexor and the ligamentary attachment of the deeper portion to the. cuneiform. The diagnosis was made by the x-rays. The symptoms were local pain on pressure and pain on forced ulnar flexion of the wrist. Reunion took place. 2. FRACTURES OF THE METACARPAL BONES. While simple fracture of a metacarpal bone is not a very common accident, still it is not so rare as some authors have inferred from hos- pital statistics. Malgaigne found 16 cases in a total of 2377 fractures of all kinds treated at the Hotel-Dieu, a percentage of 0.67 ; Polaillon, 64 cases in a total of 5517 fractures treated in the Paris hospitals during the years 1861-63, a percentage of 1.16. Of Polaillon's 64 cases, 57 were men, only two were old, and none were infants. The third and fourth are most frequently broken, the first and fifth least. Simultaneous fracture of two or more is frequent when the injury is compound. A very few cases of probable separation of the distal epiphysis have been recorded, one by Malgaigne, one by Hamilton, and one quoted by Polaillon from a thesis by Pichon, the ages being nine, eight, and twelve years respectively. There was failure of union in Malgaigne's case, but without disturbance of function when last seen, thirteen years 1 Harrigan: Annals of Surg., Dec, 1908, p. 917. 2 Alsberg: Zeitschrift fur Orthop. Chir., 1908, vol. 20. PLATE XXXIII Fig. 1. — Fracture of First Metacarpal. Fig. 2.— Fracture of First Metacarpal. FRACTURES OF THE CARPUS AND II AM). 311 after the injury. Bennett 1 has described a variety of fracture of the base of the first metacarpal, an oblique fracture by which the palmar half of this end is separated and the remainder is displaced more or less backward, so that at first sight the injury appears to be a subluxa- tion. He collected nine examples. The usual displacement is angu- lar, the apex of the angle being directed backward or forward, and at the same time the fragments may override longitudinally. Miles and Struthers (Edinb. Med. Journal, April, 1904) observed ten cases in four years, and Russ (Journ. Am. Med. Assoc, 1906, vol. 46, p. 1824) eight in one year. Cause. The cause may be direct or indirect violence. When direct it is a blow upon the back or even the palm of the hand, a fall or blow upon its side, or a crushing force, the hand being caught between two solid bodies. The first, second, and fifth metacarpals are the ones most frequently broken by direct violence. The commonest indirect cause is violence received upon the distal end of the bone in the direction of its long axis, by which its normal curve is exaggerated and fracture produced, as in a fall upon the knuckles or a blow with the fist. Lonsdale reported a case in which fracture of the third metacarpal was caused by a fall upon the end of the outstretched middle finger. In a case reported by Dupuytren, the third metacarpal bone w T as broken by being bent backward in a trial of strength, the contestants trying to force each other's wrist back with their fingers interlocked. Velpeau saw the same bone broken by traction upon the index- and middle fingers with some twisting. Symptoms. The symptoms are the deformity due to the displace- ment of the distal fragment, abnormal mobility, crepitus, pain, and inability to use the fingers. The deformity is usually slight and may be wholly masked by the swelling ; abnormal mobility and crepitus may be found by flexing and extending the corresponding finger and at the same time making pressure upon the palm at the supposed seat .of fracture, so as to make the fragments prominent behind. The pain can be suddenly and sharply increased by pressing the finger toward the carpus. The course of the fracture is usually simple, and ends in consolida- tion in the course of three or four weeks. The complications which occurred in the eighty-one cases collected by Polaillon were inflamma- tion of the carpo-metacarpal joint, union with marked displacement, fusion of adjoining bones when both were broken, and deviation of the extensor tendons by a voluminous callus in one each, and failure of union in three. In neglected cases of fracture at or near the knuckle suppuration is not infrequent and may so extend as to cause marked disability. Treatment. The first indication is to prevent a too severe inflam- matory reaction if it threatens, and with this object the hand should be kept at rest in an elevated position. If there is no displacement or tendency thereto, a simple immobil- izing dressing of cotton, bound on snugly with a roller-bandage, is suf- ficient, the fingers being left free to prevent their stiffening. 1 Bennett: British Medical Journal, July, 1SS6, p. 13. 312 FRACTURES. A method that has long found favor is to fill the palm with a mass of tightly packed cotton or some similar substance, or a ball, over which the fingers are closed and fastened down with a bandage or adhesive plaster. The flexion of the finger over the firm mass tends to draw the knuckle downward, and thus prevent shortening. . The support furnished by the adjoining bones is an additional aid against displacement, and the back of the hand can be left partly uncovered for inspection. In fracture of the third and fourth metacarpals the hand may be bound upon a dorsal or palmar longitudinal splint suitably padded and fastened with a roller, but this plan is unsuited to fractures of the second or fifth because the circular compression exerted by the bandage tends to cause lateral displacement. If continuous traction seems necessary to overcome a tendency to displacement the finger may be bound to the adjoining ones for a few days, but it is important that immobilization of the fingers, especially in the extended position, should be avoided or made as brief as pos- sible. In Bennett's fracture of the first metatarsal reduction is made by strong traction and pressure against the base of the bone ; maintenance by splints and adhesive plaster or by plaster of Paris. 3. FRACTURES OF THE PHALANGES. These fractures are usually due to direct violence, and in conse- quence are frequently compound or at least accompanied by laceration or bruising of the soft parts. A few cases have been reported of frac- ture by indirect violence, as in a fall or blow upon the end of the finger, or by having the finger caught and fixed while the hand con- tinued to move. The proximal phalanx is the one most frequently broken, the ter- minal phalanx most rarely. The symptoms upon which the diagnosis is made in simple fractures are mobility and crepitus. The progress of the case in simple fracture is toward prompt repair ; in compound fractures the suppuration is apt to be prolonged, and necrosis of splinters and even of one of the principal fragments is not uncommon. A well-established rule of treatment of injuries of the hand is to save everything that can be saved, but it needs limitation in compound fractures of the fingers. While it is desirable to save the thumb or any part of it, even at the price of anchylosis of both the joints, the same value does not attach to the fingers, and a rigid deformed finger that has been saved with much difficulty is often a source of so much inconvenience that the patient subsequently seeks relief in amputation. It is better that members so injured that rigidity will probably result should be removed at first, for the attempt to save them cannot be made without incurring certain risks, prolonged suppuration, phlegmon of the forearm, tetanus, which, although somewhat remote, should not be lost sight of. FRACTURES OF THE CARPUS AND J1AXI). 313 In the treatment of simple fracture the usual indication to prevent displacement is habitually met by means of a moulded palmar splint made of pasteboard, felt, or gutta-percha to which the finger, slightly flexed, is made fast. This answers very well for the terminal and middle phalanges, but it does not support the proximal one sufficiently. Sometimes a straight splint is used, sometimes a plaster-of- Paris bandage. A common displacement, important to be guarded against, is an angular one with the apex directed forward and caused, I think, by the action of the interosseous muscles. The persistence of this dis- placement constitutes a serious inconvenience, for it limits flexion of the metacarpophalangeal joint and creates a prominence upon the palmar aspect of the phalanx, the skin covering which may become so sensitive that a firm grasp cannot be taken of any hard object. As a palmar splint does not entirely prevent this displacement I prefer to close the hand upon some firm cylindrical body, a roller-ban- dage for example, and fasten the fingers down with strips of adhesive plaster applied longitudinally along the back of the hand, the fingers, and the front of the forearm, and additionally secured with a few turns of a bandage. The roll must be large enough to give ample support, and by passing the finger along the dorsum of the phalanx the occur- rence of displacement can be recognized. It will be remembered that the tendon of each extensor muscle is attached to the base of the prox- imal phalanx by a short band which limits the action of the muscle to that phalanx, and that the extension of the middle and distal pha- langes is accomplished by the interossei, which also flex the metacarpo- phalangeal joint and are relaxed when the fingers are closed. The tendency to overriding is thus effectively opposed by this position, and the displacement which then most needs to be guarded against is the one also that is most readily detected, angular displacement with the angle directed backward. Support that may be sufficient in some cases can be readily obtained by binding the broken finger to the adjoining ones and supporting both or all three upon a common splint. In compound fractures prophylactic doses of tetanus antitoxin have been much used, and apparently with good results. CHAPTER XXII. FRACTURES OF. THE PELVIS. Fractures of the Ring of the Pelvis, Sacrum, Coccyx, Ilium, Ischium, Pubis, Rim of the Acetabulum. Following well-founded custom I group in one section all fractures which break the continuity of the ring of the pelvis and consider sepa- rately fractures of the individual bones which do not break the con- tinuity of the ring. 1. FRACTURES OF THE RING OF THE PELVIS. The most frequent cause of this lesion is the passage of the wheel of a heavily laden wagon across the thigh and hypogastrium ; among the others are falls upon the feet or the buttocks, the caving, in of an embankment, and crushing between the buffers of railway cars or other heavy moving objects. The position and the number of the frac- tures vary with the degree of the violence and the portion of the ring upon which it is received. When it falls upon the symphysis and is directed backward the arch yields at its weakest point, and the line of fracture passes through the horizontal and descending branches of the pubis, sometimes on one side alone, sometimes on both sides. If the force then continues to act it presses the sides apart, and either breaks the sacrum vertically (by avulsion) or ruptures the ligaments of the sacro-iliac synchondrosis, or breaks the ilium into the synchondrosis or into the sacro-sciatic notch ; and it does this sometimes also on one side alone, and sometimes on both. When the violence is received upon the side of the pelvis, or the great trochanter, or even upon the foot, it may cause what Malgaigne described as double vertical fracture of the pelvis, or fracture of the acetabulum to a variable extent, and in one case a fall upon the foot caused dislocation of the entire os innominatum, separating it cleanly at the symphysis pubis and sacro-iliac joint and forcing it upward. In double vertical fracture the anterior fracture occupies the same position as when the force has been received upon the symphysis, it crosses the pubis ; the posterior one is usually entirely within the ilium and behind the acetabulum. In fracture of the acetabulum, which can be caused only by violence transmitted through the femur, the bone may be simply fissured, or the head of the femur may be driven entirely through into the cavity of the pelvis. In the slighter cases the continuity of the pelvic ring is not broken, but in the more extensive ones it is. In young people the lines of fracture may follow those of the develop- mental division of the bone into three. 314 FRACTURES OF THE PELVIS. 315 The displacements arc seldom great, but complications are numerous and serious. The most frequent is rupture of the urethra, usually in its membranous portion ; among the others are rupture of the bladder and laceration of the iliac veins or the external iliac artery. Rupture of the bladder may be intra- or extra-peritoneal ; in some cases it appears to have been caused by the direct pressure upon the bladder of the object which caused the fracture, in others by a splinter or the dis- placed fragment. The other two % lesions mentioned are due to the displacements. The separation of the pubes tears the urethra across at or near the triangular ligament, and the projecting edge of the pos- terior line of fracture lacerates one of the iliac veins, or the edge of the anterior one tears the external iliac vein or artery. In a case briefly referred to by Legros Clark l there were several fractures, and separation of the sacro-iliac synchondrosis on each side and of the pubic symphysis to the extent of four inches. The rectum was ruptured and feces were extra vasated into the pelvis ; the bladder was ruptured and the urethra torn completely from the prostate gland. The varieties and the symptoms, which vary notably with them, require separate mention. Separation of the symphysis pubis may be produced by external vio- lence directly pressing the anterior superior spines or the ischia apart or through forced abduction of the thighs, or by the descent of the foetus through the superior strait in parturition. Malgaigne collected seventeen cases of the latter, most of them occurring in primiparae, and most by the unaided action of the patient's muscles ; in a few cases the forceps was used. Usually the separation takes place with a distinct cracking sound, and the gap can be felt with the finger, and in one or two cases the fracture has been made compound by simultaneous lace- ration of the soft parts. The gap is the chief diagnostic symptom. The scanty information possessed upon the subject indicates that, in the traumatic cases at least, the separation takes place not through the cartilage, but between the cartilage and the bone. The traumatic cases are no less numerous arid more varied in their details, although in a large proportion of them the force seems to have been exerted through the adductor muscles of the thighs. In two cases quoted by Malgaigne, in a third reported by Weber, 2 and in a fourth by Earle, 3 the patient was on horseback and received the injury either by being thrown forward upon the withers, or first to one side and then to the other, or by the muscular effort made to' keep his seat. In one of Malgaigne's cases the results were an immediate hernia, rupture of the perineum with a separation at the symphysis that would admit the hand, and pain at each sacro-iliac synchondrosis. The patient recov- ered in three and a half months, the treatment consisting of a bandage drawn tightly about the pelvis, with the limbs resting upon a double inclined plane. In Earle's case there were collapse, severe pain, flattening of the pubes, and free bleeding from the anus. An incision in the perineum 1 Legros ("lark : Diagnosis of Visceral Lesions, p, ;>:>!'. 2 Weber: Gaz. Mted. de Strasbourg, 1.872. 3 Earle: Med. Chir. Trans., L835, vol. xix. p. 257, 316 FRACTURES. gave exit to blood and urine. The patient .survived for only forty hours, and the autopsy showed a separation of three inches at the symphysis, the left sacro-iliac synchondrosis gaping one inch, and the prostate torn completely away from the bladder and hanging down in a cavity filled with clot. The patient was between sixty and seventy years of age. In another singular case quoted by Malgaigne the patient, a lad eighteen years old, was learning to be a dancer. His teacher made him lie upon his back on the floor with his thighs flexed, and then stand- ing upon him with one foot on each knee, sought to force the thighs outward. It caused the bones to separate at the symphysis to the extent of half a finger-breadth. Separation in Front and Behind. In one of Mr. Earle's l cases there was complete separation of the left os innominatum, both in front and behind ; the bone was forced up to a considerable extent, and the com- mon iliac vein torn across. The patient was a young man, and received the injury by jumping from a third story ; he landed upon the left foot, causing also a compound comminuted fracture of the calcaneum and astragalus. Similar cases were collected by Malgaigne, and two have been pub- lished by Salleron. 2 Creite 3 reports one case and collects seven others. The injury has been caused by a fall upon one foot or upon the side of the pelvis, or by the pressure of a heavy weight upon the front of the pelvis. The characteristic symptom is the elevation of the corre- sponding half of the pelvis with absence of the crepitus which is usu- ally present in double vertical fracture. Salleron was able to reduce the dislocation in his cases, and both recovered, but, as a rule, the prognosis is extremely grave. Separation of the Sacro-iliac Synchondrosis. Simple separation of this joint is very rare. Malgaigne 4 quotes one case of it, and four others in which there was in addition fracture of the ilium. I have seen one well-marked case. The lesion is said also to have been produced during labor. The diagnosis is made by recognition of the displacement, which is backward and outward. Separation of all Three Joints. A few cases have been reported as such, but in most there has been also fracture at one or more points, and the separation of one or both of the sacro-iliac synchondroses has been only the gaping of the joint due to the lateral separation of the two halves of the pelvis and not a real displacement. Malgaigne quotes briefly five cases, in four of which there were associated frac- tures of the pelvic bones. Dolbeau, 5 Dubrueil, 6 and Pollock 7 have since reported others. DubrueiFs is the only one in which there seems to have been actual displacement at all three points, and even in it there was also a slight fracture. The patient was run over by a wagon. There was separation of two and a half inches at the symphysis pubis 1 Earle : Loc. cit., p. 261, Case 5. 2 Salleron : Archives Gen. de Med., 1871, vol. ii. p. 34, Cases 1 and 2. 3 Creite: Deutsche Zeitschrift fur Chir., vol. 83, p. 391. 4 Malgaigne : Loc. cit., vol. ii. p. 777. 5 Dolbeau : Gazette des Hopitaux. 1868. p. 194. 6 Dubrueil : Ibid., 1871, p. 413. ' Pollock : The Lancet, 1872, vol. ii. p. 409. FRACTURES OF THE PELVIS. 317 and gaping of both sacro-iliac synchondroses. The sacrum was dis- placed forward, projecting at the level of the superior strait two centi- metres in front of the right ilium and one and a half in front of the left. There was a fracture at the junction of the right ischium and pubis, and partial fracture of the body of the right pubis. In each case the injury was caused by extreme violence acting directly upon the pelvis, the passage of a heavy wagon, the fall of a heavy object. All terminated fatally. Fracture of the pubic portion of the pelvic ring, which is the most com- mon of all, passes usually through the horizontal ramus just in front of the ilio-pectineal eminence and through the descending ramus near its junction with the ischium. The fracture may be oblique or trans- verse, may be double (of one or both pubic bones), or may be associated with separation of the symphysis or with other fractures of the lateral or posterior portions of the pelvis. As has been already mentioned, rupture of the ligaments of one or both sacro-iliac synchondroses with gaping of the joint is a frequent accompaniment when the action of the fracturing force is momentarily prolonged. The displacement is sometimes so marked that it can be easily recog- nized by the eye ; in other cases the diagnosis can only be made after pal- pation of the outline of the bone, which is quite accessible to the touch. Interference with the voiding of the urine, either by rupture of the urethra or by pressure upon it, is a frequent complication. Injury to the urethra takes place usually in the membranous portion. The bladder, too, has been sometimes torn by a fragment or ruptured by pressure. The following are the more noteworthy complications and varieties that have been recorded. A man, twenty years old, was run over by a railway train and received a fracture of the crest of the right ilium, the ramus of the left pubis, and of the " right pubis close to its junc- tion with the iliac portion of the bone, the sharp end of this fracture had entirely divided the external iliac artery. 7 ' l A man, forty-three years old, was run over by a wagon, w r as brought to the hospital insen- sible, and died in three hours. There was fracture of the " ramus and body of the pubis on both sides, and separation of the sacrum from the left os innominatum. Fracture of the left ilium, the fracture extend- ing across the pectineal line and causing laceration of the left external iliac vein." 2 Fracture of the lateral portion of the ring occurs in two principal forms, one in connection with fracture of the pubic portion, the other a fracture radiating from the cavity of the acetabulum. The former is the one to which attention was first called by Malgaigne under the title of double vertical fracture of the pelvis, a variety of which has been described at much length by Voillemier 3 as vertical fracture of the sacrum. The posterior line of fracture lies either in the ilium entirely behind the acetabulum, or in the sacrum, or partly in the ilium or sacrum and partly in the sacro-iliac synchondrosis, and sometimes the sacrum is crushed rather than fractured. The cause apparently may 1 Lancet, 1878, vol. i. p. 347, Case 2. a Lancet, Idem., Case 3. :i Voillemier : Cliuique Cliirurgicale, 1862, p. 77. 318 FRACTURES. be a force acting in either anteroposterior or transverse diameter of the pelvis or upward against the tuberosity of the ischium. The Fig. 174. Double vertical fracture of the pelvis ; united. most prominent symptoms in these cases are in the position of the leg and in the extent to which it can be moved. The femur is attached Ftg. 175. Double vertical fracture of the pelvis ; vertical of sacrum, double of pelvis. to the portion of bone which is intermediate between the two lines of fracture, and as this piece is usually displaced upward and inward FRACTURES OF THE PELVIS. 319 there is apparent shortening of the limb. At the same time the piece is commonly rotated about an antero-posterior axis so that the upper part of the pelvis is broadened and the lower part narrowed. The inability to move the limb is due in part to the lack of a solid support and the fear of pain, and in part perhaps to laceration of the muscles of the iliac fossa. Pain in the distribution of the obturator nerve is not uncommon. The prognosis is unfavorable (35 deaths in 106 cases, Dreschler) because of the probability of associated injuries. It may result in lameness or in a permanent change in the shape of the pelvis, which in a woman may have serious consequences if pregnancy should follow. Walther ! describes a variation in which the anterior fracture occu- pied the body and descending ramus of the pubis, and the second frac- ture ran below the anterior superior spine of the ilium to the sacro- sciatic notch ; in addition the upper fragment of the ilium was split vertically, and the fifth sacral vertebra was broken. The fragment between the two principal lines of fracture was displaced inward and had reunited. The second form of lateral fracture of the pelvis, radiating fracture of the acetabulum and fracture of the floor of the acetabulum are described in the following section. Vertical fractures of the sacrum are not known except in connection with fractures of the pelvic ring at other points, as already mentioned. A few cases of very extensive injury have been recorded, extensive crushing and multiple fractures. All proved fatal. Course and Prognosis. The course and prognosis in all these cases depend mainly upon the lesions associated with the fracture. The only additional point which requires mention is one referred to by Legros Clark, the tendency to suppuration in the loose connective tissue between the pubes and the bladder, especially after fracture of the pubis or separation of the epiphysis. The uncomplicated and simpler forms of fracture tend to easy repair, and even fractures that are very extensive are by no means necessarily fatal. Diagnosis. The diagnosis is usually easy, but may be very obscure if the fracture is limited and without much displacement. The outline of the pubis should be carefully followed with the finger to detect irreg- ularity or localized pain, and pressure should be made backward alter- nately with either hand upon the anterior portion of each ilium in the search for abnormal mobility and crepitus. In vertical fracture of the sacrum or in separation of the sacro-iliac synchondrosis displacement will change the position of the posterior spine of the ilium. In double vertical fracture the intermediate portion, which bears the anterior superior spine, is usually displaced upward, and the displacement is easy of recognition and can be diminished or perhaps reduced by trac- tion upon the leg. Treatment. In cases without much displacement rest in bed en the back is all that is required, aided in the multiple forms or in separa- tion at or near the symphysis pubis by a stout girdle drawn snugly about the pelvis. Reduction of a fragment of the pubis may some- 1 Walther: Soc. Anat., October, 1891. 320 FRACTURES. times be made by digital pressure, and that of the intermediate frag- ment in double fracture by traction upon the limb aided by pressure with the finger from the vagina or rectum. In compound fractures loose fragments should be removed. Treatment of the complications belongs more properly to the subject of general surgery, but the frequency of laceration of the urethra and the advantages of its early recognition and treatment are so great that it deserves mention. On the first indication of probable injury to the urethra the catheter should be introduced, and if its passage is pre- vented or even rendered difficult by injury to the urethra, an incision should be made through the perineum to the injured part cutting upon the end of the catheter as a guide. I have almost always found the membranous urethra not only torn across but also so freely separated by laceration of the soft parts amid which it lies that its recognition was difficult. It is so thin and collapsed and its torn end so shreddy that it can hardly be distinguished. For this reason it is desirable to make the incision with the aid only of local anaesthesia — cocaine or freezing — in order that the patient may aid the recognition by passing urine. If possible the two torn ends of the urethra should be united by one or two sutures along its roof so as to aid the permanent resto- ration of the continuity of the canal ; and each torn end should be split for half an inch along the floor so as to avoid the cicatricial narrowing which follows circular division. If the bladder has been ruptured, intra- or extra-peritoneally, supra- pubic cystotomy may be needed to evacuate the escaped urine and close the opening or for drainage of the bladder. Permanent catheteriza- tion through the perineal opening may sometimes take -the place of suprapubic drainage; it is not needed if the bladder is uninjured. 2. RADIATING FRACTURE OF THE ACETABULUM AND FRACTURE OF THE FLOOR OF THE ACETABULUM. In the typical form the first three lines of fracture pass from the acetabulum across its margin into the sciatic notch, the obturator foramen, and across the brim of the pelvis ; the most frequent variation seems to be the breaking off of the pubic portion of the brim. An- other form of fracture, that of the floor of the acetabulum, seems to be a variant of the beginning of the typical form and appears either as a slight splintering of the central portion or a more extensive break in which the floor is driven inward in several pieces the lines of fracture of which extend outward more or less into the adjoining bone. As the head of the femur may be forced inward in any of the forms, pressing the fragments apart, the term luxatio centralis femorls is fre- quently applied to them all, and under that name several articles treat- ing of the subject in detail, with collation of reported cases have been published. 1 The term has also been applied, but, I think, quite im- 1 Simon: Beitrage zur klin. Chir., 1905, vol. 45, p. 555; Wolff, Idem., 1906-7, vol. 52, p. 561, and Worner, Idem, 1907-8, vol. 56, p. 185. See also Guibe, Revue de Chir., An. 24, No. I., and Thevenot, Idem, No. II. FRACTURES OF THE PELVIS. 321 properly, to the very exceptional form in which the entire acetabulum is separated from the rest of the os innominatum and displaced inward. AVorner seeks further to restrict the term to those cases in which the fracture is confined mainly to the acetabulum and its margins, at the most breaking the pelvic ring only on the pubic side. Typical form. In one or two of the typical class in young patients the lines of fracture have apparently followed the conjugal Y-cartilage of the acetabulum. The external iliac artery and vein have each been torn once. The injury has been caused always by great violence acting upon the side of the pelvis and doubtless also on the great trochanter. The patient is completely disabled, and it is easy to recognize that the injury is extensive and severe. The details may be made out by systematic exploration of the accessible portions of the pelvis, including its inner face so far as it can be felt through the rectum. Palpation within Poupart's ligament discloses the change in the line of the pelvic ring at that point and possibly the head of the femur displaced inward. The finger in the rectum or vaginia finds the palpable surface swollen and tender. The great trochanter is sunken, approximated to the median line, to an extent corresponding to the dis- placement inward of the head of the femur. FlG - 176. Occasionally there has been bleeding from