Chapter XXXIV: Fractures (3)

=Treatment.=--Treatment of pelvic fractures should comprise, first, absolute rest. This means not merely confinement in bed, with traction applied to one or both limbs, but probably fixation of the pelvis and perhaps the thighs, either in a compressing bandage or in a plaster-of-Paris double spica, the pelvic jacket running as high as may be necessary upon the trunk of the body. Cases which seem to permit of operation and suturing are entitled to it, but they will constitute but a small proportion of the total. While patients are so rigidly confined provision should be made for free elimination, and possibly conveniences provided for receiving the evacuations without possibility of infection. Recovery is in many instances complete; occasionally it occurs with considerable displacement. If the viscera escape injury much may be expected in the way of repair of the bones under suitable treatment.

The _margin of the acetabulum_ is occasionally chipped off, sometimes by itself, sometimes as a complication of dislocation of the hip. The posterior margin of the brim is the part which usually suffers. Diagnosis should be made by the ease with which such a dislocation recurs after manual reduction. Sufficient traction to keep the limb from displacing the fragment, and snug bandaging with pressure, especially around the injured hip and above the trochanter, is indicated in such cases.

The _coccyx_ and even the lower portion of the _sacrum_ are occasionally broken loose, either by external violence or during parturition. Here the fragment is drawn forward by the levator ani, displacement is marked, and pain and soreness are great. Should there be doubt as to the nature of the injury, combined manipulation, with a finger in the rectum, will make diagnosis positive. Fibrous union is about all that can be expected in either of these cases. The fragment may be justifiably removed at any time.

FRACTURES OF THE THIGH.

Fractures at the upper end of the thigh are more common than those at the lower. At the upper end there may be fractures of the _head_, of the _neck_, those which pass _between the trochanters_, and _epiphyseal separations_. All of these are rare except those of the neck.

Fractures of the _neck of the femur_ occur most commonly in those who have passed the fiftieth year of life. They occur, however, during the middle period and even in children, and, as Whitman has shown, are by no means so rare in the young as was until recently supposed.

The shape and structure of this portion of the bone, and the peculiar changes which occur with advancing years, constitute the explanation for the frequency of this injury in late life. As the jaw begins to change in shape, and the teeth to drop out, there occur also unseen changes within the cancellous structure of the head and neck of the femur by which the strength of the latter is materially reduced. It is still further weakened by the change in shape which the bone also undergoes as it loses its obtuse angle and becomes set more at a right angle with the shaft. The reduced ability to resist strain produced by these changes is remarkable, and accounts for the ease with which fractures occur, even from so apparently trivial an accident as tripping on the floor. With all the violence directly transmitted there is usually present an element of twist or torsion by which fracture is still further favored.

As between so-called _intracapsular_ and _extracapsular_ fractures surgeons have made distinctions to which unnecessary importance has been attached. Anteriorly the capsule is attached to the intertrochanteric line, while posteriorly it does not extend nearly so far outward; it can thus be seen that many fractures are partly intracapsular and partly extracapsular. These lines vary in different individuals, especially that of the posterior insertion; it is not usually possible to make minute distinctions of this kind. The principal importance which attaches to them is in the direction of prognosis, for if the fragment be absolutely intracapsular it can derive its blood supply only through the ligamentum teres, which is, to say the least, a precarious method of existence and usually disappointing. In general it may be assumed that a fracture close to the head is intracapsular, but that when it occurs well out toward the shaft it may partake of both characters. In this connection the _x_-rays will afford, usually, more satisfactory information than can be obtained by even extensive or rude manipulation.

_Impaction_ occurs with considerable frequency in these cases, and, unless accompanied by too much deformity or displacement, is rather a fortunate occurrence, since by it is afforded an automatic splint which it should be the surgeon’s endeavor to not break apart. There can be no doubt, moreover, but that trifling degrees of impaction with incomplete fracture occur, especially in the aged, in many injuries to the hip. It would be the greatest misfortune to the patient in one of these cases to complete the separation, and when assured of the existence of such a lesion it is best to treat the case as though it were a fracture. I am sure that many cases which have gone into court have been due to incomplete fractures with impaction, where there has been later absorption of bone, by which the femoral neck has been much shortened, so that recognizable deformity as well as more or less disability have resulted. Other changes comprised among those already described in the chapter on Joints, under the section on Arthritis Deformans, may also occur. Callus which has been at one time abundant may also undergo too great absorption.

Sections of impacted extracapsular fractures of neck of femur, showing the degree of impaction and of splintering in different cases. (Erichsen.)]

Extracapsular fracture of thigh.]

Fig. 311 illustrates extracapsular fracture and comminution. Figs. 312 and 313, also from specimens in the author’s collection, show some of the changes described above, including impaction, displacement, and some osteophytic outgrowth.

FIG. 313

Impacted fractures of necks of femurs.]

_Signs of fracture of the neck of the femur_ of special import are _history of injury_, _pain_, _loss of function_, _shortening_, _rotary displacement_, usually eversion, _crepitus_, _relaxation of the fascia lata_, and _disarrangement of the lines of triangulation_ between the bony prominences of the pelvis and the trochanter. Diagnosis should be attempted with as little manipulation as possible lest impaction be dislodged. The patient should be placed upon a comfortably hard surface. Anesthesia will sometimes afford important aid. It should be ascertained, first, that there had been no previous injury which could produce shortening. If, then, _shortening_ be apparent it is of itself almost a diagnostic sign. Such a limb is practically helpless, and unless the neck be so driven in upon itself as to produce impaction the foot will be usually everted, while the tension of the fascia lata will be relaxed and there will be fulness in Scarpa’s triangle. Absolute inability to use the limb implies fracture without impaction. Should the patient have been able to help himself or work after the injury, impaction may be safely assumed. The parts are exceedingly tender and pain is easily produced. Shortening is to be assumed only after placing the limbs and body in a _perfectly symmetrical position_ (the pelvis being at right angle with the spine), after which the measurement most usually made is from the anterior superior spine to the internal malleolus. _Nélaton’s line_ is the shortest line which can be made to pass around the hip, in one plane, from the anterior superior spine to the tuberosity of the ischium. While the line is curved it should lie in the same plane. Normally this passes just over the great trochanter. If there be real shortening the trochanter should rise above this line to an extent corresponding with the shortening made out by other measurements. Still another method of measurement is to hold a straight edge opposite to the superior spine and perpendicular to the surface upon which the patient is lying; the distance between this edge and the great trochanter should be as much less than the distance found by similar measurement on the other side as the amount of shortening measured by the other methods. This is the easiest way to measure the lines included in Bryant’s iliofemoral triangle. Both are illustrated in Fig. 314. Impaction can sometimes be determined by comparing triangles drawn between three points on either side, these points being, respectively, the great trochanters, the anterior spine, and the centre of the pubis, which is common to both. The lower line of the triangle on the injured side should be shorter than on the other, in proportion as the head and the end of the shaft have been driven toward each other.

Nélaton’s line, dark. Bryant’s iliofemoral triangle, dotted. (Erichsen.)]

_Crepitus_ is a sign to be elicited with care and gentleness. Up-and-down movements of the thigh upon the side of the pelvis or gentle rotary movements, combined with circumduction of the knee, will yield it if it is to be easily detected. Every effort of this kind disturbs the injured bone and should be minimized as much as possible. One other sign of considerable value is the fact that if the patient be turned upon his face a fractured femoral neck will permit the leg to be _hyperextended_ to a degree not permitted by the normal condition. In making this test the pelvis should be held firmly; it should be made but once, the intent being to disturb the parts as little as possible.

=Diagnosis.=--The diagnosis of fracture is often easy, but in some cases it is accompanied by many difficulties. It would be better to give the patient the benefit of a doubt and treat him for a fracture with rest than to subject him to excessive manipulation. Such an injury is not likely to be mistaken for anything else save a dislocation of the hip, although occasionally separation of the margin of the acetabulum might cause confusion.

=Prognosis.=--The prognosis depends upon the age and vitality of the patient, the location and extent of the fracture, the method of treatment, and upon causes which seem at first foreign to the subject. Patients with pulmonary or cardiac trouble, who need frequent change in position, or perhaps absolute rest, are likely to develop something hurriedly which will disarrange ordinary calculations. Sometimes they die suddenly or they may develop pulmonary edema or hypostatic pneumonia. The circulation may be so poor as to lead to early development of bed-sores, while ordinary complications in prostatics, or habitual constipation in the aged, may make care and treatment exceedingly difficult. It should be emphasized, then, that treatment of the fracture alone is by no means all that these patients require, and prognosis means something more than what may merely happen to the bone. In this last respect, however, the better nourished the fragment the more likely is bony union to take place _if_ good position can be maintained. When osseous union has failed patients get fairly useful limbs with _fibrous or ligamentous union_, even with one or two inches of shortening, and such patients may hobble about for years, with a cane or a crutch, with limbs that are semiserviceable.

=Treatment.=--Of these cases it may be said that interests of life are paramount to those of limb, and the treatment should be directed to that which the patient can tolerate. Reasonably healthy, muscular people can bear the application of adhesive strips and traction such as the thin and delicate cannot tolerate. The ideal method is that by which sufficient traction is made to overcome all muscle pull which shall produce shortening, the measure of weight to be used in these cases being the effect thereby produced. Thus if twenty pounds be sufficient, well and good; if not, it should be increased to thirty or forty pounds, providing that the patient can tolerate it. At the same time a broad binder around the pelvis may afford sufficient support with a tractable patient, while many will require a _long side splint_, extending from the axilla to beneath the foot, to which both body and the injured limb should be fastened, in order to more perfectly maintain that physiological rest which is so necessary. This last is the so-called “Physick” splint, which has been variously modified, while the method of traction has been usually spoken of as Buck’s extension. It seems well thus to commemorate the names of the American surgeons who showed the value of these methods. When a long side splint cannot be borne, sandbags 15 in. or 20 in. in length and 3 in. in diameter may be used to give support. Any decided tendency to eversion of the limb should be corrected as well as the shortening. When the long side splint is used the foot can be held in place with it and thus the position of the shaft of the femur controlled. At other times this may be done by flexing the knee and thus preventing upward rotation. In all methods of traction it is advisable to _keep the heel free from the bed_, in order that the effect of the method may not be lost by the obstruction of the mattress.

Fracture of upper third of femur. Vicious union.]

Shortening resulting from overlapping.]

Overlapping fracture of femur.]

Other methods of treatment of these fractures are common as well to those of the shaft, and will be considered later. These include the single and double inclined plane and the method by anterior suspension. In general the _first indication is efficient traction_. This should be made as efficiently as possible. When the patient cannot tolerate any of the usual methods, then the double-inclined plane may be used, the knee being hung over its apex, or anterior suspension may be practised. In severe cases patients should be simply made comfortable, with such local treatment as they can bear. It may be even necessary to place them in the semi-upright position in bed, in order to free the lungs, or to frequently change their position to avoid the formation of pressure sores.

Fracture of lower end of femur, with great displacement of condyles.]

=Fractures of the Shaft of the Femur.=--Fractures of the shaft of the femur are usually oblique and accompanied by considerable displacement, because of the powerful thigh muscles which tend to shorten the limb. These fractures are often _compound_, and occasionally the femoral fragment causes serious damage to important vessels or nerve trunks. When the fracture is just below the insertion of the psoas into the lesser trochanter this muscle tends to not only pull up but to externally rotate the upper fragment. Inasmuch as there is no way of controlling this muscle or the fragment, the fractured limb should be dressed upon an inclined plane, or in anterior suspension, in such a way as to make the axis of the shaft fall into line with that of the fragment. When the fracture is in the middle of the thigh, or lower, there is sufficient length of the upper portion so that pressure can be made upon it, or that psoas activity can be overcome. Fig. 315 illustrates the tremendous deformity that may result from neglect of these precautions. Fig. 316 illustrates a certain degree of overlapping without conspicuous other deformity. Fig. 317 shows the shortening which is often inevitable.

_Muscle spasm_ should be overcome as an essential part of successful treatment, the most important feature in making traction being to use force sufficient to tire out and overcome the irritated muscles.

=Fractures of the Lower End of the Femur.=--Fractures of the lower end of the femur are usually the result of extreme violence, and may be classified as were those of the lower end of the humerus. When there is a _supracondyloid_ fracture the two heads of the gastrocnemius will help to displace backward the upper end of the lower fragment to an extent permitting injury to the bloodvessels, while there is always marked shortening. Here the patella will be made unduly prominent, and there will be depression above it. _Either condyle_ may be broken loose alone, or there may be _intercondyloid_ or T-fractures which are serious because the amount of force required to produce them may have played serious havoc with the soft tissues. The joint capsule will probably be filled with blood, the ligaments rent, and perhaps the blood supply of the limb compromised. In such a case as this the joint may be opened, the contents turned out, and the fragments readjusted and wired or fastened in place (Fig. 318). _Epiphyseal separations_, which may occur up to the twentieth year, are not essentially different, although lateral displacement is perhaps more common, while they are often compound.

=Treatment.=--Oblique fractures of the femoral shaft can be more easily adjusted under the influence of powerful and continuous traction than the transverse, where lateral displacement and overlapping tend to occur. A more general application can be made of the method described above when dealing with fractures at the upper end of the shaft, _i. e._, when the upper fragment cannot be controlled the balance of the limb must be adjusted to it in whatever position it may be required to maintain. By the use of sufficient traction, combined with molded or other splints, a fair result may usually be obtained. In stout individuals it is by no means easy to determine just how the fragments lie, save by the use of the _x_-rays. If traction be so adjusted as to maintain the limb at equal length with the other the surgeon may feel that, with certain coaptation splints, he is doing the best he can. Application of the same rule given above would lead him to place the limb on a double inclined plane, in case of fracture near the knee-joint, in order that in this position the sural muscles (the calf) may be relaxed and backward displacement of the lower fragment be adjusted. If the apex of this plane be arranged sufficiently high, so that the patient’s knee is practically hung over it, and that the weight of the body makes sufficient _countertraction_, then the use of weight and pulley may not be necessary. Here, however, pressure which will be efficient may produce numbness, as will any long-continued pressure in the popliteal space, and after a few days it may be necessary to assume some other position. Fractures which loosen the condyles will need lateral pressure, while the position of each condyle may be controlled by the position of the leg, through the medium of the corresponding lateral ligament.

Extension band and foot-piece.]

Same, folded and ready for use.]

The standard “Buck’s extension” (for which latter word I prefer to substitute the term “traction”), by weight and pulley, with the limb in the extended position, is still the resort of the majority of surgeons, but combined with other support by long side splints or coaptation splints as may be needed. Fig. 321 illustrates the method of its use, except that the ends of the adhesive strips should be extended upward to a point nearly opposite the site of the fracture. The amount of weight to be used should be graduated to the effect produced. From ten to forty pounds, or even more, may be needed. After the muscles are thoroughly tired the amount of weight may be somewhat reduced[41] (Figs. 319, 320 and 321).

[41] Before applying the strips of adhesive, the best for the purpose
being that made of moleskin spread with material with which zinc
oxide is incorporated, the limb should be carefully washed and shaved
and then completely dried. A little cotton should be placed over each
malleolus, in order to avoid pressure-sores, while the strip of wood
beneath the foot should be sufficiently wide to prevent or minimize
this pressure. The heel should be kept off the mattress.

Mode of applying adhesive plaster. (When the dressings are completed the limb should not be allowed to rest on the bed.)]

Continuous and anterior traction was devised by Nathan R. Smith, in the use of a so-called _anterior splint_, which was later modified and improved in device by Hodgen. The method of its use is shown in Fig. 322. Adhesive strips are used in this method as well, permitting the leg and foot to be attached to the lower bar of the wire frame. The position of the frame which contains the limb, swung within it upon turns or strips of bandage, is then controlled by a suspension apparatus, as shown, which tends to constantly pull the frame and its attached lower part of the limb _away_ from the patient, the effect being to make a constant but gentle traction. If the point of suspension were placed directly above the limb there would be no traction whatever. The essential feature of the method, then, consists in arranging it as shown, so that the pull shall be oblique, and that, according to the obliquity of the suspension cords, the amount of traction shall be regulated.

The Hodgen suspension splint.]

In this method of treatment there is no violent attempt made at reduction or overcoming displacement, but dependence is placed, at least for two or three days, on the effect of the constant pull and its overcoming muscular activity. After this such added splints or expedients may be adopted as the case may require. The knee is usually flexed at a comfortable angle, the intent being not to lift the foot too high, so as to avoid being compelled to overcome this added weight, but to regulate the tension by the obliquity of the suspending cord.

Fracture of the femur in a child treated by vertical extension. (Bryant.)]

This method has found favor in the West under the enduring influence of Hodgen’s teaching. In the East it is not so generally practised. It has, however, several advantages, as follows: (1) Equably perfect and comfortable extension; (2) easy adjustment; (3) easy exposure for inspection; (4) when a fracture is compound it permits of easy application of dressings; (5) adaptability to nearly all fractures of the femur. It is peculiarly serviceable for feeble and aged patients who chafe at restraint. If it be desirable to flex the knee to a considerable degree this can be done, _e. g._, in fractures near the lesser trochanter.

In fractures of the thigh, patients are frequently disturbed by muscle spasms occurring during sleep. This can usually be obviated or minimized by suitable doses of sulphonal, given early in the evening.

Fractures of the femur _in children_ are not uncommon. In those who still wear diapers, and perhaps in those a little older, these injuries may be best treated by vertical suspension, with sufficient weight to overcome all shortening. Here the adhesive strips and the suspending cords should be attached to both limbs alike, in order to have sufficient access to the perineum, and in order to judge of the effect which we are obtaining. Figs. 323 and 324 illustrate this method.

Plaster-of-Paris dressings for fractures of the thigh appeal especially to those who are most familiar with the use of the material. Some patients with fracture of the neck of the femur may be early put in the erect posture, upon an elevated surface, allowing the injured limb to hang down while the patient rests upon crutches. In this upright position, with the down-hanging leg, to which traction can be made by an assistant, a plaster-of-Paris spica may be applied, extending from the waist-line down to or below the knee. As a limb is thus dressed so it will heal, and it is of importance that complete reduction be effected as a part of the procedure.

Fracture of the thigh; vertical suspension. The fracture is compound in the patient on the right. (Stimson).]

FRACTURES OF THE PATELLA.

During the active period of middle life the patella is the bone most frequently broken by muscular violence. In many cases it is practically cracked over the condyles, as one would crack a piece of wood over the knee. If direct force be applied, as by a fall, in connection with the above, the effect is even more marked. In such cases the fracture is sometimes comminuted (Fig. 325), or the line of fracture may run more or less perpendicularly rather than horizontally. Ordinarily, however, these fractures are transverse, while the upper fragment is pulled upward, sometimes to a considerable distance, by the powerful extensors of the leg. When the fracture runs vertically the displacement is very slight. Occasionally these fractures are compound, a most undesirable complication, since the knee-joint is thus exposed to infection, from which it suffers unless first attention be prompt and scientific. There is usually sufficient hemorrhage to distend the joint cavity, and it may at first be quite impossible to bring the fragments near enough to each other to get crepitus, but the loss of the power of extension and the evident gap between the fragments will serve to make diagnosis positive, at least in all transverse fractures. A _vertical_ fracture without much separation is a milder form of injury which may be regarded in a much more favorable light (Figs. 326, 327 and 328).

In these transverse fractures it is rare that bony union can be secured by non-operative methods. This is not only because of the difficulty in maintaining parts in apposition, but because it is notably the case that fragments of periosteum or other tissue drop in between bony surfaces and tend to prevent their actual contact, no matter how firmly they may be pressed toward each other. Osseous union then _may_ occur without operation, but is rare. The best that can be expected is fibrous union, the intervening fibrous band being short or long, according to the success met with in treatment and to the amount of strain later put upon it by too early use of the limb. Even with two inches of fibrous tissue intervening patients are not completely disabled. The usefulness of a limb under these conditions, however, is seriously impaired. Something will depend, also, on the extent to which the joint capsule and the aponeurosis terminating the vasti muscles may have suffered.

=Treatment.=--The non-operative treatment consists in placing such a limb upon a single inclined plane, for the purpose of relaxing the quadriceps extensor group. In this position the limb should be maintained for at least from ten to fourteen days. Some expedient should be added, so soon as swelling has subsided, by which the upper fragment can be coaxed downward toward its fellow. A neatly molded splint, formed out of gutta-percha or of plaster of Paris, may be fitted to the thigh above the fragment, held in position, and then drawn downward by elastic traction on either side of the leg, the principle of traction being thus given a special application. Something of this kind should be done if the fragments are to be approximated to each other.

Comminuted fracture.]

Stellate fracture of the patella. (Erichsen.)]

Fracture of patella, united by ligamentous tissue. (Erichsen.)]

Side view of same.]

The more completely mechanical method, partaking of the operative, is afforded by the use of certain _hooks_, whose points are permitted to pass through the skin above and below the fragments and to engage in the bone. By a screw mechanism these points are drawn toward each other, and thus approximation is effected. This method was first devised by Malgaigne and is usually known under his name, although his device has been much improved. This is far from ideal, and yet has given good results in some cases. The surgeon should constantly guard against infection through the punctures.

By far the most ideal method, when it can be suitably carried out, is the _open operation_, a transverse incision being made across the front of the joint, which is completely opened; this affords an opportunity to empty out clots and to thoroughly cleanse it, which of itself is a great advantage, since these clots often produce subsequent adhesions. The exposed surfaces may now be freed from clot and all soft tissue, or they may be neatly sawed as near to the fractured surfaces as possible, the intent being to permit them to come into absolute and complete contact, and to hold them there by wire or other sutures, for a length of time sufficient for absolute bony union. When properly performed this operation gives ideal results; it, of course, exposes to great danger if improperly done.

Treatment by non-operative method rarely affords a useful member under an average period of from thirteen to fourteen weeks, while the operative method permits a reduction of this time to less than half. It, therefore, has obvious advantages for those (_e. g._, laboring men) to whom time is of great importance. The operation, however, is not to be practised as a rude emergency affair, but only when we may be absolutely certain of everything pertaining to aseptic technique. After operation it is rarely necessary to use a drain, and such a limb can usually be dressed in a plaster-of-Paris splint. Compound fractures, however, will probably need drainage at least for a day or two, and because of this need may as well be operated at once. In _comminuted fractures_ the method is desirable, since by a loop or by some other expedient fragments can be held together as in no other way (Figs. 329 and 330).

FIG. 330

Wiring patella. (Lejars.)]

Injuries to the patellar region, equivalent to fractures, are _separations_, either of the _tendon_ from the bone, or of the bone from the _ligament_ which holds it to the tibia. Such injuries can be recognized by the fact that the contour of the bone itself is preserved; in the former case it is not drawn up, although the extensor muscles have lost their power while in the latter it is drawn up, leaving a well-marked gap below it.

Remarks concerning the treatment of fractures apply equally here. Choice can be made between the operative and the non-operative treatment. In well-selected cases the former seems much the more desirable, the fibrous end of the tendon or ligament being held to the bone by strong sutures of silk or wire.

THE LEG; FRACTURES OF THE TIBIA.

The _head of the tibia_ is occasionally broken as the result of extreme violence, the fragment being usually held reasonably in place by one or other of the lateral ligaments. Hemorrhage into the joint will be profuse, with swelling extreme, while disability will be complete. Not a few of these cases justify operation, directed toward opening the joint, removing all clot, and fastening the fragment in place with suitable sutures (Figs. 331 and 332).

_Transverse fracture below the tubercle_ is less rare. The insertion of the terminal ligament of the quadriceps extensor group will, in all of these injuries to the upper portion of the tibia, tend to pull up the upper fragment and make it project beneath, even protrude through the skin. Fractures of the _lower part_ of the tibia are freer from such distorting influences. Fig. 333 illustrates the distortion produced as above, while Fig. 335 shows one of the tendencies in fracture of the lower end of the tibial shaft, which has to be overcome by correct emplacement of the foot within the dressing. Fig. 334 illustrates synostosis as the result of fracture of both bones at about the same level. Torsion is a factor of no small importance in the production of most of the fractures of the leg, to such an extent as sometimes to make a completely spiral fracture, a condition generally held to be more serious than fracture of the ordinary type. The line of fracture often extends in such a direction as to leave a sharp spicule of bone close beneath the skin; here rough handling, or carelessly made pressure in the dressing, may cause a perforation within a few hours or days after the injury, by which a simple is converted into a compound fracture. Such a complication should always be avoided.

FIG. 332

Wiring tibia. (Lejars.)]

FRACTURES OF THE FIBULA.

The lower end of this bone is much more often fractured than the upper, although it may be broken at any point. Into its upper termination is inserted the external lateral ligament, and this insertion may be torn off from the bone in cases of violent sprain of the knee, damage occurring which is similar to that which happens in injuries about the ankle. The upper portion of the bone lies well buried beneath muscles, and fractures here are not so easily recognized. A good maneuver for their recognition is to seize the bones at the lower portion of the leg and press them together; if such pressure gives severe pain above, or if it be shown that the fibula is more movable than natural, fracture may be practically diagnosticated, even though crepitus be not detected. A skiagram would, of course, clear up such a diagnosis.

Fractures of _both bones of the leg_ occur almost as frequently as of either alone, usually as the result of direct violence, with or without more or less torsion; as, for instance, when the foot is more or less entangled, and, at the same time, twisted at the time of injury. These double fractures are by no means necessarily placed upon the same level; thus the tibia may be broken low down and the fibula high up, so high indeed that the latter fracture may escape observation. With fracture of both bones disability becomes complete, while shortening is very likely to occur, all the muscles passing from the leg to the foot conspiring to this effect. These fractures, moreover, are often _comminuted_ and _compound_, sometimes to an extent necessitating exsection of fragments or of an inch or more from the shaft of each bone. In exsection of the tibia an equivalent amount should for obvious reasons be taken from the fibula. Displacements are extremely likely to occur, and in every compound fracture the presence of the opening may be utilized for the emplacement of sutures or suitable means for enforcing approximation. Indeed, other means failing, resort may be had to this measure in order to secure an ultimately good result.

Fracture of upper end of tibia.]

Transverse fracture, with anterior displacement. (From the Buffalo Museum.)]

Line of fracture at junction of lower and middle thirds of tibia.]

While wire sutures may be used as freely as may be indicated it will be well, at least in the majority of cases, to leave the ends protruding in such a way that they can later be untwisted and removed. The presence of wire after a certain length of time rather interferes with the process of ossification than helps it.

Fractures of the _lower end of the leg_ nearly always involve the joint, to some extent at least, in respect of being accompanied by sprain if nothing else. They are accompanied by displacement of the foot, and are produced by violence, which first involves the foot. The term “_Pott’s fracture_” is meant to include the injury originally described by Pott himself. In the typical Pott’s fracture, as shown in Figs. 336 and 337, there are a chipping off of the internal malleolus, of the outer portion of the articular end of the tibia, and fracture of the fibula a little above the joint. In spite of the classical description which Pott gave fractures of the fibula alone, those accompanied by tearing of the internal lateral ligament, or chipping off of the malleolus, are frequently referred to under the same term. The more complete the injury the greater the possibility for displacement. Eversion and outward displacement, of course, are conspicuous. Lesser degrees of injury are accompanied by less displacement, but all of these injuries will be followed by extreme swelling of the ankle-joint, which may at first make diagnosis somewhat difficult, because of the extreme tenderness which prevents the handling necessary for careful determination. It is not always easy to so completely replace the bones, when we have the combination of three fractures as above, as to get an ideal result. Nevertheless with suitable treatment usually very useful limbs are secured. When the injury has been made _compound_ the difficulties are increased. Such a result will not be obtained, however, unless the tendency to backward and lateral displacement be overcome, when the limb is placed in its permanent plaster-of-Paris splint, as it should be after a few days. Great care should be given to this point in the management.

Pott’s fracture. (Hoffa.)]

Exaggerated deformity in Pott’s fracture.]

=Treatment of Fractures of the Leg.=--Nearly all these fractures are likely to be followed by swelling, even to a degree which makes it impracticable to put them up in permanent dressing until the swelling has subsided. This means a period of two to several days, during which the limb should be kept absolutely at rest, and the bones maintained in apposition by side splints, while the limb is restrained within a folded pillow or other comfortable cushion. More frequently here than in any other part of the body there will form blebs or large blisters, which are most liable to occur in alcoholic subjects. The leg should be scrubbed and shaved before putting on dressings, in order that the skin may be reasonably clean before its surface epithelium is raised. Ecchymosis, infiltration, and sometimes general edema may become somewhat pronounced, and the splint which would be required to fit a limb under these circumstances would soon be too large when this disturbance has subsided. The limb should not, therefore, be placed in a fixed or permanent dressing until it is in every respect ready.

While these disturbances are subsiding, or perhaps being encouraged to subside by the use of an ice-bag or of cold wet applications, extreme care should be taken that proper position and apposition are maintained. This will at times need considerable ingenuity. A delirious or maniacal patient would need restraint far beyond that required for one who is rational and docile. Moreover in all of these fracture cases which entail confinement to bed there is a tendency to deficiency of elimination which will require judicious use of laxatives and other eliminatives.

The writer prefers a well-molded set of side splints, properly padded, to any other first dressing for fractures of the leg. A limb thus dressed may be supported on a pillow and even made adaptable for transportation should it be necessary to remove the patient from one place to another. The fracture box can be well superseded by this method.

So soon as swelling has subsided, plaster of Paris should be used for a fixed dressing. The limb should be enveloped in a layer of cotton, by which the skin is protected, within which swelling may occur without much strangulation. Over this and down the front of the leg a strip of thick pasteboard should be placed, which can be moistened and made to adapt itself, or a strip of sheet tin, an inch wide, which can be made to fit the part, and upon which one may cut down later in removing the splint. This refers especially to the use of the roller bandage saturated with plaster of Paris. Molded splints can be made, as recommended for the upper extremity, out of surgeons’ lint, canton flannel, or old blanketing, while at the lower end of these splints may be incorporated, with the plaster, a strip of bandage or other material, by which a loop is formed beneath the foot, which may be utilized for the purpose of traction.

The foot should _always be placed at a right angle to the leg_. If there be too much muscle spasm to permit this, or make it too uncomfortable, the tendo Achillis may be divided. This position should be maintained during the period of repair, in order that so soon as one resumes the use of the limb the foot may be planted naturally upon the ground. In addition to this precaution it must be noted that backward displacement is completely overcome, and that eversion is perhaps a trifle overcorrected.

In all fractures of the lower end of the leg the foot and entire leg should be enclosed in a bandage. In fractures near or above the middle not only the leg but the lower part of the thigh should be immobilized if the promptest and most satisfactory results are to be obtained.

The limb being immobilized it soon becomes a question as to how quickly the patient can leave the bed and begin to move about on crutches. This will depend to some extent on the patient’s temperament. Timid women are less desirous of getting out of bed than are active men and children. Some patients acquire facility with crutches very slowly. Others are so tenderly built that crutches give pain and even produce crutch paralysis. It is advisable to get patients at least into the sitting posture so soon as the immobilization has been secured, while those inclined may be encouraged to use the uninjured limb and move about with crutches. A foot and leg too long kept off the ground will swell when again lowered. The later this dependent position is attained the greater the liability to edema. Patients should be cautioned about this.

The so-called _ambulatory method of treatment_ has found favor with some surgeons. This implies something more than merely permitting motion with crutches; it means really such dressing as to permit use of the injured limb in locomotion. The various forms of splints used for immobilizing the limb in hip-joint disease may be used in this way. A useful splint is made with body and perineal bands, or an inside steel bar with ischiatic crutch and a cross-bar below the sole of the foot, on which the weight of the body may be supported. This is to be combined with a plaster-of-Paris support.

The ambulatory treatment is occasionally of value, but the advantages claimed for it have not been generally sustained.

FRACTURES OF THE FOOT.

The astragalus and the calcis suffer more often than the other tarsal bones, partly because of their size and partly because they are in the line of transmission of force as usually directed after accident. When the posterior end of the calcis is broken off there remains a fragment which is easily palpated, and which would be displaced backward and upward by the tendo Achillis were it not for the plantar fascial fibers which are inserted into it. The bone may also be comminuted, in which case that part of the foot will lose much of its shape and distinctive peculiarities. The sole will be flattened, but swelling and hemorrhage will at first be so great that there will be much difficulty in recognizing the exact nature of the injury.

The _astragalus_ is usually broken by being caught between the calcis and the lower end of the leg. It is generally broken through the line of its so-called neck. Not infrequently one or more of the fragments is forced out of place, usually beneath the anterior tendons. When such extensive displacement occurs the fragments should be removed if the fracture is compound. In both of these bones results are generally satisfactory when displacement is not marked, also after removal of the entire astragalus. The foot and leg should be immobilized in the best possible position, and this can be best accomplished within a plaster-of-Paris dressing.

In regard to the _tarsal bones_, diagnosis can now be made accurately by the use of the _x_-rays. These bones, according to Eisendrath, may be fractured in any one of the following ways: (1) Compression, as when the weight of the body is violently thrown upon the feet; (2) sudden dorsal flexion, often with fracture of the inner malleolus; (3) forced supination or pronation, the interosseous ligaments being stronger, the bones forcibly pulling the latter apart; (4) violent traction upon the heel through the calf muscles, by which the tuberosity of the calcis may be torn from the rest of the bone; (5) extensive crushing injuries, in which several tarsal bones may be involved; (6) gunshot fractures. Some assistance in diagnosis may be obtained by computing the distance from the malleoli to the bottom of the heel, which will be shortened when the bones are compressed; or shortening of the length of the foot, or by fixed abnormal positions.

The _metatarsal bones_ are broken by direct violence, the first and fifth being most exposed. As in other fractures of the foot contusion will be a serious feature, and swelling and laceration will frequently seriously complicate, while the fractures themselves may be compound. The same is true, also, of fractures of the _phalanges_, crushing and comminution being common. The matter of treatment often includes an estimation of the blood supply and of the vitality of the distal portion. The operator may sometimes temporize with an antiseptic dressing until this matter is settled. Simple fractures require only immobilization in good position.