The Home Medical Library, Volume 1 (of 6)

by Unknown

CHAPTER IV

Fractures

How to Tell a Broken Bone—A Simple Sling—Splints and Bandage,—A Broken Rib—Fractures of Arm, Shoulder, Hand, Hips Leg and Other Parts.

BROKEN BONE; FRACTURE.[5]

First Aid Rule 1.—Be sure bone is broken. If broken, patient can scarcely (if at all) move the part beyond the break, while attendant can move it freely in his hands. If broken, grating of rough edges of bone may be felt by attendant but should not be sought for. If broken, limb is generally shortened.

Rule 2.—Do not try to set bone permanently. Send at once for surgeon.

COMPOUND FRACTURE.

Important. If there is opening to the air from the break, because of tearing of tissues by end of bone, condition is very dangerous; first treatment may save life, by preventing infection. Before reducing fracture, and without stirring the patient much, after scrubbing your hands very clean, note:

First Aid Rule 1.—If hairy, shave large spot about wound.

Rule 2.—Clean large area about wound with soap and water, very gently. Then wash most thoroughly again with clean water, previously boiled and cooled. Flood wound with cool boiled water.

Rule 3.—Cover wound with absorbent cotton (or pieces of muslin) which has been boiled. Then attend to broken bone, as hereafter directed, in the case of each variety of fracture.

After the bone is set, according to directions, then note:

Rule 4.—Renew pieces of previously boiled muslin from time to time, when at all stained with discharges. Every day wash carefully about wound, between the splints, with cool carbolic-acid solution (one teaspoonful to a pint of hot water) before putting on the fresh cloths.

BROKEN BONES OR FRACTURES.[6]—It frequently happens that the first treatment of fracture devolves upon the inexperienced layman. Immediate treatment is not essential, in so far as the repair of the fracture is directly concerned, for a broken bone does not unite for several weeks, and if a fracture were not seen by the surgeon for a week after its occurrence, no harm would be done, provided that the limb were kept quiet in fair position until that time. The object of immediate care of a broken bone is to prevent pain and avoid damage which would ensue if the sharp ends of the broken bone were allowed to injure the soft tissues during movements of the broken limb.

Fractures are partial or complete, the former when the bone is broken only part way through; simple, when the fracture is a mere break of the bone, and compound, when the end of one or both fragments push through the skin, allowing the air with its germs to come in contact with the wound, thus greatly increasing the danger. To be sure that a bone is broken we must consider several points. The patient has usually fallen or has received a severe blow upon the part. This is not necessarily true, for old people often break the thigh bone at the hip joint by simply making a false step.

Inability to use the limb and pain first call our attention to a broken bone. Then when we examine the seat of injury we usually notice some deformity—the limb or bone is out of line, and there may be an unusual swelling. But to distinguish this condition from sprain or bruise, we must find that there is a new joint in the course of the bone where there ought not to be any; e. g., if the leg were broken midway between the knee and ankle, we should feel that there was apparently a new joint at this place, that there was increased capacity for movement in the middle of the leg, and perhaps the ends of the fragments of bones could be heard or felt grating together.

These, then, are the absolute tests of a broken bone—unusual mobility (or capacity for movement) in the course of the bone, and grating of the broken fragments together. The last will not occur, of course, unless the fragments happen to lie so that they touch each other and should not be sought for. In the case of limbs, sudden shortening of the broken member from overlapping of the fragments is a sure sign.

SPECIAL FRACTURES.

BROKEN RIB.—First Aid Rule.—Patient puts hands on head while attendant puts adhesive-plaster band, one foot wide, around injured side from spine over breastbone to line of armpit of sound side. Then put patient to bed.

A rib is usually broken by direct violence. The symptoms are pain on taking a deep breath, or on coughing, together with a small, very tender point. The deformity is not usually great, if, indeed, any exists, so that nothing in the external appearance may call the attention to fracture. Grating between the fragments may be heard by the patient or by the examiner, and the patient can often place his finger on the exact location of the break.

When it is a matter of doubt whether a rib is broken or not the treatment for broken rib should be followed for relief of pain.

Fig. 8.

METHOD OF BANDAGING BROKEN RIB (Scudder).

Note manner of sticking one end of wide adhesive plaster along backbone; also assistant carrying strip around injured side.

Treatment consists in applying a wide band of surgeon's adhesive plaster, to be obtained at any drug shop. The band is made by overlapping strips four or five inches wide, till a width of one foot is obtained. This is then applied by sticking one end along the back bone and carrying it forward around the injured side of the chest over the breastbone as far as a line below the armpit on the uninjured side of the chest, i. e., three-quarters way about the chest. These four- or five-inch strips of plaster may be cut the right length first and laid together, overlapping about two inches, and put on as a whole, or, what is easier, each strip may be put on separately, beginning at the spine, five inches below the fracture, and continuing to apply the strips, overlapping each other about two inches, until the band is made to extend to about five inches above the point of fracture, all the strips ending in the line of the armpit of the uninjured side. ([Fig. 8].)

If surgeon's plaster cannot be obtained, a strong unbleached cotton or flannel bandage, a foot wide, should be placed all around the chest and fastened as snugly as possible with safety pins, in order to limit the motion of the chest wall. The patient will often be more comfortable sitting up, and should take care not to be exposed to cold or wet for some weeks, as pleurisy or pneumonia may follow. Three weeks are required for firm union to be established in broken ribs.

COLLAR-BONE FRACTURE.

First Aid Rule.—Put patient flat on back, on level bed, with small pillow between his shoulders; place forearm of injured side across chest, and retain it so with bandage about chest and arm.

Fig. 9.

A BROKEN COLLAR BONE (Scudder).

Usual attitude of patient with a fracture of this kind; note lowering and narrowed appearance of left shoulder.

Fracture of the collar bone is one of the commonest accidents. The bone is usually broken in the middle third. A swelling often appears at this point, and there is pain there, especially on lifting the arm up and away from the body. It will be noticed that the shoulder, on the side of the injury, seems narrower and also lower than its fellow. The head is often bent toward the injured side, and the arm of the same side is grasped below the elbow by the other hand of the patient and supported as in a sling. (See [Fig. 9].) In examining an apparently broken bone the utmost gentleness may be used or serious damage may result.

Treatment.—The best treatment consists in rest in bed on a hard mattress; the patient lying flat on the back with a small pillow between the shoulders and the forearm of the injured side across the chest. This is a wearisome process, as it takes from two to three weeks to secure repair of the break. On the other hand, if the forearm is carried in a sling, so as to raise and support the shoulder, while the patient walks about, a serviceable result is usually obtained; the only drawback being that an unsightly swelling remains at the seat of the break. To make a sling, a piece of strong cotton cloth a yard square should be cut diagonally from corner to corner, making two right-angled triangles. Each of these will make a properly shaped piece for a sling. (See Figs. [10] and [11].)

Fracture of the collar bone happens very often in little children, and is commonly only a partial break or splitting of the bone, not extending wholly through the shaft so as to divide it into two fragments, but causing little more than bending of the bone (the "green-stick fracture").

Fig. 10.

Fig. 11. The above illustration shows sling in position. It is made of cotton cloth a yard square cut diagonally from corner to corner.

HOW TO MAKE A SLING (Scudder).

In Fig. 10 note three-cornered bandage; No. 2 end is carried over right shoulder, No. 1 over left, then both fastened behind neck; No. 3 brought over and pinned.

A fall from a chair or bed is sufficient to cause the accident. A child generally cries out on movement of the arm of the injured side, or on being lifted by placing the hands under the armpits of the patient. A tender swelling is seen at the point of the injury of the collar bone. A broad cotton band, with straps over the shoulders to keep it up, should encircle the body and upper arm of the injured side, and the hand of the same side should be supported by a narrow sling fastened above behind the neck.

LOWER-JAW FRACTURE.

First Aid Rule.—Put fragments into place with your fingers, securing good line of his teeth. Support lower jaw by firmly bandaging it against upper jaw, mouth shut, using four-tailed bandage. ([Fig. 12].)

Fracture of the lower jaw is caused by a direct blow. It involves the part of the jaw occupied by the lower teeth, and is more apt to occur in the middle line in front, or a short distance to one side of this point. The force causing the break usually not only breaks the bone, but also tears the gum through into the mouth, making a compound fracture. There is immediate swelling of the gum at the point of injury, and bleeding. The mouth can be opened with difficulty.

The condition of the teeth is the most important point to observe. Owing to displacement of the fragments there is a difference in the level of the teeth or line of the teeth, or both, at the place where the fracture occurs. Also one or more of the teeth are usually loosened at this point. In addition, unusual movement of the fragments may be detected as well as a grating sound on manipulation.

Treatment.—The broken fragments should be pressed into place with the fingers, and retained temporarily with a four-tailed bandage, as shown in the cut. Feeding is done through a glass tube, using milk, broths, and thin gruels. A mouth wash should be employed four times daily, to keep the mouth clean and assist in healing of the gum. A convenient preparation consists of menthol, one-half grain; thymol, one-half grain; boric acid, twenty grains; water, eight ounces.

Fig. 12.

BANDAGE FOR A BROKEN JAW (American Text-Book).

Above cut shows a four-tailed bandage; note method of tying; one strip supports lower jaw; the other holds it in place against upper jaw.

SHOULDER-BLADE FRACTURE.

First Aid Rule.—There is no displacement. Bandage fingers, forearm, and arm of affected side, and put this arm in sling. Fasten slung arm to body with many turns of a bandage, which holds forearm against chest and arm against side.

Shoulder-blade fracture occasions pain, swelling, and tenderness on pressure over the point of injury. On manipulating the bone a grating sound may be heard and unnatural motion detected. The treatment consists in bandaging the forearm and arm on the injured side from below upward, beginning at the wrist; slinging the forearm bent at a right angle across the front of the body, suspended by a narrow sling from the neck, and then encircling the body and arm of the injured side from shoulder to elbow with a wide bandage applied under the sling, which holds the arm snugly against the side. This bandage is prevented from slipping down by straps attached to it and carried over each shoulder.

ARM FRACTURE.

First Aid Rule.—Pad two pieces of thin board nine by three inches with handkerchiefs. Carefully pull fragments of bone apart, grasping lower fragment near elbow while assistant pulls gently on upper fragment near shoulder. Put padded boards (splints) one each side of the fracture, and wind bandage about their whole length, tightly enough to keep bony fragments firm in position. Put forearm and hand in sling.

In fracture of the arm between the shoulder and elbow, swelling and shortening may give rise to deformity. Pain and abnormal motion are symptoms, while a grating sound may be detected, but manipulation of the arm for this purpose should be avoided. The surface is apt soon to become black and blue, owing to rupture of the blood vessels beneath the skin.

The hand and forearm should be bandaged from below upward to the elbow. The bone is put in place by grasping the patient's elbow and pulling directly down in line with the arm, which is held slightly away from the side of the patient, while an assistant steadies and pulls up the shoulder. Then a wedge-shaped pad, long enough to reach from the patient's armpit to his elbow (made of cotton wadding or blanketing sewed in a cotton case) and about four inches wide and three inches thick at one end, tapering up to a point at the other, is placed against the patient's side with the tapering end uppermost in the armpit and the thick end down. This pad is kept in place by a strip of surgeon's adhesive plaster, or bandage passing through the small end of the wedge, and brought up and fastened over the shoulder.

Fig. 13.

Fig. 14.

BANDAGE FOR BROKEN ARM (Scudder).

In Fig. 13 note splints secured by adhesive plaster; also pad in armpit; in Fig. 14 see wide bandage around body; also sling.

While the arm is pulled down from the shoulder, three strips of well-padded tin or thin board (such as picture-frame backing) two inches wide and long enough to reach from shoulder to elbow, are laid against the front, outside, and back of the arm, and secured by encircling strips of surgeon's plaster or bandage. The arm is then brought into the pad lying against the side under the armpit, and is held there firmly by a wide bandage surrounding the arm and entire chest, and reaching from the shoulder to elbow. It is prevented from slipping by strips of cotton cloth, which are placed over the shoulders and pinned behind and before to the top of the bandage. The wrist is then supported in a sling, not over two inches wide, with the forearm carried in a horizontal position across the front of the body. Firm union of the broken arm takes place usually in from four to six weeks. (See Figs. [13] and [14].)

FOREARM FRACTURE.

First Aid Rule.—Set bones in proper place by pulling steadily on wrist while assistant holds back the upper part of the forearm. If unsuccessful, leave it for surgeon to reduce after "period of inaction" comes, a few days later, when swelling subsides. If successful, put padded splints (pieces of cigar box padded with handkerchiefs) one on each side, front and back, and wind a bandage about whole thing to hold it immovably.

Two bones enter into the structure of the forearm. One or both of these may be broken. The fracture may be simple or compound,[7] when the soft parts are damaged and the break of the bone communicates with the air, the ends of the bone even projecting through the skin.

In fracture of both bones there is marked deformity, caused by displacement of the broken fragments, and unusual motion may be discovered; a grating sound may also be detected but, as stated before, manipulation of the arm should be avoided.

Fig. 15.

SETTING A BROKEN FOREARM (Scudder).

See manner of holding arm and applying adhesive plaster strips; one splint is shown, another is placed back of hand and forearm.

When only one bone is broken the signs are not so marked, but there is usually a very tender point at the seat of the fracture, and an irregularity of the surface of the bone may be felt at this point. If false motion and a grating sound can also be elicited, the condition is clear. The broken bones are put into their proper place by the operator who pulls steadily on the wrist, while an assistant grasps the upper part of the forearm and pulls the other way. The ends of the fragments are at the same time pressed into place by the other hand of the operator, so that the proper straight line of the limb is restored.

Fig. 16.

FRACTURE OF BOTH BONES IN FOREARM (Scudder).

This cut shows the position and length of the two padded splints; also method of applying adhesive plaster.

After the forearm is set, it should be held steadily in the following position while the splints are applied. The elbow is bent so that the forearm is held at right angles with the arm horizontally across the front of the chest with the hand extended, open palm toward the body and thumb uppermost. The splints, two in number, are made of wood about one-quarter inch thick, and one-quarter inch wider than the forearm. They should be long enough to reach from about two inches below the elbow to the root of the fingers. They are covered smoothly with cotton wadding, cotton wool, or other soft material, and then with a bandage. The splints are applied to the forearm in the positions described, one to the back of the hand and forearm, and the other to the palm of the hand and front of the forearm.

Usually there are spaces in the palm of the hand and front of the wrist requiring to be filled with extra padding in addition to that on the splint. The splints are bound together and to the forearm by three strips of surgeon's adhesive plaster or bandage, about two inches wide. One strip is wound about the upper ends of the splints, one is wrapped about them above the wrist, and the third surrounds the back of the hand and palm, binding the splints together below the thumb. The splints should be held firmly in place, but great care should be exercised to use no more force in applying the adhesive plaster or bandage than is necessary to accomplish this end, as it is easy to stop the circulation by pressure in this part. There should be some spring felt when the splints are pressed together after their application. A bandage is to be applied over the splints and strips of plaster, beginning at the wrist and covering the forearm to the elbow, using the same care not to put the bandage on too firmly. The forearm is then to be held in the same position by a wide sling, as shown above. (See Figs. [15], [16], [17].)

Fig. 17.

DRESSING FOR BROKEN FOREARM (Scudder).

Proper position of arm in sling; note that hand is unsupported with palm turned inward and thumb uppermost.

Four weeks are required to secure firm union after this fracture. When the fracture is compound the same treatment should be employed as described under Compound Fracture of Leg, p. [116].

FRACTURE OF THE WRIST; COLLES'S FRACTURE.—This is a break of the lower end of the bone on the thumb side of the wrist, and much the larger bone in this part of the forearm. The accident happens when a person falls and strikes on the palm of the hand; it is more common in elderly people. A peculiar deformity results. A hump or swelling appears on the back of the wrist, and a deep crease is seen just above the hand in front. The whole hand is also displaced at the wrist toward the thumb side.

Fig. 18.

A BROKEN WRIST (Scudder).

Characteristic appearance of a "Colles's fracture"; note backward displacement of hand at wrist; also fork-shaped deformity.

It is not usual to be able to detect abnormal motion in the case of this fracture, or to hear any grating sound on manipulating the part, as the ends of the fragments are generally so jammed together that it is necessary to secure a surgeon as soon as possible to pull them apart under ether, in order to remedy the existing "silver-fork" deformity. (See Figs. [18], [19], [20], [21], [22].)

Treatment.—Until medical aid can be obtained the same sort of splints should be applied, and in the same way as for the treatment of fractured forearm. If the deformity is not relieved a stiff and painful joint usually persists. It is sometimes impossible for the most skillful surgeon entirely to correct the existing deformity, and in elderly people some stiffness and pain in the wrist and fingers are often unavoidable results.

Fig. 19.	Fig. 20.
Fig. 21.	Fig. 22.

FRACTURE OF THE WRIST (Scudder).

Above illustrations show deformities resulting from a broken wrist; Figs. 19 and 20 the crease at base of thumb; Fig. 21 hump on back of wrist; Fig. 22 twisted appearance of hand.

FRACTURE OF BONE OF HAND, OR FINGER.

First Aid Rule.—Set fragments of bone in place by pulling with one hand on finger, while pressing fragments into position with other hand. Put on each side of bone a splint made of cigar box, padded with folded handkerchiefs, and retain in place with bandage wound about snugly. Put forearm and hand in sling.

This accident more commonly happens to the bones corresponding to the middle and ring finger, and occurs between the knuckle and the wrist, appearing as a swelling on the back of the hand. On looking at the closed fist it will be seen that the knuckle corresponding to the broken bone in the back of the hand has ceased to be prominent, and has sunken down below the level of its fellows. The end of the fragment nearer the wrist can generally be felt sticking up in the back of the hand.

Fig. 23.

A BROKEN FINGER (Scudder).

Note splint extending from wrist to tip of finger; also manner of applying adhesive plaster strips and pad in palm.

If the finger corresponding to the broken bone in the back of the hand be pulled on forcibly, and the fragments be held between the thumb and forefinger of the other hand of the operator, pain and abnormal motion may be detected, and the ends of the broken bone pressed into place. A thin wooden splint, as a piece of cigar box, about an inch wide at base and tapering to the width of the finger should be applied to the palm of the hand extending from the wrist to a little beyond the finger tip, secured by strips of adhesive plaster, as in the cut, and covered by a bandage. The splint should be well padded, and an additional pad should be placed in the palm of the hand over the point of fracture. Three weeks are required for firm union, and the hand should not be used for a month.

It is usually easy to recognize a broken bone in a finger, unless the break is near a joint, when it may be mistaken for a dislocation. Pain, abnormal motion, and grating between the fragments are observed.

If there is deformity, it may be corrected by pulling on the injured finger with one hand, while with the other the fragments are pressed into line. A narrow, padded wooden or tin splint is applied, as in the cut (p. [102]), reaching from the middle of the palm to the finger tip. Any existing displacement of the broken bone can be relieved by using pressure with little pads of cotton held in place by narrow strips of adhesive plaster where it is needed to keep the bone in line. The splint may be removed in two weeks and a strip of adhesive plaster wound about the finger to support it for a week or two more.

In fracture of the thumb, the splint is applied along the back instead of on the palm side.

HIP FRACTURE.

First Aid Rule.—Put patient flat on back in bed, with limb wedged between pillows till surgeon arrives.

Fig. 24.

TREATING A BROKEN HIP (Scudder).

Note the manner of straightening leg and getting broken bone into line; also assistant carefully steadying the thigh.

A fracture of the hip is really a break of that portion of the thigh bone which enters into the socket of the pelvic bone and forms the hip joint. It occurs most commonly in aged people as a result of so slight an accident as tripping on a rug, or in falling on the floor from the standing position, making a misstep, or while attempting to avoid a fall. When the accident has occurred the patient is unable to rise or walk, and suffers pain in the hip joint. When he has been helped to bed it will be seen that the foot of the injured side is turned out, and the leg is perhaps apparently shorter than its fellow. There is pain on movement of the limb, and the patient cannot raise his heel, on the injured side, from the bed. Shortening is an important sign.

With the patient lying flat on the back and both legs together in a straight line with the body, measurements from each hip-bone are made with a tape to the bony prominence on the inside of each ankle, in turn. One end of the tape is held at the navel and the other is swung from one ankle to the other, comparing the length of the two limbs. Shortening of less than half an inch is of no importance as a sign of fracture. The fragments of broken bone are often jammed together (impacted) so that it is impossible to get any sound of grating between them, and it is very unwise to manipulate the leg or hip joint, except in the gentlest manner, in an attempt to get this grating. If the ends of the fragments become disengaged from each other it often happens that union of the break never occurs.

Fig. 25.

TREATMENT FOR FRACTURED HIP (Scudder).

Note method of holding splints in place with muslin strips; one above ankle, one below and one above knee, one in middle and one around upper part of thigh.

The treatment simply consists in keeping the patient quiet on a hard mattress, with a small pillow under the knee of the injured side and the limb steadied on either side by pillows or cushions until a surgeon can be obtained. (See Thigh-bone Fracture.)

THIGH-BONE FRACTURE.

First Aid Rule.—Prepare long piece of thin board which will reach from armpit to ankle, and another piece long enough to reach from crotch to knee, and pad each with folded towels or blanket.

While one assistant holds body back, and another assistant pulls on ankle of injured side, see that the fragments are separated and brought into good line, and then apply the splints, assistants still pulling steadily, and fasten the splints in place with bandage, or by tying several cloths across at three places above the knee and two places below the knee.

Finally, pass a wide band of cloth about the body, from armpit to hips, inclosing the upper part of the well-padded splint, and fasten it snugly. The hollow between splint and waist must be filled with padding before this wide cloth is applied.

In fracture of the thigh bone (between the hip and knee), there is often great swelling about the break. The limb is helpless and useless. There is intense pain and abnormal position in the injured part, besides deformity produced by the swelling. The foot of the injured limb is turned over to one side or the other, owing to a rolling over of the portion of the limb below the break. With both lower limbs in line with the body, and the patient lying on the back, measurements are made from each hip-bone to the prominence on the inside of either ankle joint. Shortening of the injured leg will be found, varying from one to over two inches, according to the overlapping and displacement of the fragments.

Treatment.—To set this fracture temporarily, a board about five inches wide and long enough to reach from the armpit to the foot should be padded well with towels, sheets, shawls, coats, blanket, or whatever is at hand, and the padding can best be kept in place by surgeon's adhesive plaster, bicycle tape, or strips of cloth.[8] Another splint should be provided as wide as the thigh and long enough to reach along the back of the leg from the middle of the calf to the buttock, and also padded in the same way. A third splint should be prepared in the same manner to go inside the leg, reaching from the crotch to the inside of the foot. Still a fourth splint made of a thin board as wide as the thigh, extending from the upper part of the thigh to just above the knee, is padded for application to the front of the thigh.

When these are made ready and at hand, the leg should be pulled on steadily but carefully straight away from the body to relax the muscles, an assistant holding the upper part of the thigh and pulling in the opposite direction. Then, when the leg has been straightened out and the thigh bone seems in fair line, the splints should be applied; the first to the outside of the thigh and body, the second under the calf, knee, and thigh; the third to the inside of the whole limb, and the fourth to the front of the thigh.

Wide pads should be placed over the ribs under the outside splint to fill the space above the hips and under the armpit. Then all four splints are drawn together and held in place by rubber-plaster straps or strips of strong muslin applied as follows: one above the ankle; one below the knee; one above the knee; one in the middle of the thigh, and one around the upper part of the thigh. A wide band of strong muslin or sheeting should then be bound around the whole body between the armpits and hips, inclosing the upper part of the outside splint. The patient can then be borne comfortably upon a stretcher made of boards and a mattress or some improvised cushion. (See Figs. [24] and [25].)

When the patient can be put immediately to bed after the injury, and does not have to be transported, it is only necessary to apply the outer, back, and front splints, omitting the inner splint. It is necessary for the proper and permanent setting of a fractured thigh that a surgeon give an anæsthetic and apply the splints while the muscles are completely relaxed. It is also essential that the muscles be kept from contracting thereafter by the application of a fifteen- or twenty-pound weight to the leg, after the splints are applied, but it is possible to outline here only the proper first-aid treatment.

KNEEPAN FRACTURE.

First Aid Rule.—Pain is immediate and intense. Separated fragments may be felt at first. Swelling prompt and enormous. Even if not sure, follow these directions for safety.

Prepare splint: thin board, four inches wide, and long enough to reach from upper part of thigh to just above ankle. Pad with folded piece of blanket or soft towels. Place it behind leg and thigh; carefully fill space behind knee with pad; fasten splint to limb with three strips of broad adhesive plaster, one around upper end of splint, one around lower end, one just below knee.

Lay large flat, dry sponge over knee thus held, and bandage this in place. Keep sponge and bandage wet with ice water. If no sponge is available, half fill rubber hot-water bottle with cracked ice, and lay this over knee joint. Put patient to bed.

Fracture of kneepan is caused either by direct violence or muscular strain. It more frequently occurs in young adults. Immediate pain is felt in the knee and walking becomes impossible; in fact, often the patient cannot rise from the ground after the accident. Swelling at first is slight, but increases enormously within a few hours. Immediately after the injury it may be possible to feel the separate broken fragments of the kneepan and to recognize that they are separated by a considerable space if the break is horizontally across the bone.

Fig. 26.

A BROKEN KNEEPAN (Scudder).

A padded splint, supporting knee, is shown reaching from ankle to thigh. Note number and location of adhesive plaster strips.

Nothing can be done to set the fracture until the swelling about the joint has been reduced, so that the first treatment consists in securing immediate rest for the kneejoint, and immobility of the fragments. A splint made of board, about a quarter of an inch thick and about four inches wide for an adult, reaching from the upper part of the thigh above to a little above the ankle below, is applied to the back of the limb and well padded, especially to fill the space behind the knee. The splint is attached to the limb by straps of adhesive plaster two inches and a half wide; one around the lower end of the splint, one around the upper part, and the third placed just below the knee. To prevent and arrest the swelling and pain, pressure is then made on the knee by bandaging.

One of the best methods (Scudder's) is to bind a large, flat, dry sponge over the knee and then keep it wet with cold water; or to apply an ice bag directly to the swollen knee; a splint in either case being the first requisite. The patient should of course be put to bed as soon as possible after the accident, and should lie on the back with the injured leg elevated on a pillow with a cradle to keep the clothes from pressing on the injured limb. (See cut, p. [110].)

FRACTURE OF LEG BONES, BETWEEN KNEE AND ANKLE.

First Aid Rule.—Handle very carefully; great danger of making opening to surface. Special painful point, angle or new joint in bone, disability, and grating felt will decide existence of break. Let assistant pull on foot, to separate fragments, while you examine part of supposed break. If only one bone is broken, there may be no displacement.

Put patient on back. While two assistants pull, one on ankle and one on thigh at knee, thus separating fragments, slide pillow lengthwise under knee, and, bringing its edges up about leg, pin them snugly above leg.

Prepare three pieces of thin wood, four inches wide and long enough to reach from sole of foot to a point four inches above knee. While assistants pull on limb again, as before, put one splint each side and third behind limb, and with bandage or strips of sticking plaster fasten these splints to the leg inclosed in its pillow as tight as possible.

In fracture of the leg between the knee and ankle we have pain, angular deformity or an apparent false joint in the leg, swelling and tenderness over the seat of fracture, together with inability to use the injured leg. Two bones form the framework of the leg; the inner, or shinbone, the sharp edge of which can be felt in front throughout most of its course, being much the larger and stronger bone. When both bones are broken, the displacement of the fragments, abnormal motion and consequent deformity, are commonly apparent, and a grating sound may be heard, but should not be sought for.

Fig. 27.

FRACTURE OF BOTH LEG BONES (Scudder).

This cut shows the peculiar deformity in breaks of this kind; see position of kneepan; also prominence of broken bone above ankle.

An open wound often communicates with the break, making the fracture compound, a much more serious condition. To avoid making the fracture a compound one, during examination of the leg, owing to the sharp ends of the bony fragments, the utmost gentleness should be used. Under no circumstances attempt to move the fragments from side to side, or backward and forward, in an effort to detect the grating sound often caused by the ends of broken bones. The greatest danger lies in the desire to do too much. We again refer the reader to First Aid Rule 1.

Fig. 28.

BANDAGE FOR BROKEN LEG (Scudder).

Note the pillow brought up around leg and edges pinned together; also length and method of fastening splint with straps.

When one bone is broken there may be only a point of tenderness and swelling about the vicinity of the break and no displacement or grating sound. When in doubt as to the existence of a fracture always treat the limb as if a fracture were present. "Black and blue" discoloration of the skin much more extensive than that following sprain will become evident over the whole leg within twenty-four hours.

Treatment.—When a surgeon cannot be obtained, the following temporary pillowdressing, recommended by Scudder in his book on fractures, is one of the best. With the patient on his back, the leg having been straightened and any deformity removed as far as possible by grasping the foot and pulling directly away from the body while an assistant steadies the thigh, a large, soft pillow, inclosed in a pillowcase, is placed under the leg. The sides of the pillow are brought well up about the leg and the edges of the pillowcase are pinned together along the front of the leg.

Then three strips of wood about four inches wide, three-sixteenths to a quarter of an inch thick, and long enough to reach from the sole of the foot to about four inches above the knee, are placed outside of the pillow along the inner and outer aspects of the leg and beneath it. The splints are held in place, with the pillow as padding beneath, by four straps of webbing (or if these cannot be obtained, by strips of stout cloth, adhesive plaster, or even rope); but four pads made of folded towels should be put under the straps where they cross the front of the leg where little but the pillowcase overlaps. These straps are applied thus: one above the knee, one above the ankle, and the other two between these two points, holding all firmly together. This dressing may be left undisturbed for a week or even ten days if necessary. (See Figs. [27] and [28].)

The leg should be kept elevated after the splints are applied, and steadied by pillows placed either side of it. From one to two months are required to secure union in a broken leg in adults, and from three to five months elapse before the limb is completely serviceable. In children the time requisite for a cure is usually much shorter.

ANKLE-JOINT FRACTURE.

First Aid Rule.—One or both bones of leg may be broken just above ankle. Foot is generally pushed or bent outward. Prepare two pieces of thin wood, four inches wide and long enough to go from sole of foot to just below knee:—the splints. Pad them with folded towels or pieces of blanket.

While assistants pull bones apart gently, one pulling on knee, other pulling on foot and turning it straight, apply the splints, one each side of the leg.

A fracture of the ankle joint is really a fracture of the lower extremities of the bones of the leg. There are present pain and great swelling, particularly on the inner side of the ankle at first, and the whole foot is pushed and bent outward. The bony prominence on the inner side of the ankle is unduly marked. The foot besides being bent outward is also displaced backward on the leg. This fracture might be taken for a dislocation or sprain of the ankle. Dislocation of the ankle without fracture is very rare, and when the foot is returned to its proper position it will stay there, while in fracture the foot drops back to its former displaced state. In sprained ankle there are pain and swelling, but not the deformity caused by the displacement of the foot.

This fracture may be treated temporarily by returning the foot to its usual position and putting on side splints and a back splint, as described for the treatment of fracture of the leg.

COMPOUND OR OPEN FRACTURE OF THE LEG.—This condition may be produced either by the violence which caused the fracture also leading to destruction of the skin and soft parts beneath, or by the end of a bony fragment piercing the muscles and skin from within. In either event the result is much more serious than that of an ordinary simple fracture, for germs can gain entrance through the wound in the skin and cause inflammation with partial destruction or death of the part.

Treatment.—Immediate treatment is here of the utmost value. It is applicable to open or compound fracture in any part of the body. The area for a considerable distance about the wound, if covered with hair, should be shaved. It should then be washed with warm water and soap by means of a clean piece of cotton cloth or absorbent cotton. Then some absorbent cotton or cotton cloth should be boiled in water in a clean vessel for a few minutes, and, after the operator has thoroughly washed his hands, the boiled water (when sufficiently cool) should be applied to the wounded area and surrounding parts with the boiled cotton, removing in the most painstaking way all visible and invisible dirt. By allowing some of the water to flow over the wound from the height of a few feet this result is favored. Finally some of the boiled cotton, which has not been previously touched, is spread over the wound wet, and covered with clean, dry cotton and bandaged.

Splints are then applied as for simple fracture in the same locality (p. [113]). If a fragment of bone projects through the wound it may be replaced after the cleansing just described, by grasping the lower part of the limb and pulling in a straight line of the limb away from the body, while an assistant holds firmly the upper part of the limb and pulls in the opposite direction. During the whole process neither the hands of the operator nor the boiled cotton should come in contact with anything except the vessel containing the boiled water and the patient.

FOOTNOTES:

[5] The engravings illustrating the chapters on "Fractures" and "Dislocations" are from Buck's "Reference Handbook of Medical Science," published by William Wood & Co., New York; also, Scudder's "Treatment of Fractures" and "American Text-Book of Surgery," published by W. B. Saunder's Company, Philadelphia.

[6] It should be distinctly understood that the information about fractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtained and, like other advice in this book, is intended to furnish first-aid information or directions to those who are in places where physicians cannot be secured.

[7] For treatment of compound fracture, see Compound Fracture of Leg (p. [116]).

[8] This method follows closely that recommended by Scudder, in his book "The Treatment of Fractures."