If the treatment recommended for delayed union fails, recourse must be had to operation, the most satisfactory procedure being to insert a bone graft in the form of an intra-medullary splint. In certain cases met with in the bones of the leg in children, the degree of atrophy of the bones is such that it has been found necessary to amputate after repeated attempts to obtain union by operative measures have failed.
In the tibia we have found that with the double electric saw a rod of bone can be rapidly and accurately cut, extending well above as well as below the site of fracture but unequally in the two directions; the rod is then reinserted into the trough from which it was taken with the ends reversed, so that a strong bridge of bone is provided at the seat of non-union.
Clinical Features of Simple Fractures
In the first place, the history of the accident should be investigated, attention being paid to the nature of the violence—whether a blow, a twist, a wrench, or a crush, and whether the violence was directly or indirectly applied. The degree of the violence may often be judged approximately from the instrument inflicting it—whether, for example, a fist, a stick, a cart wheel, or a piece of heavy machinery. The position of the limb at the time of the injury; whether the muscles were braced to meet the blow or were lax and taken unawares; and the patient's sensations at the moment, such as his feeling something snap or tear, may all furnish information useful for purposes of diagnosis.
Signs of Fracture.—The most characteristic signs of fracture are unnatural mobility, deformity, and crepitus.
Unnatural mobility—that is, movement between two segments of a limb at a place where movement does not normally occur—may be evident when the patient makes attempts to use his limb, or may only be elicited when the fragments are seized and moved in opposite directions. Deformity, or the part being “out of drawing” in comparison with the normal side, varies with the site and direction of the break, and depends upon the degree of displacement of the fragments. Crepitus is the name applied to the peculiar grating or clicking which may be heard or felt when the fractured surfaces are brought into contact with one another.
The presence of these three signs in association is sufficient to prove the existence of a fracture, but the absence of one or more of them does not negative this diagnosis. There are certain fallacies to be guarded against. For example, a fracture may exist and yet unnatural mobility may not be present, because the bones are impacted into one another, or because the fracture is an incomplete one. Again, the extreme tension of the swollen tissues overlying the fracture may prevent the recognition of movement between the fragments. Deformity also may be absent—as, for instance, when there is no displacement of the fragments, or when only one of two parallel bones is broken, as in the leg or forearm. Similarly, crepitus may be absent when impaction exists, when the fragments completely override one another, or are separated by an interval, or when soft tissues, such as torn periosteum or muscle, are interposed between them. A sensation simulating crepitus may be felt on palpating a part into which blood has been extravasated, or which is the seat of subcutaneous emphysema. The creaking which accompanies movements in certain forms of teno-synovitis and chronic joint disease, and the rubbing of the dislocated end of a bone against the tissues amongst which it lies, may also be mistaken for the crepitus of fracture.
It is not advisable to be too diligent in eliciting these signs, because of the pain caused by the manipulations, and also because vigorous handling may do harm by undoing impaction, causing damage to soft parts or producing displacement which does not already exist, or by converting a simple into a compound fracture.
It is often necessary for purposes of diagnosis to administer a general anæsthetic, particularly in injuries of deeply placed bones and in the vicinity of joints. Before doing so, the appliances necessary for the treatment of the injury should be made ready, in order that the fracture may be reduced and set before the patient regains consciousness.
Radiography in the Diagnosis of Fractures.—While radiography is of inestimable value in the diagnosis of many fractures and other injuries, particularly in the vicinity of joints, the student is warned against relying too implicitly on the evidence it seems to afford.