Surgery, with Special Reference to Podiatry

by Maximilian Stern; Edward Adams

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

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

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

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

The “blanket splint” can be readily made by folding a blanket in such a manner that it extends from the middle of the injured thigh to below the foot. Two pieces of narrow, strong board, or better still, two broomsticks are rolled up in the blanket, one at either end. The rolled-up blanket is now turned in so that the board supports with their enveloping turns of blanket, lie upon the posterior surface. Thus, a trough is formed in which the limb is placed and firmly secured by loops of bandage, one below the foot, the second just above the ankle, the third below the knee, and the fourth near the upper end of the blanket.

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

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

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

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

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