Elements of Surgery

by Robert Liston

Compound fracture is rare, and likely to be productive of serious consequences. I have treated and witnessed several cases. In one the process was cut off by the patient falling out of bed on an earthenware vessel, which broke under the limb. The joint is necessarily opened. Violent inflammation soon commences, and can very seldom be kept within moderate bounds. Discharge of increased and vitiated synovial secretion takes place, followed by profuse and unhealthy suppuration. The cartilages ulcerate, and then the bones. The cellular tissue around becomes infiltrated, the parts swell and are discoloured, and collections of matter form probably at more points than one; perhaps there is a succession of abscesses. The condyles, and often a portion of the shaft of the bone, are denuded by the suppuration, and superficial necrosis results. Ultimately the patient grows hectic. Amputation had to be resorted to in three of the cases which have come under my observation, at the end of some weeks or months from the receipt of the accident.

Union of the simple fracture will take place by bone, if the portions be retained accurately and permanently in contact; but there is a risk of the joint remaining stiff, and of re-separation being produced by even slight violence. Union by ligament is as rapid as that by osseous matter; and if the ligament is short, the arm is quite as useful. Approximation of the broken surfaces is favoured by extension of the elbow-joint, the triceps muscle being thus relaxed. The limb must not, however, be but perfectly straight. The position is preserved by a splint placed on the fore part of the limb, extending from the middle of the arm to the lower part of the forearm, and retained by a roller applied, not over-tight, from the fingers upwards. The application of apparatus to the separated portion, with the view of forcing it into contact with the shaft of the ulna, is useless. The figure of 8 bandage, and such like, are hurtful. Permanent relaxation of the triceps, with prevention of motion, is sufficient. This is continued for three or four weeks; by that time the fracture will in all probability have united, and then gentle and gradual passive motion of the joint is to be commenced.

In compound fracture the prognosis is always unfavourable. Means must be taken to avert incited action—the limb must be properly placed without delay, the edges of the wound accurately approximated, and antiphlogistic measures pursued. Purulent collections must be opened early. Rest of the joint is to be insured, and support afforded, by bandaging and by the application of a splint. The patient will be fortunate if he escape mutilation by the amputating knife; but when the wound is trifling, and the parts not much lacerated or bruised, and the treatment carefully conducted, a cure may be effected by the same process as the simple fracture.

Fractures of the bones of the forearm, of one or both, are common; generally simple. The Radius may be broken at various points—at the upper part—near its head—at the middle—most frequently near the distal extremity. At the two first points the fracture will probably have been produced by direct violence; but near the carpus, it is usually the result of force applied to its extremity, as by falls in which the weight of the body is thrown on the palm of the hand. The ulna is usually broken by force directly applied, as when the arm is brought in contact with hard bodies in falls. By direct violence also, both bones may give way about the middle, and at corresponding points: or, when force is applied in the direction of the bones, the ulna may be found broken near the wrist, and the radius near the elbow.

When one bone is broken, there is little displacement. The power of motion is lost to a considerable degree, and there is some deformity, but little or no shortening. The existence of fracture is ascertained by tracing the bones with the fingers, and by gently rotating the limb; the broken portions moving on each other produce distinct crepitation. When the radius is broken near its middle, the forearm is kept pronated, and the broken extremities are drawn towards the ulna; by bringing the limb towards the supine position, the ends come together, and the one bone is removed from the other. Fracture of the radius near or through its distal extremity produces displacement of the wrist, with great deformity; and this is increased by bloody effusion into the sheaths of the tendons, and into the superficial cellular tissue. In fracture of both bones, there is much deformity and shortening of the limb; the power of moving the hand is lost; the muscles are bruised and torn, and great swelling soon results.

There is little difficulty in remedying the slight displacement which takes place when but one bone is broken, and in retaining the parts in a favourable position. In children, occasionally, one of the bones of the forearm is broken, the other being bent very considerably, so as to cause great deformity.[62] When both have given way, slight extension is required, and the forearm is placed in the middle state between pronation and supination. Two pasteboard splints, softened in hot water, and padded with tow, are applied, one on each aspect, from a little above the elbow to over the fingers; the outer should extend to the tips of the fingers, the inner need not pass the palm; they are retained by a roller. In fracture of both bones, a wooden splint should be retained on the outside of the limb for a few hours; but this precaution is scarcely required when but one has suffered. Similar treatment, along with attention to the wound, is required in compound fracture.

The metacarpal bones and phalanges of the fingers are subject to fractures, both simple and compound. The metacarpal bone supporting the little finger most frequently suffers from force applied to the knuckle, as in pugilistic encounters. The other metacarpal bones are occasionally broken from crushing of the hand, as by a heavy body falling on it, or by its becoming entangled amongst machinery. The injury is readily ascertained by moving the fingers, and pressing in the course of the bone. On laying hold of the distal end of the bone suspected to have given way, placing the fingers over the shaft, and attempting slight motion, distinct crepitation is perceived. For the cure, motion of the parts must be prevented for a sufficient time, and inflammation warded off when threatened; there is a little or no displacement, and consequently retentive apparatus can be almost wholly dispensed with.

Simple fractures of the phalanges are recognised and treated by even the most unlearned in the surgical profession. The deformity is so striking as to render mistakes as to the nature of the accident impossible; reduction is accomplished without difficulty; and the bones are kept in their proper places by a small splint, either of wood or pasteboard, placed on each side of the finger, and retained by a narrow roller fixed by glue or starch.

Compound fractures of the phalanges are almost uniformly followed by most violent inflammatory action in all the tissues, terminating in disease of the joints, and in death of the tendinous and fibrous tissues. The suppuration is profuse and unhealthy, and the infiltration of the soft parts extensive. The diseased action not unfrequently pervades the palm of the hand. In the great majority of cases, necessity for amputation arrives sooner or later.

Fracture of the bones composing the pelvis occasionally takes place, but can be produced only by the application of great force, as by a loaded vehicle passing over the body, or by a fall from a great height. The accident is usually attended with serious injury of the viscera contained in the pelvic cavity, or in that of the abdomen; they may be either ruptured, or lacerated by sharp projecting spiculæ, or merely bruised. The nature and extent of the injury is not easily ascertained. There is great pain on motion of the body or of the limbs, and usually extensive extravasation of blood in the soft parts; these circumstances, along with the symptoms that may arise from internal organs which have been injured, and a knowledge of the way in which the injury was inflicted, lead to a strong suspicion of fracture of the pelvis.