Elements of Surgery

by Robert Liston

The tibia is broken at its upper part near the tuberosity, with or without similar injury of the fibula. There is considerable displacement, particularly in the bent position of the knee; there is no restraint to the action of the extensor muscles inserted immediately above the point of fracture, and these, though not acting with unusual power, cause protrusion of the upper end of the tibia, the condyles of the femur serving as a fulcrum over which the muscles are stretched. This injury is usually the result of direct violence.

Fracture of one bone, at a point lower in the limb, is not attended with much displacement or deformity. Indeed, attentive manipulation is often required to detect the site of the injury; and a sense of crepitation is perceived, only when the lower and upper portions of the bone are pressed on alternately or during rotation of the foot. When both bones are broken, the displacement and swelling are great. The foot is sometimes turned inwards, but usually it falls outwards; and if there has been much laceration of the soft parts, with or without division of the integuments, the lower portion of the limb hangs quite loose.

By the application of great force, as by a rope being twisted round and run tight on the limb, both bones and soft parts may be reduced almost to a pulp, without much or any division of the integument. Such an accident is followed by rapid and great swelling, violent incited action, gangrene, and severe constitutional disturbance. The progress of the mortification is not in all cases uniform; in some, the swelling and discoloration extend to the groin and trunk in two or three days, attended with furious delirium; in others, the disorganisation of the limb is very slow, some days elapsing before it reaches the knee, and in these the constitutional symptoms are less severe.

In some cases there is extensive wound of the integuments, without serious injury of the bone, muscles, or vessels. The skin either has been divided by the external force acting upon the resisting bone, or the sharp fractured end of the bone has been thrust through. Sometimes the bone is protruded to a considerable extent, and entangled amongst the more superficial soft parts.

Fractures of the lower portions of the bones are generally the consequence of twisting and partial displacement of the ankle. The fibula is most frequently broken by twisting of the foot outwards, and the fracture is almost uniformly between two and three inches above the articulation. The broken ends are displaced inwards upon the tibia. The injury is detected by moving the foot, and tracing the line of bone; after swelling has taken place, examination, though almost equally easy, is productive of much more pain, and it is of importance to ascertain the nature of the injury at once, and immediately after the accident. The outer malleolus sometimes gives way from the same cause; or it may be snapped off by a direct blow. The lower portion of the tibia is sometimes longitudinally split by bending inwards of the foot, the patient having fallen from a considerable height; occasionally the inner malleolus is broken transversely. Inquiry as to how the accident happened, particularly as to the direction of the twist, the displacement of the foot, and the degree and extent of crepitation, will determine the nature of the injury.

The astragalus, os calcis, the other bones of the tarsus, and those of the metatarsus, are sometimes broken by the application of great force, but they are not much displaced. Sometimes the foot is violently concussed in consequence of a fall from a height, and though no fracture may have occurred, the patient is equally lame and pained; severe inflammation is sure to supervene rapidly, and may terminate untowardly.

Fracture of the upper part of the tibia is to be treated in the straight position, for it has been already observed, that when the knee is bent the upper portion necessarily projects. A hollowed splint of wood, extending from the middle of the thigh to near the heel, is applied behind, whilst one of pasteboard may be placed on each side: all are secured by bandaging, the foot and lower part of the limb being rolled previously to prevent infiltration; by this simple apparatus, motion of the knee-joint, and of the ends of the bones on each other, is completely prevented; the heel is raised, if necessary, for complete adaptation.

Fractures of the middle and lower portions of the bones are treated most advantageously, whether simple or compound, in the bent position, the angle being made more or less obtuse, according to the degree of flexion most conducive to easy reduction and retention. Extension is made on the limb, and the parts brought into as natural and handsome a shape as possible; in doing so, the appearance of the sound member should be kept in view. There is seldom any difficulty in accomplishing reduction; the extending and counter-extending power need be but slight; the upper part of the limb is steadied by an assistant, whilst the lower is stretched and moulded by the hands of the surgeon. In compound fractures at this part, the portions of bone completely detached from the hard and soft parts are to be extracted. And if reduction cannot be effected in consequence of a sharp and long end of the bone projecting through a narrow wound, either the portion must be abridged by the saw or cutting pliers, or the wound must be enlarged. Sometimes the one mode is preferable—sometimes the other—occasionally both are required. When the protruding portion composes but a small portion of the shaft, though perhaps of considerable length, it should be taken away; when, on the contrary, it is more thick than long, it is better to enlarge the wound; but on this subject no general rules can be laid down. The splint is the same as that recommended when treating of fractured thigh, composed of a thigh and leg-piece, with a moveable foot-board—the double inclined plane, improved by the late Mr. M’Intyre of Newcastle and others. A very simple and efficient apparatus has been used in our hospital for some years back. It answers every purpose fully better than the others, and can be had of all the instrument makers for a third of the expense of those previously in use. The foot-board is fixed so as to make the leg-piece of the proper length, and the splint is secured at a convenient angle. It is padded by means of a cushion filled with oat chaff. The foot is rolled separately; the limb is then raised carefully, and laid down on the splint placed quickly beneath by an assistant; it is retained in a proper position by the hands of the assistant, whilst a roller is carried from the toes round the foot-board, and along the limb to the knee. A broad roller is then made to surround the thigh and splint, and having been turned several times round the loins, is secured to the upper part of the cushion. The limb is thus rendered independent of the motions of the trunk; it is made as of a piece with the splint. It should be raised considerably above the level of the trunk, whilst the patient is in bed, in order, by favouring the return of blood, to prevent swelling and inflammatory action. The wound, if any, is to be approximated. If discharge follow, part of the bandage may be undone from day to day, for the purpose either of employing fomentation or of applying suitable dressing, and still the limb is kept perfectly steady. Abscesses must be opened early—spiculæ removed—constitutional symptoms warded off, and, if they do occur, combated,—at one time inflammatory action must be kept down—at another and more advanced stage, the strength must be supported by all means. In simple fracture it is seldom necessary to undo the bandage, till the apparatus is loosened by subsidence of the swelling—and if the fracture be early reduced, and kept steady, that will be but slight. Then the bandages are undone and reapplied, and the position of the limb attended to. It is seldom necessary to interfere with the leg during readjustment, but should there be any deviation, even considerable, from the proper position, it is easily remedied at the end of the first, second, third, or even of the fourth week; but the sooner the better. The patient may be removed from bed, and may sit up during the greater part of the day, with the heel on a level with the pelvis, within the first week. His health, appetite, and spirits, are thus kept up, sore back is avoided, the tedium of confinement diminished, and the cure greatly accelerated. At the end of five, six, seven, or eight weeks, according to the age, and as the consolidation advances, the patient may be allowed to move about on crutches, some few days after removal of the apparatus, the foot and leg being still bandaged, and supported by light splints, or the bandages may be starched and applied moist, with portions of coarse brown paper interposed. A firm case is thus formed for the protection of the limb and retention of the bones. No weight should be put on the limb for several weeks after, otherwise a leg cured well and straightly may become bent, twisted, and deformed.

Fractures of the lower extremities of the bones, and of the malleoli, are reduced by placing the foot straight, and retaining it so by the application of a wooden splint; the parts are protected by a wedge-shaped pad, and the whole is retained by a common roller. The splint is made to project two inches or two inches and a half beyond the ankle, and to reach near to the knee-joint. It has two perforations in the upper end; to these a bandage is attached by its split end, and it is then carried down along the inside of the splint, and rolled round the foot and ankle; thus the apparatus is prevented from shifting upwards. The other extremity of the bandage, during its convolutions round the foot, is made to pass through notches in the farther end of the splint; the foot is thus turned to the side opposite to that in which it was placed by the accident, and ought to be retained so till consolidation has taken place. The splint is of course always placed on the side of the limb opposite to the fracture.

Disunited Fracture.—In some cases union takes place very slowly. On removing the splints, with the expectation of finding the bones firmly united, the ends can be moved very freely on each other without crepitation or much pain. This, as already stated, may be referrible to various causes,—necessary or accidental evacuations, natural or not—diversion of the nutritious fluids to some particular organ, as in pregnancy—the period of life—a diseased state of the bone of the periosteum or medullary web. By keeping the parts immoveable and firmly compressed for some time longer, consolidation may be brought about. But in spite of every care, the ends of the bones in some cases remain unconnected by any save a soft medium. This happens, however, very rarely under proper management. I have had but one case of it in my own practice, when the patient was from the first under my own inspection and care; and in that the occurrence of false joint was attributable solely to the absurd conduct of the patient. He was tripped up on the street by some individuals following their avocation as pickpockets, fell, and broke his forearm. The fracture was immediately reduced and splints applied—one of pasteboard on each side, with a wooden one exteriorly till the pasteboard hardened. He soon cut away the ends of the splints—within thirty-six hours after they had been put on—so as to allow motion of the fingers and hand, sufficient for indulgence in card-playing. The splints were still farther shortened, and wholly removed much too soon; shortly afterwards he fell from horseback. No union took place by bone. Unless in the case of previous disease of the bone, disunion is generally attributable to some carelessness or recklessness, either of the surgeon or of the patient.