Intra-uterine fractures have not as yet been mentioned. These occur during the intra-uterine life of the fetus; this term does not include such fractures as may be inflicted during delivery with or without instruments. In a fetus already affected with congenital rickets it may not require any severe contusion upon the abdomen of the mother to inflict a fracture. Starvation (i. e., scurvy, syphilis, and struma) in the mother may so disturb nutrition as to weaken the osseous system of her offspring.
Such previous conditions as ensue from osteomyelitis (i. e., caries and necrosis) may often weaken the bone. Nevertheless with distinct necrosis there is usually so much new bone formation as to strengthen rather than weaken the part. Bones may also become fragile as the result of syphilis, especially when gummas develop within them.
Fractures frequently produce certain deformities which are more or less conspicuous and easily recognized. They are designated as angular, lateral, or axial (i. e., when the axes of bone are considerably displaced, even though they may be more or less parallel), longitudinal (when ends overlap), rotary, etc.; while by the interposition of muscles and other soft tissues more or less wide separation may be produced, the same result occurring when the olecranon or the upper half of the patella is widely separated from the main bone or portion by muscle pull.
DIAGNOSIS OF FRACTURES.
Fractures give rise to subjective symptoms and objective signs. In diagnosis the history is also of value, especially in those cases where it is a question of some constitutional affection and a minimum or absolute absence of violence. The apparent immunity which the intoxicated enjoy is in large measure due to the fact that by virtue of their condition one of the predisposing causes of fracture is avoided. There can be no doubt but what muscle tension, due to voluntary or instinctive efforts to avoid harm, is a contributing factor in the separation of many bones or their processes. A patient stupidly drunk will not make these efforts, and will fall in a relaxed condition, in which violence will probably be much less extensive, and the consequences less disastrous than if he made an effort to save himself from falling.
Pain and tenderness are evidences of injury, and will often serve for its location; even the reference of pain is somewhat suggestive. It is stated as a universal rule that when pressure is applied laterally or in the long axis of a bone and evokes pain, referred to a distance from the point where pressure is made, it will indicate fracture at the point to which it is referred. There is always impairment, usually loss of function, while effort to move a thus injured limb will give rise again to localized pain and tenderness. The pain of contusion is usually diffuse, and that of fracture is referred to a limited area. The tenderness produced by handling or examination will vary with the stolidity, the age, and the character of the patient, as well as the nature of the injury.
Objective signs are crepitus, mobility, deformity, ecchymosis, redisplacement. Crepitus means the sensation of grating or rubbing produced when fractured bone surfaces are moved upon each other. It is recognized by the sense of touch, sometimes by that of hearing. Its presence is pathognomonic, but its absence is a negative sign, and an effort should be made to obtain it. To repeat the demonstration, especially to demonstrate it to others, means superfluous manipulation, which is not to the best interest of the patient. Crepitus, then, should be carefully sought for; once detected it should be sufficient.
Abnormal mobility is explained only by fracture. It is easy to detect it in the shaft of a long bone, but when near the joint it is confusing. Its determination by manipulation is not seen in green-stick or impacted fracture unless these are further broken up by manipulation. When evident it should serve as a caution against unnecessary or rough handling, for if it be easily recognizable crepitus need not be sought.
Deformity is a striking and pathognomonic feature of fracture. It may be imitated by hematoma or sudden swelling of the soft parts or of joints. It may consist of shortening or of angular, lateral, or rotary displacement, or perhaps of depression or indentation. Careful inspection, then, and palpation should precede other methods of examination, as they are often sufficient to indicate the location, the nature, and sometimes even the character of the active causes.
Inspection of the injured part alone is not always sufficient. Careful comparison between the two sides of the body should be made in order that actual measurement or comparative examination may reveal what mere inspection would not. In connection with inspection it should be ascertained whether the individual has ever received previous injuries. The writer recalls a case where a physician claimed a recovery after fracture of the femur, treated by incompetent method, yet with ideal result, inasmuch as he said there was absolutely no shortening. A personal question, however, to the patient revealed the fact that he had had the other thigh broken some years previously, and that an apparently similar amount of shortening followed in each case.