The principles and practice of modern surgery

by Roswell Park

DELAYED UNION; NON-UNION.

The above description refers to the process which is supposed to take place in normal bone repair. When, however, this is disturbed, as it may be from a variety of causes, there may be delayed union; when it completely fails we have non-union. General conditions have bearing on these local failures. Whatever makes a strain upon the system may interrupt the process, e. g., pregnancy, lactation, exhausting hemorrhages, acute diseases, starvation. Again, failure may result from purely local conditions, such as marked displacement, and particularly the intervention of some of the soft tissues, or any foreign body. Suppuration will also frequently cause great disappointment. The humerus is the bone most often troublesome in this direction; next the bones of the leg, the femur, and the bones of the forearm. It is necessary to distinguish between delayed union and absolute non-union. In the former normal processes may be simply retarded. When thus delayed they may be stimulated by rough handling, rubbing the bones together, or by perforating the callus with the point of a drill, from several directions. This method of drilling was introduced by Brainard, of Chicago. The existence of syphilis has much to do with delay, and should be combated by free use of antispecifics. Many patients will be found to have phosphaturia, i. e., to be eliminating phosphates which should go to repairing the bone. Such patients should be given phosphoric acid, with some of the phosphates, preferably of calcium, in order to make up for loss in this direction. Much can be done also by massage, and by everything which stimulates nutrition and general health ([fig. 280]).

Fig. 280

Vicious union with great deformity after fracture, requiring extensive operation. (Buffalo Clinic.)

In non-union efforts at repair are at a standstill; the bone ends become rounded off, the marrow cavity is plugged on either side, while in time the surrounding granulation or connective tissue undergoes condensation, as well as organization, and a capsule is formed in which a certain amount of fluid resembling true synovia collects, and thus is formed sometimes an almost perfect pseudarthrosis or false joint, whose perfection as a joint must be admired, although its presence is so deplored. The causes of non-union are now better understood than formerly, and consist largely in the interposition of fibrous and muscular tissues, that act as a barrier and keep the granulation tissue or the callus on one side from coalescing with that on the other.

Treatment of these cases will vary with their causes. In delayed union patients should be encouraged to use the parts, thereby causing greater activity, but in the presence of an actual false joint no method is of avail except that of actual exposure, by incision, with removal of all intervening fibrous tissue, and freshening of the bone surfaces by saw or chisel, the endeavor being to so shape them that they may lie in contact, and then be so maintained, by some mechanical expedient, such as a wire nail or suture, an ivory peg, a chromicized tendon, a bone ring, a small metal brace fastened with screws, or by any other expedient which may suggest itself to the ingenuity and the means of the operator. There are, however, occasions when one deliberately endeavors to secure a pseudarthrosis, as after ankylosis of the shoulder-joint, if in making powerful effort to break up adhesions the neck of the humerus should snap it would be better to prevent union rather than favor it, as in this way something resembling the original joint, so far as function is concerned, would be obtained. At the hip, also, after such an accident, the same principles may be adhered to or more deliberately secured by a subcutaneous osteotomy, as is sometimes done for relief of deformity.

Fibrous union implies such organization of granulation tissue as converts it into simple fibrous or ligamentous tissue, the change stopping here and not going on to formation of cartilage or bone. There are three localities especially where fibrous union is sometimes the best that can be obtained and often proves sufficient of itself; these are the olecranon, the patella, and the neck of the femur. Even though the halves of the patella be separated by two inches of ligamentous tissue the patient may still have reasonable use of the limb. A separation of half an inch to one inch at the olecranon does not materially disable the arm, while at the hip-joint two or three inches of ligamentous tissue between the main end of the bone and the fragment will not totally interfere with locomotion, except so far as it permits an equivalent amount of shortening of the leg. There are, then, occasions especially when the hip is involved in elderly and decrepit people, when ligamentous union is the best that can be hoped for or attained.

TREATMENT OF FRACTURES.

In principle the treatment of fractures is very simple. It consists in putting the parts in apposition and maintaining them there for sufficient time to permit of complete repair. That which is so simple in theory is often very difficult and sometimes even impossible in practice, made so by the nature of the injury or the disposition of the patient. In the aged, who cannot lie long in one position for fear of pulmonary stasis; also in the insane, in the epileptic, and in those suffering from delirium tremens, will be met difficulties which are insuperable. In such instances the first indication is to preserve the life of the patient, the second is to get a good result, the third is to do the best we can. Good management is not the least important feature of such treatment. This will include suitable nutrition, provision for elimination, prevention of bed-sores or pressure-sores, and many other less important features.