Diagnosis having been made, the surgeon should study how he may best carry out the fundamental principle of putting the parts in apposition and so maintaining them.
The greatest obstacle to reduction and maintenance in position is muscle pull. After an injury of this kind there will be more or less muscle spasm, the more powerful groups displacing bones in the natural direction of their pull. In the humerus and femur especially all arm or thigh muscles will coöperate to produce shortening. As indicated in the chapter on Joint Affections, nothing so thoroughly overcomes chronic muscle spasm as traction. The principle underlying treatment by traction is exceedingly simple, but there are numerous ways and mechanical expedients for effecting it. In the lower limb, whether this shall be done by anterior suspension, by weight and pulley, by elastic contraction, or by some of the more complicated splints, matters little so long as it be efficiently made. Of all these methods it may be said in general the simplest is the best. In the upper extremity traction may be made by similar methods with the patient in bed, or the patient may be allowed to rise and be about with a weight hanging from the elbow or some simple expedient of this kind.
The method of traction is one to be combined usually with further protection, by which not only longitudinal but lateral displacement maybe overcome. This suggests the use of splints in addition to mere traction methods.
It is not always possible to put in operation at first that method which we may prefer a little later, as swelling is usually so pronounced as to make it advisable only to put the parts at rest and hasten absorption. The same is true of hemorrhage. In rarer instances it may be a question as to whether the distal parts may undergo gangrene from the disturbance of circulation. These are matters to be duly regarded before the later and more complete dressing. Mechanical aids, usually in the shape of splints, are therefore necessary. The physiological rest which it is so necessary to ensure will lead to a certain wasting of muscles and stiffening of joints, which are only temporary, but which by no means lessen disability when splints are removed. That splint is best for a given case which best fits it and permits the surgeon to carry out its peculiar indications. The writer is opposed to manufactured splints, as they seldom fit the part. This can be obviated by packing cotton or other compressible material into the splint. For temporary purposes they will frequently suffice. For fixed dressing, however, it is preferable to make a splint which shall fit the limb to which it is affixed. Immobilization is difficult of accomplishment and at many points impossible. Thus in fracture of the ribs or clavicle it is impossible to avoid a certain amount of motion with each respiratory effort, even though an uncomfortably tight dressing be applied.
Splints are made of various materials, metal, wood, various compositions hardened in molds, plaster of Paris, or some of its substitutes, i. e., glue, soluble glass, or a composition like one made of equal parts of powdered starch and fine isinglass, added to a solution of potassium silicate, this being allowed to stand for several days, after which a little fine boric acid powder is added; when this is painted over gauze dressings it solidifies and forms a light and rigid splint. There is one objection to all methods which comprise a solution that hardens slowly—that is, that during the time required for the purpose redisplacement may occur. It is not advisable to dress a recent fracture in a wet pasteboard splint or in such a composition as that mentioned above. Later, when a certain amount of consolidation has already occurred they may serve a useful purpose.[38]
[38] Jenkins’ packing, such as is used on some engines, has been recommended by Spotswood as a substitute for plaster-of-Paris bandages, its advantages being that it is not affected by any antiseptic washes as a plaster dressing would be, that it is lighter, and that by placing it in hot water it can be molded to assume the shape of the limb.
There are two methods of using plaster of Paris: one is gauze bandages sprinkled with it, rolled, and kept ready for use, to be placed in water at the time of their employment. A limb may be enveloped in these, after being covered with a layer of wadding or some other protective material, by which the plaster shall not come in actual contact with the skin. It is also a good plan to place a strip of tin or pasteboard along the exposed surface of the limb, over which the surgeon cuts to remove the splint. Thus one may avoid any danger of injuring the skin with the point of the knife. It is also a good plan to make at least a part of this cut before the plaster has sufficiently hardened, i. e., to do most of the work, leaving perhaps a layer or two of gauze to be cut through some time later. It is necessary to impress the fact that when a quickly hardening fixed dressing is used approximation should be ensured by the greatest attention, maintaining it until the splint is so hardened that redislocation is impossible. Another method of using plaster of Paris is by sopping strips of surgeons’ lint, ordinary canton flannel, or almost any other similar material, in plaster-of-Paris cream, then molding these to the injured limb, maintaining the same rigid precaution as to the proper position of the same while the splint hardens. In this way a splint can be adapted to the part, and, at the same time, made removable, permitting as frequent access to it as may be desired.
COMPOUND FRACTURES AND THEIR TREATMENT.
As already stated, it is the communication of fractured bone surfaces with the external air which makes a fracture compound in the strictly surgical sense. This may occur through a minute and tortuous opening or through a large and extensive wound. Although the communication is with the atmosphere the danger comes not so much from germs floating in the air as from those on the surface of the body and within the pores of the skin, or else from foreign material admitted through the external wound. Obviously the great danger is of septic infection. Whether the tissues may prove more or less susceptible, and thus resist or break down, cannot at the outset be foretold. This leaves but one imperative ride to follow, to act in every instance as though serious injection had occurred and to take precautions accordingly. Even a small puncture made by a spicule of bone may permit germs to be withdrawn into the tissues as the bone is replaced. If, then, the surgeon seals such a puncture he necessarily takes the chances and must abide the result. Whether he shall do this or not will depend upon the patient and the injury. At all events, the site of puncture should be carefully cleansed and disinfected and the case so dressed that it may be carefully watched. Complete sterilization of every particle of exposed tissue is absolutely necessary, and for this purpose hydrogen dioxide or some of its later substitutes will prove effective. A protruding splinter of bone should be removed with cutting forceps, unless the wound must be enlarged as a part of the treatment of the fracture. In most instances it will be safer to pursue this course, i. e., to extend the wound which makes the fracture compound, to a degree permitting thorough exploration and cleansing. Not infrequently fragments of bone will be found, which when nearly or completely detached should be removed. Such a free opening permits also of wiring, or other means of fastening together bone ends, by which apposition may be more perfectly secured. A compound fracture which has been long unattended may be safely assumed to be septic. Here free incision, with cleansing and ample drainage, will be a far safer course than non-compliance with the general rule.
Compound fractures of the skull are nearly always depressed fractures, and practically always call for operation. Their proper treatment will be dealt with when considering Injuries to the Head. A fracture of the ribs may be made compound by penetration of a sharp bone end, and such injury to the lung as may permit air to escape into the pleural cavity. Such a pneumothorax may be followed by a hemothorax and hydrothorax, and these perhaps by empyema. Compound fractures of the pelvis are not infrequently complicated by perforation of the bladder or bowel, or rupture of the urethra, or some other serious visceral injury which may determine their fate. Compound fractures are difficult of treatment because they entail frequent changes of dressing and prevent the use of desirable splints. These fractures are also sometimes so serious as to necessitate amputation, which may be necessitated either by such comminution of bone as to make repair impossible, or such injury to vessels as may determine gangrene. If the circulation can be shown to be sufficient, either at the time or perhaps by delay of a few hours or a day, a limb may be saved by the resection of one or both bones, which in pre-antiseptic days would have required amputation.