The surgeon does not always see these cases in their recent or fresh state. He may be called to a case complicated by suppuration, cellulitis, and sepsis. Here though amputation may be required he may still delay it, hoping to improve local conditions, and thus to make it more promising, or he may have to resort to various expedients, such as suspension with constant irrigation, or temporary packing with yeast, in order to justify any further attack upon the parts already involved.
In the treatment of compound as of simple fractures we should never lose sight of the dangers of too tight bandaging and of pressure sores. I have seen both these lead to gangrene, with its necessary mutilation, in cases where the attendant has forgotten the proneness of injured parts to swell, and has either not allowed for this within the dressings or has not atoned for it in time when it has already occurred.
In the treatment of all these cases the operator should never forget the medicolegal aspects of such a case nor the necessity for constant attention and caution on his part. He should remember that his minutest precautions will often be disobeyed. He may, however, be cheered by the fact that only in cases of carelessness will he incur legal responsibility.
SPECIAL FRACTURES.
Fractures of the skull and of the vertebræ will be considered under the respective headings of Injuries to the Head and to the Spine.
FRACTURES OF THE NOSE.
The nose is the most frequently broken of all the bony parts about the face. One nasal bone or both may be broken, and each may be separated from its bony supports as well as from the other. The fracture may be compound in either direction, most frequently so into the nasal cavity, as a result of which infection may as easily take place from within as from without. The cartilages may also participate in the injury.
The injury would be easy of recognition were it not for the amount of swelling that often accompanies it. The signs are mobility and crepitus, with more or less deformity. So long as the nose can be grasped between the fingers recognition of fracture is easy. If swelling prevents this an instrument or the finger can be passed into one nostril and combined manipulation practised. There is generally more or less bleeding from the nose, and sometimes considerable emphysema. Swelling and ecchymosis are also often pronounced. This will all subside under cool and soothing applications. The most important indication is to replace the nose and hold it where it should remain. The difficulty is increased by the efforts which the patient instinctively makes to dislodge clot or secretion. The importance of accurate reposition is in some cases sufficient to justify an anesthetic and instrumental help. This will permit of the application of such force as may be necessary to elevate or to shift fragments, while a gutta-percha splint may be molded upon the outside, or a sterilized pin or needle made to transfix the nose from one side to the other (Mason), passing behind the fragments and through the septum in such a way as to keep it from dropping backward. A good plan is to introduce a tube into each nostril, perhaps a piece of silk catheter, around which a certain amount of gauze can be packed, and which can thus be used as an internal splint, while on either side and externally a little roll of gauze is held in place by adhesive plaster crossing the cheeks. The operator should take as much pains to see that the septum is in its original position as in attending to outside and cosmetic effects. The septum can be controlled by a pair of forceps.
A nose properly held in place will heal within a few days, to a point requiring little if any support. A transfixion pin should not be needed, if used, for more than four or five days. An internal splint should be removed each day, so that the nose may be sprayed with cleansing solution (Dobell’s) and retained secretions removed.
The disfigurement resulting after this injury is dropping in at the root of the nose, constituting the so-called saddle-nose defect. Such disfigurement as results can be later atoned for by subcutaneous injection of paraffin. (See chapter on [Surgery of the Face].)