Prognosis.
—The prognosis depends upon the age and vitality of the patient, the location and extent of the fracture, the method of treatment, and upon causes which seem at first foreign to the subject. Patients with pulmonary or cardiac trouble, who need frequent change in position, or perhaps absolute rest, are likely to develop something hurriedly which will disarrange ordinary calculations. Sometimes they die suddenly or they may develop pulmonary edema or hypostatic pneumonia. The circulation may be so poor as to lead to early development of bed-sores, while ordinary complications in prostatics, or habitual constipation in the aged, may make care and treatment exceedingly difficult. It should be emphasized, then, that treatment of the fracture alone is by no means all that these patients require, and prognosis means something more than what may merely happen to the bone. In this last respect, however, the better nourished the fragment the more likely is bony union to take place if good position can be maintained. When osseous union has failed patients get fairly useful limbs with fibrous or ligamentous union, even with one or two inches of shortening, and such patients may hobble about for years, with a cane or a crutch, with limbs that are semiserviceable.
Treatment.
—Of these cases it may be said that interests of life are paramount to those of limb, and the treatment should be directed to that which the patient can tolerate. Reasonably healthy, muscular people can bear the application of adhesive strips and traction such as the thin and delicate cannot tolerate. The ideal method is that by which sufficient traction is made to overcome all muscle pull which shall produce shortening, the measure of weight to be used in these cases being the effect thereby produced. Thus if twenty pounds be sufficient, well and good; if not, it should be increased to thirty or forty pounds, providing that the patient can tolerate it. At the same time a broad binder around the pelvis may afford sufficient support with a tractable patient, while many will require a long side splint, extending from the axilla to beneath the foot, to which both body and the injured limb should be fastened, in order to more perfectly maintain that physiological rest which is so necessary. This last is the so-called “Physick” splint, which has been variously modified, while the method of traction has been usually spoken of as Buck’s extension. It seems well thus to commemorate the names of the American surgeons who showed the value of these methods. When a long side splint cannot be borne, sandbags 15 in. or 20 in. in length and 3 in. in diameter may be used to give support. Any decided tendency to eversion of the limb should be corrected as well as the shortening. When the long side splint is used the foot can be held in place with it and thus the position of the shaft of the femur controlled. At other times this may be done by flexing the knee and thus preventing upward rotation. In all methods of traction it is advisable to keep the heel free from the bed, in order that the effect of the method may not be lost by the obstruction of the mattress.
Fig. 315
Fig. 316
Fig. 317
