Transcriber's note: The inverted 'Y' symbol used in this book has been transcribed as [inverted Y].

OXFORD MEDICAL PUBLICATIONS

MANUAL OF SURGERY

BY
ALEXIS THOMSON, F.R.C.S.Ed. AND Eng.
PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH
SURGEON EDINBURGH ROYAL INFIRMARY
AND
ALEXANDER MILES, F.R.C.S.Ed.
SURGEON EDINBURGH ROYAL INFIRMARY

VOLUME SECOND
EXTREMITIES—HEAD—NECK

SIXTH EDITION REVISED AND ENLARGED
WITH 288 ILLUSTRATIONS

LONDON
HENRY FROWDE and HODDER & STOUGHTON
THE LANCET BUILDING
1 & 2 BEDFORD STREET, STRAND, W.C. 2

Printed in Great Britain by
Morrison and Gibb Ltd., Edinburgh

CONTENTS

LIST OF ILLUSTRATIONS

MANUAL OF SURGERY

CHAPTER I
INJURIES OF BONES

• [Contusions]
• —[Wounds]
• —[Fractures]:
• [Pathological];
• [Traumatic];
• [Varieties]
• —[Simple fractures]
• —[Compound fractures]
• —[Repair of fractures]
• —[Interference with repair]
• —[Gun-shot fractures]
• —[Separation Of Epiphyses].

The injuries to which a bone is liable are Contusions, Open Wounds, and Fractures.

Contusions of Bone are almost of necessity associated with a similar injury of the overlying soft parts. The mildest degree consists in a bruising of the periosteum, which is raised from the bone by an effusion of blood, constituting a hæmatoma of the periosteum. This may be absorbed, or it may give place to a persistent thickening of the bone—traumatic node.

Open Wounds of Bone of the incised and contused varieties are usually produced by sabres, axes, butcher's knives, scythes, or circular saws. Punctured wounds are caused by bayonets, arrows, or other pointed instruments. They are all equivalent to compound, incomplete fractures.

FRACTURES

A fracture may be defined as a sudden solution in the continuity of a bone.

Pathological Fractures

A pathological fracture has as its primary cause some diseased state of the bone, which permits of its giving way on the application of a force which would be insufficient to break a healthy bone. It cannot be too strongly emphasised that when a bone is found to have been broken by a slight degree of violence, the presence of some pathological condition should be suspected, and a careful examination made with the X-rays and by other means, before arriving at a conclusion as to the cause of the fracture. Many cases are on record in which such an accident has first drawn attention to the presence of a new-growth, or other serious lesion in the bone. The following conditions, which are more fully described with diseases of bone, may be mentioned as the causes of pathological fractures.

Atrophy of bone may proceed to such an extent in old people, or in those who for long periods have been bed-ridden, that slight violence suffices to determine a fracture. This most frequently occurs in the neck of the femur in old women, the mere catching of the foot in the bedclothes while the patient is turning in bed being sometimes sufficient to cause the bone to give way. Atrophy from the pressure of an aneurysm or of a simple tumour may erode the whole thickness of a bone, or may thin it out to such an extent that slight force is sufficient to break it. In general paralysis, and in the advanced stages of locomotor ataxia and other chronic diseases of the nervous system, an atrophy of all the bones sometimes takes place, and may proceed so far that multiple fractures are induced by comparatively slight causes. They occur most frequently in the ribs or long bones of the limbs, are not attended with pain, and usually unite satisfactorily, although with an excessive amount of callus. Attendants and nurses, especially in asylums, must be warned against using force in handling such patients, as otherwise they may be unfairly blamed for causing these fractures.

Among diseases which affect the skeleton as a whole and render the bones abnormally fragile, the most important are rickets, osteomalacia, and fibrous osteomyelitis. In these conditions multiple pathological fractures may occur, and they are prone to heal with considerable deformity. In osteomalacia, the bones are profoundly altered, but they are more liable to bend than to break; in rickets the liability is towards greenstick fractures.

Of the diseases affecting individual bones and predisposing them to fracture may be mentioned suppurative osteomyelitis, hydatid cysts, tuberculosis, syphilitic gummata, and various forms of new-growth, particularly sarcoma and secondary cancer. It is not unusual for the sudden breaking of the bone to be the first intimation of the presence of a new-growth. In adolescents, fibrous osteomyelitis affecting a single bone, and in adults, secondary cancer, are the commonest local causes of pathological fracture.

Intra-uterine fractures and fractures occurring during birth are usually associated with some form of violence, but in the majority of cases the fœtus is the subject of constitutional disease which renders the bones unduly fragile.

Traumatic Fractures

Traumatic fractures are usually the result of a severe force acting from without, although sometimes they are produced by muscular contraction.

Fig. 1.—Multiple Fracture of both Bones of Leg.

When the bone gives way at the point of impact of the force, the violence is said to be direct, and a “fracture by compression” results, the line of fracture being as a rule transverse. The soft parts overlying the fracture are more or less damaged according to the weight and shape of the impinging body. Fracture of both bones of the leg from the passage of a wheel over the limb, fracture of the shaft of the ulna in warding off a stroke aimed at the head, and fracture of a rib from a kick, are illustrative examples of fractures by direct violence.

When the force is transmitted to the seat of fracture from a distance, the violence is said to be indirect, and the bone is broken by “torsion” or by “bending.” In such cases the bone gives way at its weakest point, and the line of fracture tends to be oblique. Thus both bones of the leg are frequently broken by a person jumping from a height and landing on the feet, the tibia breaking in its lower third, and the fibula at a higher level. Fracture of the clavicle in its middle third, or of the radius at its lower end, from a fall on the outstretched hand, are common accidents produced by indirect violence. The ribs also may be broken by indirect violence, as when the chest is crushed antero-posteriorly and the bones give way near their angles. In fractures by indirect violence the soft parts do not suffer by the violence causing the fracture, but they may be injured by displacement of the fragments.

In fractures by muscular action the bone is broken by “traction” or “tearing.” The sudden and violent contraction of a muscle may tear off an epiphysis, such as the head of the fibula, the anterior superior iliac spine, or the coronoid process of the ulna; or a bony process may be separated, as, for example, the tuberosity of the calcaneus, the coracoid process of the scapula, or the larger tubercle (great tuberosity) of the humerus. Long bones also may be broken by muscular action. The clavicle has snapped across during the act of swinging a stick, the humerus in throwing a stone, and the femur when a kick has missed its object. Fractures of ribs have occurred during fits of coughing and in the violent efforts of parturition.

Before concluding that a given fracture is the result of muscular action, it is necessary to exclude the presence of any of the diseased conditions that lead to pathological fracture.

Although the force acting upon the bone is the primary factor in the production of fractures, there are certain subsidiary factors to be considered. Thus the age of the patient is of importance. During infancy and early childhood, fractures are less common than at any other period of life, and are usually transverse, incomplete, and of the nature of bends. During adult life, especially between the ages of thirty and forty, the frequency of fractures reaches its maximum. In aged persons, although the bones become more brittle by the marrow spaces in their interior becoming larger and filled with fat, fractures are less frequent, doubtless because the old are less exposed to such violence as is likely to produce fracture.

Males, from the nature of their occupations and recreations, sustain fractures more frequently than do females; in old age, however, fractures are more common in women than in men, partly because their bones are more liable to be the seat of fatty atrophy from senility and disease, and partly because of their clothing—a long skirt—they are more exposed to unexpected or sudden falls.

Clinical Varieties of Fractures.—The most important subdivision of fractures is that into simple and compound.

In a simple or subcutaneous fracture there is no communication, directly or indirectly, between the broken ends of the bone and the surface of the skin. In a compound or open fracture, on the other hand, such a communication exists, and, by furnishing a means of entrance for bacteria, may add materially to the gravity of the injury.

A simple fracture may be complicated by the existence of a wound of the soft parts, which, however, does not communicate with the broken bone.

Fractures, whether simple or compound, fall into other clinical groups, according to (1) the degree of damage done to the bone, (2) the direction of the break, and (3) the relative position of the fragments.

(1) According to the Degree of Damage done to the Bone.—A fracture may be incomplete, for example in greenstick fractures, which occur only in young persons—usually below the age of twelve—while the bones are still soft and flexible. They result from forcible bending of the bone, the osseous tissue on the convexity of the curve giving way, while that on the concavity is compressed. The clavicle and the bones of the forearm are those most frequently the seat of greenstick fracture ([Fig. 41]). Fissures occur on the flat bones of the skull, the pelvic bones, and the scapula; or in association with other fractures in long bones, when they often run into joint surfaces. Depressions or indentations are most common in the bones of the skull.

The bone at the seat of fracture may be broken into several pieces, constituting a comminuted fracture. This usually results from severe degrees of direct violence, such as are sustained in railway or machinery accidents, and in gun-shot injuries ([Fig. 2]).

Fig. 2.—Radiogram of Comminuted Fracture of both Bones of Forearm.

Sub-periosteal fractures are those in which, although the bone is completely broken across, the periosteum remains intact. These are common in children, and as the thick periosteum prevents displacement, the existence of a fracture may be overlooked, even in such a large bone as the femur.

Fig. 3.—Showing (1) Oblique fracture of Tibia; (2) Oblique fracture with partial separation of Epiphysis of upper end of Fibula; (3) Incomplete fracture of Fibula in upper third. Result of railway accident. Boy æt. 16.

A bone may be broken at several places, constituting a multiple fracture ([Fig. 1]).

Separation of bony processes, such as the coracoid process, the epicondyle of the humerus, or the tuberosity of the calcaneus, may result from muscular action or from direct violence. Separation of epiphyses will be considered later.

(2) According to the Direction of the Break.—Transverse fractures are those in which the bone gives way more or less exactly at right angles to its long axis. These usually result from direct violence or from end-to-end pressure. Longitudinal fractures extending the greater part of the length of a long bone are exceedingly rare. Oblique fractures are common, and result usually from indirect violence, bending, or torsion ([Fig. 3]). Spiral fractures result from forcible torsion of a long bone, and are met with most frequently in the tibia, femur, and humerus.

(3) According to the Relative Position of the Fragments.—The bone may be completely broken across, yet its ends remain in apposition, in which case there is said to be no displacement. There may be an angular displacement—for example, in greenstick fracture. In transverse fractures of the patella or of the olecranon there is often distraction or pulling apart of the fragments ([Fig. 35]). The broken ends, especially in oblique fractures, may override one another, and so give rise to shortening of the limb ([Fig. 2]). Where one fragment is acted upon by powerful muscles, a rotatory displacement may take place, as in fracture of the radius above the insertion of the pronator teres, or of the femur just below the small trochanter. The fragments may be depressed, as in the flat bones of the skull or the nasal bones. At the cancellated ends of the long bones, particularly the upper end of the femur and humerus, and the lower end of the radius, it is not uncommon for one fragment to be impacted or wedged into the substance of the other ([Fig. 28]).

Causes of Displacement.—The factors which influence displacement are chiefly mechanical in their action. Thus the direction and nature of the fracture play an important part. Transverse fractures with roughly serrated ends are less liable to displacement than those which are oblique with smooth surfaces. The direction of the causative force also is a dominant factor in determining the direction in which one or both of the fragments will be displaced. Gravity, acting chiefly upon the distal fragment, also plays a part in determining the displacement—for example, in fractures of the thigh or of the leg, where the lower segment of the limb rolls outwards, and in fractures of the shaft of the clavicle, where the weight of the arm carries the shoulder downwards, forwards, and medially. After the break has taken place and the force has ceased to act, displacement may be produced by rough handling on the part of those who render first aid, the careless or improper application of splints or bandages, or by the weight of the bedclothes.

In certain situations the contraction of unopposed, or of unequally opposed, groups of muscles plays a part in determining displacement. For example, in fracture immediately below the lesser trochanter of the femur, the ilio-psoas tends to tilt the upper fragment forward and laterally; in supra-condylar fracture of the femur, the muscles of the calf pull the lower fragment back towards the popliteal space; and in fracture of the humerus above the deltoid insertion, the muscles inserted into the inter-tubercular (bicipital) groove adduct the upper fragment.

Repair of Injuries of Bone

In a simple fracture the vessels of the periosteum and the marrow being torn at the same time as the bone is broken, blood is poured out, and clots around and between the fragments. This clot is soon permeated by newly formed blood vessels, and by leucocytes and fibroblasts, the latter being derived from proliferation of the cells of the marrow and periosteum. The granulation tissue thus formed resembles in every particular that described in the repair of other tissues, except that the fibroblasts, being the offspring of cells which normally form bone, assume the functions of osteoblasts, and proceed to the formation of bone. The new bone may be formed either by a direct conversion of the fibrous tissue into osseous tissue, the osteoblasts arranging themselves concentrically in the recesses of the capillary loops, and secreting a homogeneous matrix in which lime salts are speedily deposited; or there may be an intermediate stage of cartilage formation, especially in young subjects, and in cases where the fragments are incompletely immobilised. The newly formed bone is at first arranged in little masses or in the form of rods which unite with each other to form a network of spongy bone, the meshes of which contain marrow.

Fig. 4.—Excess of Callus after compound fracture of Bones of Forearm.

The reparative material, consisting of granulation tissue in the process of conversion into bone, is called callus, on account of its hard and unyielding character. In a fracture of a long bone, that which surrounds the fragments is called the external or ensheathing callus, and may be likened to the mass of solder which surrounds the junction of pipes in plumber-work; that which occupies the position of the medullary canal is called the internal or medullary callus; and that which intervenes between the fragments and maintains the continuity of the cortical compact tissue of the shaft is called the intermediate callus. This intermediate callus is the only permanent portion of the reparative material, the external and internal callus being only temporary, and being largely re-absorbed through the agency of giant cells.

Detached fragments or splinters of bone are usually included in the callus and ultimately become incorporated in the new bone that bridges the gap.

In time all surplus bone is removed, the medullary canal is re-formed, the young spongy bone of the intermediate callus becomes more and more compact, and thus the original architectural arrangement of the bone may be faithfully reproduced. If, however, apposition is not perfect, some of the new bone is permanently required and some of the old bone is absorbed in order to meet the altered physiological strain upon the bone resulting from the alteration in its architectural form. In overriding displacement, even the dense cortical bone intervening between the medullary canal of the two fragments is ultimately absorbed and the continuity of the medullary canal is reproduced.

The amount of callus produced in the repair of a given fracture is greater when movement is permitted between the broken ends. It is also influenced by the character of the bone involved, being less in bones entirely ossified in membrane, such as the flat bones of the skull, than in those primarily ossified in cartilage.

If the fragments are widely separated from one another, or if some tissue, such as muscle, intervenes between them, callus may not be able to bring about a bony union between the fragments, and non-union results.

Bones divided in the course of an operation, for example in osteotomy for knock-knee, or wedge-shaped resection for bow-leg, are repaired by the same process as fractures.

Excess of Callus.—In comminuted fractures, and in fractures in which there is much displacement, the amount of callus is in excess, but this is necessary to ensure stability. In fractures in the vicinity of large joints, such as the hip or elbow, the formation of callus is sometimes excessive, and the projecting masses of new bone restrict the movements of the joint. When exuberant callus forms between the bones in fractures of the forearm, pronation and supination may be interfered with ([Fig. 4]). Certain nerve-trunks, such as the radial (musculo-spiral) in the middle of the arm, or the ulnar at the elbow-joint, may become included in or pressed upon by callus.

Absorption of Callus.—It sometimes happens that when an acute infective disease, especially one of the exanthemata, supervenes while a fracture is undergoing repair, the callus which has formed becomes softened and is absorbed. This may occur weeks or even months after the bone has united, with the result that the fragments again become movable, and it may be a considerable time before union finally takes place.

Tumours of Callus.—Tumours, such as chondroma and sarcoma, and cysts which are probably of the same nature as those met with in osteomyelitis fibrosa, are liable to occur in callus, or at the seat of old fractures, but the evidence so far is inconclusive as to the causative relationship of the injury to the new-growth. They are treated on the same lines as tumours occurring independently of fracture.

Fig. 5.—Multiple Fractures of both Bones of Forearm showing mal-union.

Badly United Fracture—Mal-Union.—Union with marked displacement of the fragments is most common in fractures that have not been properly treated—as, for example, those occurring in sailors at sea; and in cases in which the comminution was so great that accurate apposition was rendered impossible. It may also result from imperfect reduction, or because the apparatus employed permitted of secondary displacement. Restlessness on the part of the patient from intractability, delirium tremens, or mania, is the cause of mal-union in some cases; sometimes it has resulted because the patient was expected to die from some other lesion and the fracture was left untreated.

Whether or not any attempt should be made to improve matters depends largely on the degree of deformity and the amount of interference with function.

When interference is called for, if the callus is not yet firmly consolidated, it may be possible, under an anæsthetic, to bend the bone into position or to re-break it, either with the hands or by means of a strong mechanical contrivance known as an osteoclast. In the majority of cases, however, an open operation yields results which are more certain and satisfactory. When the deformity is comparatively slight, the bone is divided with an osteotome and straightened; when there is marked bending or angling, a wedge is taken from the convexity, as in the operation for bow-leg. To maintain the fragments in apposition it may be necessary to employ pegs, plates, bone-grafts, or other mechanical means. Splints and extension are then applied, and the condition is treated on the same lines as a compound fracture.

Delayed Union.—At the time when union should be firm and solid, it may be found that the fragments are only united by a soft cartilaginous callus, which for a prolonged period may undergo no further change, so that the limb remains incapable of bearing weight or otherwise performing its functions. The normal period required for union may be extended from various causes. The most important of these is general debility, but the presence of rickets or tuberculosis, or an intercurrent acute infectious disease, may delay the reparative process. The influence of syphilis, except in its gummatous form, in interfering with union is doubtful. The influence of old age as a factor in delaying union has been overestimated; in the great majority of cases, fractures in old people unite as rapidly and as firmly as those occurring at other periods of life.

Treatment.—The general condition of the patient should be improved, by dieting and tonics. One of the most reliable methods of hastening union in these cases is by inducing passive hyperæmia of the limb after the method advocated by Bier, and this plan should always be tried in the first instance. An elastic bandage is applied above the seat of fracture, sufficiently tightly to congest the limb beyond, and, to concentrate the congestion in the vicinity of the fracture, an ordinary bandage should be applied from the distal extremity to within a few inches of the break. The hyperæmia should be maintained for several hours (six to twelve) daily. An apparatus should be adjusted to enable the patient to get into the open air, and in fractures of the lower extremity the patient should move about with crutches in the intervals, putting weight on the fractured bone. This method of treatment should be persevered with for three or four weeks, and the limb should be massaged daily while the constricting bandage is off.

Among the other methods which have been recommended are the injection between the fragments of oil of turpentine (Mikulicz), a quantity of the patient's own blood (Schmieden), or alcohol and iodine; the forcible rubbing of the ends together, under an anæsthetic if necessary; and the administration of thyreoid extract. If these methods fail, the case should be treated as one of un-united fracture. As a rule, satisfactory union is ultimately obtained, although much patience is required.

Non-Union.—Sometimes the fragments become united by a dense band of fibrous tissue, and the reparative process goes no further—fibrous union. This is frequently the case in fractures of the patella, the olecranon, and the narrow part of the neck of the femur.

False Joint—Pseudarthrosis.—In rare cases the ends of the fragments become rounded and are covered with a layer of cartilage. Around their ends a capsule of fibrous tissues forms, on the inner aspect of which a layer of endothelium develops and secretes a synovia-like fluid. This is met with chiefly in the humerus and in the clavicle.

Failure of Union—“Un-united Fracture.”—As the time taken for union varies widely in different bones, and ossification may ultimately ensue after being delayed for several months, a fracture cannot be said to have failed to unite until the average period has been long overpassed and still there is no evidence of fusion of the fragments. Under these conditions failure of union is a rare complication of fractures. In adults it is most frequently met with in the humerus, the radius and ulna ([Fig. 6]), and the femur; in children in the bones of the leg and in the forearm.

Fig. 6.—Radiogram of Un-united Fracture of Shaft of Ulna of fifteen years' duration.

In a radiogram the bones in the vicinity of the fracture, particularly the distal fragment, cast a comparatively faint shadow, and there may even be a clear space between the fragments. When the parts are exposed by operation, the bone is found to be soft and spongy and the ends of the fragments are rarefied and atrophied; sometimes they are pointed, and occasionally absorption has taken place to such an extent that a gap exists between the fragments. The bone is easily penetrated by a bradawl, and if an attempt is made to apply plates, the screws fail to bite. These changes are most marked in the distal fragment.

The want of union is evidently due to defective activity of the bone-forming cells in the vicinity of the fracture. This may result from constitutional dyscrasia, or may be associated with a defective blood supply, as when the nutrient artery is injured. Interference with the trophic nerve supply may play a part, as cases are recorded by Bognaud in which union of fractures of the leg failed to take place after injuries of the spinal medulla causing paraplegia. The condition has been attributed to local causes, such as the interposition of muscle or other soft tissue between the fragments, or to the presence of a separated fragment of bone or of a sequestrum following suppuration. In our experience such factors are seldom present.

If the treatment recommended for delayed union fails, recourse must be had to operation, the most satisfactory procedure being to insert a bone graft in the form of an intra-medullary splint. In certain cases met with in the bones of the leg in children, the degree of atrophy of the bones is such that it has been found necessary to amputate after repeated attempts to obtain union by operative measures have failed.

In the tibia we have found that with the double electric saw a rod of bone can be rapidly and accurately cut, extending well above as well as below the site of fracture but unequally in the two directions; the rod is then reinserted into the trough from which it was taken with the ends reversed, so that a strong bridge of bone is provided at the seat of non-union.

Clinical Features of Simple Fractures

In the first place, the history of the accident should be investigated, attention being paid to the nature of the violence—whether a blow, a twist, a wrench, or a crush, and whether the violence was directly or indirectly applied. The degree of the violence may often be judged approximately from the instrument inflicting it—whether, for example, a fist, a stick, a cart wheel, or a piece of heavy machinery. The position of the limb at the time of the injury; whether the muscles were braced to meet the blow or were lax and taken unawares; and the patient's sensations at the moment, such as his feeling something snap or tear, may all furnish information useful for purposes of diagnosis.

Signs of Fracture.—The most characteristic signs of fracture are unnatural mobility, deformity, and crepitus.

Unnatural mobility—that is, movement between two segments of a limb at a place where movement does not normally occur—may be evident when the patient makes attempts to use his limb, or may only be elicited when the fragments are seized and moved in opposite directions. Deformity, or the part being “out of drawing” in comparison with the normal side, varies with the site and direction of the break, and depends upon the degree of displacement of the fragments. Crepitus is the name applied to the peculiar grating or clicking which may be heard or felt when the fractured surfaces are brought into contact with one another.

The presence of these three signs in association is sufficient to prove the existence of a fracture, but the absence of one or more of them does not negative this diagnosis. There are certain fallacies to be guarded against. For example, a fracture may exist and yet unnatural mobility may not be present, because the bones are impacted into one another, or because the fracture is an incomplete one. Again, the extreme tension of the swollen tissues overlying the fracture may prevent the recognition of movement between the fragments. Deformity also may be absent—as, for instance, when there is no displacement of the fragments, or when only one of two parallel bones is broken, as in the leg or forearm. Similarly, crepitus may be absent when impaction exists, when the fragments completely override one another, or are separated by an interval, or when soft tissues, such as torn periosteum or muscle, are interposed between them. A sensation simulating crepitus may be felt on palpating a part into which blood has been extravasated, or which is the seat of subcutaneous emphysema. The creaking which accompanies movements in certain forms of teno-synovitis and chronic joint disease, and the rubbing of the dislocated end of a bone against the tissues amongst which it lies, may also be mistaken for the crepitus of fracture.

It is not advisable to be too diligent in eliciting these signs, because of the pain caused by the manipulations, and also because vigorous handling may do harm by undoing impaction, causing damage to soft parts or producing displacement which does not already exist, or by converting a simple into a compound fracture.

It is often necessary for purposes of diagnosis to administer a general anæsthetic, particularly in injuries of deeply placed bones and in the vicinity of joints. Before doing so, the appliances necessary for the treatment of the injury should be made ready, in order that the fracture may be reduced and set before the patient regains consciousness.

Radiography in the Diagnosis of Fractures.—While radiography is of inestimable value in the diagnosis of many fractures and other injuries, particularly in the vicinity of joints, the student is warned against relying too implicitly on the evidence it seems to afford.

A radiogram is not a photograph of the object exposed to the X-rays but merely a picture of its shadow, or rather of a series of shadows of the different structures, which vary in opacity. As the rays emanate from a single point in the vacuum tube, and as they are not, like the sun's rays, approximately parallel, the shadows they cast are necessarily distorted. Hence, in interpreting a radiogram, it is necessary to know the relative positions of the point from which the rays proceed, the object exposed, and the plate on which the shadow is registered. The least distortion takes place when the object is in contact with the plate, and the shadow of that part of the object which lies perpendicularly under the light is less distorted than that of the parts lying outside the perpendicular. The light and the plate remaining constant, the amount of distortion varies directly with the distance between the object and the plate.

To ensure accuracy in the diagnosis of fracture by the X-rays, it is necessary to take two views of the limb—one in the sagittal and the other in the coronal plane. By the use of the fluorescent screen, the best positions from which to obtain a clear impression of the fracture may be determined before the radiograms are taken. Stereoscopic radiograms may be of special value in demonstrating the details of a fracture that is otherwise doubtful.

Imperfect technique and faulty interpretation of the pictures obtained lead to certain fallacies. In young subjects, for example, epiphysial lines may be mistaken for fractures, or the ossifying centres of epiphyses for separated fragments of bone. The os trigonum tarsi has been mistaken for a fracture of the talus. In the vicinity of joints the bones may be crossed by pale bands, due to the rays traversing the cavity of the joint. In this way fracture of the olecranon or of the clavicle may be simulated. The neck of the femur may appear to be fractured if a foreshortened view is taken.

It is possible, on the other hand, to overlook a fracture—for example, if there is no displacement, or if the line of fracture is crossed by the shadow of an adjacent bone. In deeply placed bones such as those about the hip, or in bones related to dense, solid viscera—for example, ribs, sternum, or dorsal vertebræ—it is sometimes difficult to obtain conclusive evidence of fracture in a radiogram.

It is to be borne in mind also, and especially from the medico-legal point of view, that, as early callus does not cast a deep shadow in a radiogram, the appearance of fracture may persist after union has taken place. The earliest shadow of callus appears in from fourteen to twenty-one days, and can hardly be relied upon till the fourth or sixth week. The disturbed perspective produced by divergence of the rays may cause the fragments of a fracture to appear displaced, although in reality they are in good position. If the limb and the plate are not parallel, the bones may appear to be distorted, and errors in diagnosis may in this way arise. In this relation it should be mentioned that perfect apposition of the fragments and anatomically accurate restoration of the outline of the bones are not always essential to a good functional result.

As most of the remaining signs are common to all the lesions from which fractures have to be distinguished, their diagnostic value must be carefully weighed.

Interference with Function.—As a rule, a broken bone is incapable of performing its normal function as a lever or weight-bearer; but when a fracture is incomplete, when the fragments are impacted, or when only one of two parallel bones is broken, this does not necessarily follow. It is no uncommon experience to find a patient walk into hospital with an impacted fracture of the neck of the femur or a fracture of the fibula; or to be able to pronate and supinate the forearm with a greenstick fracture of the radius or a fracture of the ulna.

Pain.—Three forms of pain may be present in fractures: pain independent of movement or pressure; pain induced by movement of the limb; and pain elicited on pressure or “tenderness.” In injuries by direct violence, pain independent of movement and pressure is never diagnostic of fracture, as it may be due to bruising of soft tissues. In injuries resulting from indirect violence, however, pain localised to a spot at some distance from the point of impact is strongly suggestive of fracture—as, for example, when a patient complains of pain over the clavicle after a fall on the hand, or over the upper end of the fibula after a twist of the ankle. Pain elicited by attempts to move the damaged part, or by applying pressure over the seat of injury, is more significant of fracture. Pain elicited at a particular point on pressing the bone at a distance, “pain on distal pressure,”—for example, pain at the lower end of the fibula on pressing near its neck, or at the angle of a rib on pressing near the sternum,—is a valuable diagnostic sign of fracture. When nerve-trunks are implicated in the vicinity of a fracture, pain is often referred along the course of their distribution.

Localised swelling comes on rapidly, and is due to displacement of the fragments and to hæmorrhage from the torn vessels of the marrow and periosteum.

Discoloration accompanies the swelling, and is often widespread, especially in fracture of bones near the surface and when the tension is great. It is not uncommon to find over the ecchymosed area, especially over the shin-bone, large blebs containing blood-stained serum. In fractures of deep-seated bones, discoloration may only show on the surface after some days, and at a distance from the break.

Alterations in the relative position of bony landmarks are valuable diagnostic guides. Alteration in the length of the limb, usually in the direction of shortening, is also an important sign. Before drawing deductions, care must be taken to place both limbs in the same position and to determine accurately the fixed points for measurement, and also to ascertain if the limbs were previously normal.

Shock is seldom a prominent symptom in uncomplicated fractures, although in old and enfeebled patients it may be serious and even fatal. During the first two or three days after a fracture there is almost invariably some degree of traumatic fever, indicated by a rise of temperature to 99° or 100° F.

Complications.—Injuries to large arteries are not common in simple fractures. The popliteal artery, however, is liable to be compressed or torn across in fractures of the lower end of the femur; extravasation of blood from the ruptured artery and gangrene of the limb may result. If large veins are injured, thrombosis may occur, and be followed by pulmonary embolism.

Injuries to nerve-trunks are comparatively common, especially in fractures of the arm, where the radial (musculo-spiral) nerve is liable to suffer.

The nerve may be implicated at the time of the injury, being compressed, bruised, lacerated, or completely torn across by broken fragments, or it may be involved later by the pressure of callus. The symptoms depend upon the degree of damage sustained by the nerve, and vary from partial and temporary interference with sensation and motion to complete and permanent abrogation of function.

In rare instances fat embolism is said to occur, and fat globules are alleged to have been found in the urine. In persons addicted to excess of alcohol, delirium tremens is a not infrequent accompaniment of a fracture which confines the patient to bed.

Prognosis in Simple Fractures.—Danger to life in simple fractures depends chiefly on the occurrence of complications. In old people, a fracture of the neck of the femur usually necessitates long and continuous lying on the back, and bronchitis, hypostatic pneumonia, and bed-sores are prone to occur and endanger life. Fractures complicated with injury to internal organs, and fractures in which gangrene of the limb threatens, are, of course, of grave import.

The prognosis as regards the function of the limb should always be guarded, even in simple fractures. Incidental complications are liable to arise, delaying recovery and preventing a satisfactory result, and these not only lead to disappointment, but may even form a ground for actions for malpraxis.

The chief and most frequent cause of permanent disability after fracture is angular displacement. A comparatively small degree of angularity may lead to serious loss of function, especially in the lower limb; the joints above and below the fracture are placed at a disadvantage, arthritic changes result from the abnormal strain to which they are subjected, and rarefaction of the bone may also ensue.

Fibrous union is a common result in fractures of the neck of the femur in old people and in certain other fractures, such as fracture of the patella, of the olecranon, coronoid and coracoid processes, and although this does not necessarily involve interference with function, the patient should always be warned of the possibility.

Impairment of growth and eventual shortening of the limb may result from involvement of an epiphysial junction.

Stiffness of joints is liable to follow fractures implicating articular surfaces, or it may result from arthritic changes following upon the injury.

Osseous ankylosis is not a common sequel of simple fractures, but locking of joints from the mechanical impediment produced by the union of imperfectly reduced fragments, or from masses of callus, is not uncommon, especially in the region of the elbow.

Wasting of the muscles and œdema of the limb often delay the complete restoration of function. Delayed union, want of union, and the formation of a false joint have already been referred to.

Treatment.—The treatment of a fracture should be commenced as soon after the accident as possible, before the muscles become contracted and hold the fragments in abnormal positions, and before the blood and serum effused into the tissues undergo organisation.

Care must be taken during the transport of the patient that no further damage is done to the injured limb. To this end the part must be secured in some form of extemporised splint, the apparatus being so designed as to control not only the broken fragments, but also the joints above and below the fracture.

When the ordinary method of removing the clothes involves any risk of unduly moving the injured part, they should be slit open along the seams.

The patient should be placed on a firm straw, horse-hair, or spring mattress, stiffened in the case of fractures of the pelvis or lower limbs by fracture-boards inserted beneath the mattress. Special mattresses constructed in four pieces, to facilitate the nursing of the patient, are sometimes used.

In many cases, particularly in muscular subjects, in restless alcoholic patients, and in those who do not bear pain well, a general anæsthetic is a valuable aid to the accurate setting of a fracture, as well as a means of rendering the diagnosis more certain.

The procedure popularly known as “setting a fracture” consists in restoring the displaced parts to their normal position as nearly as possible, and is spoken of technically as the reduction of the fracture.

The Reduction of Fractures.—In some cases the displacement may be overcome by relaxing the muscles acting upon the fragments, and this may be accomplished by the stroking movements of massage. In most cases, however, it is necessary, after relaxing the muscles, to employ extension, by making forcible but steady traction on the distal fragment, while counter-extension is exerted on the proximal one, either by an assistant pulling upon that portion of the limb, or by the weight of the patient's body. The fragments having been freed, and any shortening of the limb corrected in this way, the broken ends are moulded into position—a process termed coaptation.

The reduction of a recent greenstick fracture consists in forcibly straightening the bend in the bone, and in some cases it is necessary to render the fracture complete before this can be accomplished.

In selecting a means of retaining the fragments in position after reduction, the various factors which tend to bring about re-displacement must be taken into consideration, and appropriate measures adopted to counteract each of these.

In addition to retaining the broken ends of the bone in apposition, the after-treatment of a fracture involves the taking of steps to promote the absorption of effused blood and serum, to maintain the circulation through the injured parts, and to favour the repair of damaged muscles and other soft tissues. Means must also be taken to maintain the functional activity of the muscles of the damaged area, to prevent the formation of adhesions in joints and tendon sheaths, and generally to restore the function of the injured part.

Practical Means of Effecting Retention—By Position.—It is often found that only in one particular position can the fragments be made to meet and remain in apposition—for example, the completely supine position of the forearm in fracture of the radius just above the insertion of the pronator teres. Again, in certain cases it is only by relaxing particular groups of muscles that the displacement can be undone—as, for instance, in fracture of the bones of the leg, or of the femur immediately above the condyles, where flexion of the knee, by relaxing the calf muscles, permits of reduction.

Massage and Movement in the Treatment of Fractures.—Lucas-Championnière, in 1886, first pointed out that a certain amount of movement between the ends of a fractured bone favours their union by promoting the formation of callus, and advocated the treatment of fractures by massage and movement, discarding almost entirely the use of splints and other retentive appliances. We were early convinced by the teaching of Lucas-Championnière, and have adopted his principles in fractures.

In the majority of cases the massage and movement are commenced at once, but circumstances may necessitate their being deferred for a few days. The measures adopted vary according to the seat and nature of the fracture, but in general terms it may be stated that after the fracture has been reduced, the ends of the broken bone are retained in position, and gentle massage is applied by the surgeon or by a trained masseur. The lubricant may either be a powder composed of equal parts of talc and boracic acid, or an oily substance such as olive oil or lanolin. The rubbing should never cause pain, but, on the contrary, should relieve any pain that exists, as well as the muscular spasm which is one of the most important causes of pain and of displacement in recent fractures. The parts on the proximal side of the injured area are first gently stroked upwards to empty the veins and lymphatics, and to disperse the effused blood and serum. The process is then applied to the swollen area, and gradually extended down over the seat of the fracture and into the parts beyond. In this way the circulation through the damaged segment of the limb is improved, the veins are emptied of blood, the removal of effused fluid is stimulated, and the muscular irritability allayed. The joints of the limb are gently moved, care being taken that the broken ends of the bone are not displaced. After the rubbing has been continued for from fifteen to twenty minutes, the limb is placed in a comfortable position, and retained there by pillows, sand-bags, or, if found more convenient, by a light form of splint.

The massage is repeated once each day; the sittings last from ten to fifteen minutes. The sequence should be, first, massage; second, passive movement; and third, active movement. At first massage predominates, and more passive than active movement; gradually massage is lessened and movements are increased, active movements ultimately preponderating.

Splints and other Appliances.—The appropriate splints for individual fractures and the method of applying them will be described later; but it may here be said that the general principle is that when dealing with a part where there is a single bone, as the thigh or upper arm, the splint should be applied in the form of a ferrule to surround the break; while in situations where there are two parallel bones, as in the forearm and leg, the splint should take the form of a box.

Simple wooden splints of plain deal board or yellow pine, sawn to the appropriate length and width; or Gooch's splinting, which consists of long strips of soft wood, glued to a backing of wash-leather, are the most useful materials. Gooch's splinting has the advantage that when applied with the leather side next the limb it encircles the part as a ferrule; while it remains rigid when the wooden side is turned towards the skin. Perforated sheet lead or tin, stiff wire netting, and hoop iron also form useful splints.

When it is desirable that the splint should take the shape of the part accurately, a plastic material may be employed. Perhaps the most convenient is poroplastic felt, which consists of strong felt saturated with resin. When heated before a fire or placed in boiling water, it becomes quite plastic and may be accurately moulded to any part, and on cooling it again becomes rigid. The splint should be cut from a carefully fitted paper pattern. Millboard, leather, or gutta-percha softened in hot water, and moulded to the part, may also be employed.

In conditions where treatment by massage and movement is impracticable, and where movable splints are inconvenient, splints of plaster of Paris, starch, or water-glass are sometimes used, especially in the treatment of fractures of the leg. When employed in the form of an immovable case, they are open to certain objections—for example, if applied immediately after the accident they are apt to become too tight if swelling occurs; and if applied while swelling is still present, they become slack when this subsides, so that displacement is liable to occur.

When it is desired to enclose the limb in a plaster case, coarse muslin bandages, 3 yards long, and charged with the finest quality of thoroughly dried plaster of Paris, are employed. The “acetic plaster bandages” sold in the shops set most quickly and firmly. Boracic lint or a loose stocking is applied next the skin, and the bony prominences are specially padded. The plaster bandage is then placed in cold water till air-bubbles cease to escape, by which time it is thoroughly saturated, and, after the excess of water is squeezed out, is applied in the usual way from below upward. From two to four plies of the bandage are required. In the course of half an hour the plaster should be thoroughly set. To facilitate the removal of a plaster case the limb should be immersed for a short time in tepid water.

A convenient and efficient splint is made by moulding two pieces of poroplastic felt to the sides of the limb, and fixing them in position with an elastic webbing bandage; this apparatus can be easily removed for the daily massage.

Padding is an essential adjunct to all forms of splints. The whole part enclosed in the splint must be covered with a thick layer of soft and elastic material, such as wool from which the fat has not been removed. All hollows should be filled up, and all bony projections specially protected by rings of wadding so arranged as to take the pressure off the prominent point and distribute it on the surrounding parts. Opposing skin surfaces must always be separated by a layer of wool or boracic lint. A bandage should never be applied to the limb underneath the splints and pads, as congestion or even gangrene may be induced thereby.

Operative Treatment of Simple Fractures.—Operation in simple fracture is specially called for (1) in fracture into or near a joint where a permanently displaced fragment will cause locking of the joint; (2) when fragments are drawn apart, as in fractures of the patella or olecranon; (3) when displacement, especially shortening, cannot be remedied by other means; (4) when complications are present, such as a torn nerve-trunk or a main artery; (5) when non-union is to be feared, as in certain cases of fracture of the neck of the femur in old people. Under such circumstances it is necessary to expose the fracture by operation, and to place the fragments in accurate apposition, if necessary, fixing them in position by wires, pegs, plates, or screws (Op. Surg., p. 52). Operative interference is usually delayed till about five to seven days after the injury, by which time the effect of other measures will have been estimated, accurate information obtained by means of the X-rays regarding the nature of the lesion and the position of the fragments, and the tissues recovered their normal powers of resistance. Such operations, however, are not to be undertaken lightly, as they are often difficult, and if infection takes place the results may be disastrous. Arbuthnot Lane and Lambotte advocate a more general resort to operative measures, even in simple and uncomplicated fractures, and it must be conceded that in many fractures an open operation affords the only means of securing accurate apposition and alignment of the fragments.

Both before and after operation, massage and movement are to be carried out, as in fractures treated by other methods.

Compound Fractures

The essential feature of a compound fracture is the existence of an open wound leading down to the break in the bone. The wound may vary in size from a mere puncture to an extensive tearing and bruising of all the soft parts.

A fracture may be rendered compound from without, the soft parts being damaged by the object which breaks the bone—as, for example, a cart wheel, a piece of machinery, or a bullet. Sloughing of soft parts resulting from the pressure of improperly applied splints, also, may convert a simple into a compound fracture. On the other hand, a simple fracture may be rendered compound from within—for example, a sharp fragment of bone may penetrate the skin; this is the least serious variety of compound fracture.

As a rule, it is easy to recognise that the fracture is compound, as the bone can either be seen or felt.

The prognosis depends on the success which attends the efforts to make and to keep the wound aseptic, as well as on the extent of damage to the tissues. When asepsis is secured, repair takes place as in simple fracture, only it usually takes a little longer; sometimes the reason for the delay is obvious, as when the compound fracture is the result of a more severe form of violence and where there is comminution and loss of one or more portions of bone that would have contributed to the repair. Sometimes the delay cannot be so explained; Bier suggested that it is due to the escape of blood at the wound, whereas in simple fractures the blood is retained and assists in repair.

If sepsis gains the upper hand in a compound fracture there is, firstly, the risk of infection of the marrow—osteomyelitis—which in former times was liable to result in pyæmia; in the second place, not only do loose fragments tend to die and be thrown off as sequestra, but the ends of the fragments themselves may undergo necrosis; involving as this does the dense cortical bone of the shaft, the dead bone is slow in being separated, and until it is separated and thrown off, no actual repair can take place. The sepsis stimulates the bone-forming tissues and new bone is formed in considerable amount, especially on the surface of the shaft in the vicinity of the fracture; in macerated specimens it presents a porous, crumbling texture. Sometimes the new bone—which corresponds to the involucrum of an osteomyelitis—imprisons a sequestrum and prevents its extrusion, in which case one or more sinuses may persist indefinitely. Cases are met with where such sinuses have existed for the best part of a long life and have ultimately become the seat of epithelioma.

It should be noted that all the above changes can be followed in skiagrams.

Treatment.—The leading indication is to ensure asepsis. Even in the case of a small punctured wound caused by a pointed fragment coming through the skin it is never wise to assume that the wound is not infected. It is much safer to enlarge such a wound, pare away the bruised edges, and disinfect the raw surfaces.

In cases of extensive laceration of the soft parts, all soiled, bruised, or torn portions of tissue should be clipped away with scissors, blood-clots removed, and the bleeding arrested by forci-pressure or ligature. If there is any reason to believe that the wound is infected, any fragments of bone completely separated from the periosteum should be removed. In comminuted fractures, extension applied by strips of plaster or by means of ice-tong callipers or Steinmann's apparatus ([p. 150]) often facilitates replacement of the fragments and their retention in position. Plates and screws are not recommended for comminuted fractures, owing to the mechanical difficulty of fixing a number of small fragments and the risks of infection. The wound should be purified with eusol, and the surrounding parts painted with iodine. On the whole, it is safer not to attempt to obtain primary union by completely closing such wounds, but rather to drain or pack them. To increase the local leucocytosis and so check the spread of infection, a Bier's constricting bandage may be applied.

In other respects the treatment is carried out on the same lines as in simple fractures, provision being made for dressing the wound without disturbance of the fracture. Massage and movement should be commenced after the wound is healed and the condition has become analogous to a simple fracture.

Question of Amputation in Compound Fractures.—Before deciding to perform primary amputation of a limb for compound fracture, the surgeon must satisfy himself (1) that the attainment of asepsis is impossible; (2) that the soft parts are so widely and so grossly damaged that their recovery is improbable; (3) that the vascular and nervous supply of the parts beyond has been rendered insufficient by destruction of the main blood vessels and nerve-trunks; (4) that the bones have been so shattered as to be beyond repair; and (5) that the limb, even if healing takes place, will be less useful than an artificial one.

In attempting to save the limb of a young subject, it is justifiable to run risks which would not be permissible in the case of an older person. To save an upper limb, also, risks may be run which would not be justifiable in the case of a lower limb, because, while a serviceable artificial leg can readily be procured, any portion of the natural hand or arm is infinitely more useful than the best substitute which the instrument-maker can contrive. The risk involved in attempting to save a limb should always be explained to the patient or his guardian, in order that he may share the responsibility in case of failure.

Whether or not the amputation should be performed at once, depends upon the general condition of the patient. If the injury is a severe one, and attended with a profound degree of shock, it is better to wait for twenty-four or forty-eight hours. Meanwhile the wound is purified, and the limb wrapped in a sterile dressing. Means are taken to counteract shock and to maintain the patient's strength, and evidence of infection or of hæmorrhage is carefully watched for. When the shock has passed off, the operation is then performed under more favourable auspices. Clinical experience has proved that by this means the mortality of primary amputations may be materially diminished, especially in injuries necessitating removal of an entire limb.

Having decided to amputate, it is important to avoid having bruised, torn, or separated tissues in the flaps, as these are liable to slough or to become the seat of infection. In this connection it should be borne in mind that the damage to soft tissues is always wider in extent than appears from external examination.

The attempt to save a limb may fail and amputation may be called for later because of spreading infective processes, osteomyelitis, or gangrene; to prevent exhaustion from prolonged suppuration and toxin absorption; or on account of secondary hæmorrhage.

Gun-shot Injuries of Bone.—Fractures resulting from the impact of bullet or fragments of shell are of necessity compound, and are usually infected from the outset by organisms carried in by the missile or by portions of clothing or other foreign material. Not infrequently the missile lodges in the bone.

Fig. 7.—Excessive Callus Formation after infected Compound Fracture of both Bones of Forearm—result of gun-shot wound. Fusion of Bones across Interosseous Space.

The extent of the injury to the bone varies infinitely, from a mere chip or gutter-shaped wound to complete pulverisation of the portion struck. The fracture is of the comminuted and fissured variety, the cracks radiating from the point of impact and extending for a considerable distance, sometimes even implicating the articular surface of the bone some inches away. In comminuted fractures of the shafts of long bones there is often a large wedge-shaped fragment completely isolated from the rest, and in the presence of infection this may form a sequestrum. Healing is often delayed by the separation of sequestra, which takes place slowly, and union is attended with excessive formation of callus. When a considerable section of the shaft has been lost, want of union, fibrous union, or the formation of a false joint may result.

The treatment is carried out on the same lines as in other forms of compound fracture, except that mention should be made of the irrigation method of Carrel, found to be the most potent means of overcoming the associated infection.

SEPARATION OF EPIPHYSES[1]

[1] We do not employ the term “diastasis,” which has been used in different senses by different writers.

In young subjects before the bones are fully developed the epiphyses may be separated from the diaphyses. The use of the X-rays has added greatly to our knowledge of these lesions.

It is useful to remember that in the upper extremity the epiphyses in the regions of the shoulder and wrist, and, in the lower extremity, those in the region of the knee, are the latest to unite; and that it is in these situations that growth in length of the bone goes on longest and most actively (twenty to twenty-one years). Injuries of these epiphyses, therefore, are most liable to interfere with the growth of the limb.

An epiphysis is nourished from the articular arteries and through the vessels of the periosteum.

Pathological Separation of Epiphyses.—There are certain pathological conditions, such as rickets, scurvy, congenital syphilis, tubercle, suppurative conditions, and tumour growths, which render separation of the epiphyses liable to occur from injuries altogether insufficient to produce such lesions under normal conditions.

Traumatic Separations.[2]—Speaking generally, it may be said that injuries which in an adult would be liable to produce dislocation, are in a young person more apt to cause separation of an epiphysis. Indirect violence, especially when exerted in such a way as to combine traction with torsion,—for example, when the foot is caught in the spokes of a carriage wheel,—is the commonest cause of epiphysial separation. Direct violence is a much less frequent cause. Muscular action occasionally produces separation of the epiphyses—for example, the anterior superior iliac spine, the small trochanter of the femur, or the upper end of the fibula.

[2] We desire here to acknowledge our indebtedness to Mr. John Poland's work on Traumatic Separation of the Epiphyses.

The majority of separations take place between the eleventh and the eighteenth years, chiefly because during this period the injuries liable to produce such lesions are most common. They do not occur after twenty-five, because by that time all the epiphyses have united. In females this form of injury is rare, and almost invariably occurs before puberty.

The following are the most common seats of separation in the order of their frequency: (1) the lower end of the femur; (2) the lower end of the radius; (3) the upper end of the humerus; (4) the lower end of the humerus; (5) the lower end of the tibia; and (6) the upper end of the tibia.

Morbid Anatomy.—In a true separation the epiphysial cartilage remains attached to the epiphysis. As a rule the epiphysis is not completely separated from the diaphysis, the common lesion being a separation along part of the epiphysial line, with a fracture running into the diaphysis ([Fig. 8]). It is not uncommon for more than one epiphysis to be separated by the same accident—for example, the lower end of the femur and the upper ends of the tibia and fibula. Epiphysial separations, like fractures, may be simple or compound. Incomplete separations are liable to be overlooked at the time of the accident, but there is reason to believe that they may form the starting-point of disease. Strain of the epiphysial junction—the juxta-epiphysial strain of Ollier—is a common injury in young children.

Clinical Features.—The symptoms simulate those of dislocation rather than of fracture. Thus, unnatural mobility at an epiphysial junction may closely resemble movement at the adjacent joint, especially when the epiphysis is an intra-capsular one. The relationship of the bony points, however, serves to indicate the nature of the lesion. The degree of deformity is often slight, because the transverse direction of the lesion, the breadth of the separated surfaces, and the firmness of the periosteal attachment along the epiphysial line often prevent displacement. In many cases a distinct, rounded, smooth, and regular ridge, caused by the projection of the diaphysis, can be felt. The peculiar “muffled” nature of the crepitus is one of the most characteristic signs. The older the patient, and the further ossification has progressed, the more does the crepitus resemble that of fracture.

Of the subsidiary signs, loss of power in the limb is one of the most constant; indeed, in young children it is sometimes the first, and may be the only, sign that attracts attention. Pain and tenderness along the epiphysial line are valuable signs, particularly when the lesion is due to indirect or muscular violence and there is no bruising of soft parts. Localised swelling, accompanied by ecchymosis, is often marked; and the adjacent joint may be distended with fluid.

As distinguishing this injury from a dislocation, it may be noted that in epiphysial separation there is no snap felt when the deformity is reduced, the tendency to re-displacement is greater, and the amount of relief given by reduction less than in dislocation. The use of the Röntgen rays at once establishes the diagnosis.

Prognosis and Results.—In the majority of cases union takes place satisfactorily by the formation of callus in the spongy tissue of the diaphysis and on the deep surface of the periosteum. In spite of the favourable nature of the prognosis in general, however, the friends of the patient should be warned that a completely satisfactory result cannot always be relied upon.

Deformity, with stiffness and locking at the adjacent joint, especially at the elbow, may result from imperfect reduction, or from exuberant callus. Arrest of growth of the bone in length is a rare sequel, and when it occurs, it is due, not to premature union of the epiphysis with the shaft, but to diminished action at the ossifying junction.

When the growth of one of the bones of the leg or forearm is arrested after separation of its epiphysis while the other bone continues to grow, the foot or hand is deviated towards the side of the shorter one.

Partial separations may be overlooked at the time of the accident and cause trouble later from bending of the bone, as in one variety of coxa vara. The epiphysis at the lower end of the femur may be displaced into the ham and press on the popliteal vessels.

Treatment.—The general principles which govern the treatment of fractures apply equally to epiphysial separations, the essential being the accurate replacement of the epiphysis.

In compound separations of epiphysis, the end of the diaphysis may be pushed through the skin. The entrance of sepsis may prove an obstacle to any operative measure that would otherwise be indicated.

CHAPTER II
INJURIES OF JOINTS

• [Surgical Anatomy]
• —[Injuries]:
• [Contusions];
• [Wounds];
• [Sprains];
• [Dislocations]
• —[Traumatic Dislocations]:
• [Causes]:
• [Varieties];
• [Clinical features];
• [Treatment]
• —[Compound dislocations]
• —[Old-standing dislocations].

Surgical Anatomy.—The function of a joint is to permit of the movement of one bone upon another. The articular surfaces are covered with a thin layer of hyaline cartilage, and are retained in apposition by the tension of ligaments and of the muscles surrounding the joint. The articular capsule (capsular ligament) is directly continuous with the periosteum, and is lined by a synovial layer, which at the line of attachment of the capsule is reflected on to the bone as far as the articular cartilage. The synovial layer invests intra-articular ligaments, and is projected into the interior of the joint in the form of loose folds wherever the articulating surfaces are not in immediate contact. The surface of the synovial layer is covered with minute processes or villi, which in diseased conditions may become hypertrophied. The synovia owes its lubricating property to mucin, derived from the solution of the endothelial cells on the free surface of the synovial layer. The opposing surfaces of a joint being always in accurate contact, the so-called cavity is only a potential one. If fluid is poured out into the joint, the synovial layer and the capsule are put upon the stretch, causing discomfort or actual pain, which is partly relieved by slightly flexing the joint. If the distension persists, the ligaments become elongated and the joint unstable.

The common origin of bone, cartilage, periosteum, and synovial layer from one parent tissue of the embryo, accords with the readiness with which any one of these tissues may be converted into another under traumatic or pathological influences; and how in ligaments and in synovial membrane foci of hyaline cartilage may form and, after increasing in size, undergo ossification.

Joints derive an abundant blood supply through the articular arteries. The lymphatics, which take origin in the synovial layer, pass to efferent vessels which run in the intermuscular and other connective-tissue planes of the limb. The nerve supply is derived chiefly from the nerves distributed to the muscles acting on the joint and to the skin over it.

Sources of Joint Strength.—The capacity of a joint to resist dislocation depends upon (1) the shape of its osseous elements; (2) the strength and arrangement of its ligaments; (3) the support it receives from muscles or tendons placed in relation to it; and (4) the relative stability of adjacent structures. While all these factors contribute to the strength of a given joint, one or other of them usually predominates, so that certain joints are osseously strong, others are ligamentously strong, while a few depend chiefly upon adjacent muscles for their stability.

The hip and elbows are the best examples of joints deriving their strength mainly from the architectural arrangement of the constituent bones. These joints are dislocated only by extreme degrees of violence, and not infrequently—especially in the elbow—portions of the bones are fractured before the articular surfaces are separated.

The knee, the wrist, the carpal, the tarsal, and the clavicular joints depend for their stability almost entirely on the strength of their ligaments. These joints are rarely dislocated, but as the main incidence of the violence falls on the ligaments they are frequently sprained.

The shoulder is the typical example of a joint depending for its security chiefly upon the muscles and tendons passing over it, and hence the frequency with which it is dislocated when the muscles are taken unawares. At the same time the great mobility of the scapula and clavicle materially increases the stability of the shoulder-joint. The tendons passing in relation to the knee, ankle, and wrist add to the stability of these joints.

The proximity of an easily fractured bone also contributes to prevent dislocation of certain joints—for example, fracture of the clavicle prevents an impinging force expending itself on the shoulder-joint; and the frequency of Colles' fracture of the radius, and of Pott's fracture of the fibula, doubtless accounts to some extent for the rarity of dislocation of the wrist and ankle-joints respectively. The immunity from dislocation which the joints of young subjects enjoy is partly due to the ease with which an adjacent epiphysis is separated.

The mechanical axiom that “what is gained in movement is lost in stability” applies to joints, those which have the widest range of movement being the most frequently dislocated.

The injuries to which a joint is liable are Contusions, Wounds, Sprains, and Dislocations.

Contusions of Joints.—Contusion is the mildest form of injury to a joint. Whether the violence is transmitted from a distance, as in contusion of the hip from a fall on the feet, or acts more directly, as in a fall on the great trochanter, the bones are violently driven against one another, and the force expends itself on their articular surfaces. The articular cartilages and the underlying spongy bone, as well as the synovial lining, are bruised, and there is an effusion of blood and serous fluid into the joint and surrounding tissues.

The most prominent clinical features are swelling and discoloration. The swelling, especially in superficially placed joints, is an early and marked symptom, and is mainly due to the effusion of blood into the joint (hæmarthrosis). In deeply placed joints, discoloration may not appear on the surface for some days, especially if the violence has been indirect. The joint is kept in the flexed position, and is painful only when moved. In hæmophilic subjects, considerable effusion of blood into a joint may follow the most trivial injury.

A slight degree of serous effusion into the joint (hydrarthrosis) often persists for some time, and tuberculous affections of joints not infrequently date from a contusion.

The treatment is the same as for sprains ([p. 36]).

Wounds of Joints.—The importance of accidental wounds of joints—such, for example, as result from a stab with a penknife or the spike of a railing—lies in the fact that they are liable to be followed by infection of the synovial cavity. The infection may involve only the synovial layer (septic synovitis), or may spread to all the elements of the joint (septic arthritis). These conditions are described with diseases of joints.

Penetration of the joint may sometimes be recognised by the escape of synovia from the wound, or the synovial layer or articular cartilage may be exposed. When doubt exists, the wound should be enlarged. The use of the probe is to be avoided, on account of the risk of carrying infective material from the track of the wound into the joint.

Penetrating wounds of joints are treated on the same lines as compound fractures. If the penetrating instrument is to be regarded as infected,—as, for example, when the spoke of a motor bicycle is driven through the upper pouch of the knee,—the injury is to be looked upon as serious and capable of endangering the function of the joint, loss of the limb, or even life itself. Reliance is chiefly laid on primary excision of the edges and track of the wound, and other measures employed in the treatment of gun-shot wounds. While the wound in the synovialis and capsule is sutured, that in the soft parts is left open. If drainage is employed, the tube extends down to the opening in the synovialis, but not into the joint itself. If sepsis supervenes, the joint is opened and irrigated by Carrel's method. Some form of splint and a Bier's bandage are valuable adjuncts. The final recourse is to amputation.

Gun-shot injuries of joints vary in severity from a mere puncture of the synovial layer by a chip of shell to complete shattering of the articular surfaces. Between these extremes are cases in which the capsular and synovial layer are extensively lacerated without involvement of the bones, and others in which the bones are implicated without serious damage being done to ligaments or synovial layer—for example, by a bullet passing through and through the cancellated part of one of the constituent bones, or by a fissure extending into the articular surface.

In all degrees the great risk is from septic infection, which may be assumed to be present in all but the last-named variety.

The treatment consists in immediately cleansing the wound by excising grossly damaged tissue and removing any foreign body that may have lodged; disinfecting the exposed part of the joint cavity with eusol, “bipp,” or other antiseptic, and closing the wound or establishing drainage, according to circumstances. The joint is then immobilised till the wound has healed, after which massage and movement are commenced. When the bones are shattered or when sepsis gets the upper hand and disorganises the joint, amputation is called for.

Sprains.—A sprain results from a stretching or twisting form of violence which causes the joint to move beyond its physiological limits, or in some direction for which it is not structurally adapted. The main incidence of the force therefore falls upon the ligaments, which are suddenly stretched or torn. The synovial layer also is torn, and the joint becomes filled with blood and synovial fluid.

Muscles and tendons passing over the joint are stretched or torn, and their sheaths filled with serous effusion. It is not uncommon for portions of bone to be torn off at the site of attachment of strong ligamentous bands or tendons, constituting a “sprain fracture”; or for intra-articular cartilages to be torn and displaced, as in the knee.

Clinical Features.—The injury is accompanied by intense sickening pain, and this may persist for a considerable time. At first it is aggravated by moving the joint, but if the movement is continued it tends to pass off. The particular ligaments involved may be recognised by the tenderness which is elicited on making pressure over them, or by putting them on the stretch. In this way a sprain may often be diagnosed from a fracture in which the maximum tenderness is over the injury to the bone.

The effusion of blood and synovia into the joint and into the tissues around gives rise to swelling and discoloration, and the fluid effused into tendon sheaths often produces a peculiar creaking sensation, which may be mistaken for the crepitus of fracture. In sprains, the bony points about the joint retain their normal relations to one another, and this usually enables these injuries to be diagnosed from dislocations. When the swelling is great, it is often necessary to have recourse to the Röntgen rays to make certain that there is no fracture or dislocation. The special features and complications of sprains of the knee are discussed with other injuries of that joint.

Repair of Sprains.—Blood and synovia are absorbed and torn structures become reunited, but in this process adhesions may form inside the joint and in the surrounding tendon sheaths and interfere with the movement of the joint.

Prognosis.—Stiffness, lasting for a longer or shorter time, follows most sprains, but may be largely prevented by proper treatment. In old and rheumatic persons, changes of the nature of arthritis deformans are liable to supervene, interfering greatly with movement. While suppuration is rare, tuberculous disease is alleged to have resulted from a sprain.

Treatment.—If seen immediately after the accident, firm pressure should be applied by means of an elastic bandage over a thick layer of cotton wool, to prevent bleeding and effusion of synovia. Later the best treatment is by massage and movement. In the ankle, for example, massage should be commenced at once, the part being gently stroked upwards. If the massage is light enough there is no pain, it is actually soothing. The rubbing is continued for from fifteen to twenty minutes, and the patient is encouraged to move the toes and ankle; a moderately firm elastic bandage is then applied. The massage is repeated once or twice a day, the sittings lasting for about fifteen minutes. The patient should be encouraged to move the joint from the first, beginning with the movements that put least strain upon the damaged ligaments, and gradually increasing the range. In the course of a few days he is encouraged to walk or cycle, or otherwise to use the joint without subjecting it to strain, or to a repetition of the movement that caused the accident. Alternate hot and cold douching, or hot-air baths, followed by massage, are also useful. Complete rest and prolonged immobilisation are to be condemned.

Traumatic Dislocations

A dislocation or luxation is a persistent displacement of the opposing ends of the bones forming a joint. We are here concerned only with such dislocations as immediately follow upon injury. Those that are congenital or that result from disease will be studied later.

Causes.—The majority of dislocations are the result of indirect violence, the more movable bone acting as a lever, on a fulcrum furnished by the natural check to movement in the form of ligament, bone, or muscle. It is in this way that most dislocations of the shoulder, hip, and elbow are produced.

At the moment the violence is applied, the muscles are relaxed or otherwise taken at a disadvantage, so that the joint is for the time being deprived of their support. The joint is moved beyond its physiological range, and the end of one of the bones being brought to bear upon the capsule, tears it, and passes through the rent thus made. The muscles then contract reflexly, and pull the head of the bone into an unnatural position outside the capsule. The position assumed will depend upon such factors as the direction of the force, the structure of the joint, the position of the limb at the time of the accident, and the relative strength of the different groups of muscles acting upon the bone which is displaced.

Violence applied directly to the joint is a much less frequent cause of dislocation. In this way, however, the knee-joint may be dislocated, one bone being driven past the other—for example, by a kick from a horse; or the acromio-clavicular joint by a blow on the shoulder.

Muscular contraction is not often the sole cause of dislocation, although, as has been mentioned, it plays an important rôle in the production of the majority of these injuries. The shoulder, mandible, and patella are, however, not infrequently displaced by muscular action alone. Acrobats sometimes acquire the power of dislocating certain joints by voluntary contraction of their muscles.

Age and Sex.—Dislocations occur most frequently in adult males, doubtless on account of the nature of their occupations and recreations. In children the epiphyses are separated, and in old people the bones are broken by such forms of violence as cause dislocation in the middle-aged.

Muscular debility and undue laxness of ligaments resulting from disease or previous dislocation are also predisposing factors.

Clinical Varieties.—The separation between the bones may be complete or partial. When partial, portions of the articular surfaces remain in apposition, and the injury is known as a sub-luxation. Like fractures, dislocations may be simple or compound, the latter being specially dangerous on account of the risk of infection. When seen within a few days of its occurrence, a dislocation is looked upon as recent; but when several weeks or months have elapsed, it is spoken of as an old-standing dislocation. The latter will be described later.

Dislocations, like fractures, may be complicated by injuries to large blood vessels or nerve-trunks, by injuries to internal organs, or by a wound of the soft tissues which does not communicate with the joint. Further, a fracture may coexist with a dislocation—a most important complication.

Clinical Features.—The most characteristic signs of dislocation are preternatural rigidity, or want of movement where movement should naturally take place; mobility in abnormal directions; and deformity, the part being “out of drawing” as compared with the uninjured side ([Fig. 18]). The bony landmarks lose their normal relationship to one another; and the deformity is characteristic, and is common to all examples of the same dislocation.

Although any of the subsidiary signs may occur in lesions other than dislocations, due weight must be given to them in making a diagnosis. Loss of function is complete as a rule. Pain is much more intense than in fracture, usually because the displaced bone presses upon nerve-trunks, and from the same cause there is often numbness and partial paralysis of the limb beyond. Swelling of the soft parts due to effused blood is usually less marked in dislocation than in fracture, but is often sufficiently great to interfere with diagnostic manipulations. The displaced bone, and sometimes the empty socket, may be palpable. Discoloration is usually later of appearing than in fractures. Alteration in the length of the injured limb—usually in the direction of shortening—is a common feature; while girth measurements usually show an increase. A peculiar soft grating or creaking sensation is often felt on attempting to move the joint; this is due to cartilaginous or ligamentous structures rubbing on one another, and must not be mistaken for the crepitus of fracture. In the majority of cases, although not in all, after reduction has been effected, the bones retain their proper relations without external support, a point in which a dislocation differs from a fracture. A careful investigation of the kind of force which produced the injury, particularly as regards its intensity and direction of action, may aid in the diagnosis. The diagnosis can always be verified by the use of the Röntgen rays, and this should be had recourse to whenever possible, as a fracture may be shown that otherwise would escape recognition.

Prognosis.—After having once been dislocated, a joint is seldom as strong as it was formerly, although for all practical purposes the limb may be as useful as ever. Some degree of stiffness, of limited movement, or of muscular weakness, and occasional arthritic changes and a liability to re-dislocation, are the commonest sequelæ. Prolonged immobilisation is liable to lead to stiffness by permitting of the formation of adhesions; while too early movement tends to produce a laxity of the ligaments which favours re-displacement from slight causes.

Treatment.—Reduction should be attempted at the earliest possible moment. Every hour of delay increases the difficulty. The guiding principle is to cause the displaced bone to re-enter its socket by the same route as that by which it left it—that is, through the existing rent in the capsule. This is done by carrying out certain manipulations which depend upon the anatomical arrangement of the parts, and which vary, not only with different joints, but also with different varieties of dislocation of the same joint. In general terms it may be said that the main impediments to reduction are: the contraction of the muscles acting upon the displaced bone; the entanglement of the bone among tendons or ligamentous bands which fix it in its abnormal position; and the rent in the capsule being small or valvular, so that it forms an obstacle to the bone reentering the socket.

Muscular contraction is best overcome by the administration of a general anæsthetic, and in all but the simplest cases this should be given to ensure accurate and painless reduction. Failing this, however, the muscles may be wearied out by the surgeon making steady and prolonged traction on the limb, while an assistant makes counter-extension on the proximal segment of the joint. Advantage may also be taken of such muscular relaxation as occurs when the patient is already faint, or when his attention is diverted from the injured part, to carry out the manipulations necessary to restore the bone to its normal position.

The appropriate manœuvres for disengaging the head of the bone from tendons, ligaments, or bony processes with which it may be entangled, will be suggested by a consideration of the anatomy of the particular joint involved, and will be described with individual dislocations.

In reducing a dislocation, no amount of physical force will compensate for a want of anatomical knowledge. All tugging, twisting, or wrenching movements are to be avoided, as they are liable to cause damage to blood vessels, nerves, or other soft parts, or even—and especially in old people—to fracture one of the bones concerned.

After reduction, great benefit is gained by the systematic use of massage and movement. Before any restraining apparatus is applied the whole region should be gently stroked in a centrifugal direction for fifteen or twenty minutes; and this is to be repeated daily, each sitting lasting for about twenty minutes. From the first day onward, movement of the joint is carried out in every direction, except that which tends to bring the head of the bone against the injured part of the capsule; and the patient is encouraged to move the joint as early as possible. The appropriate apparatus and the period during which it should be worn will be considered with the individual dislocations.

Operation in Simple Dislocations.—In a limited number of cases, even with the aid of an anæsthetic, reduction by manipulation is found to be impossible. Resort must then be had to operation, which is a comparatively safe and satisfactory proceeding, although often difficult. It may happen in rare instances that the undoing of the displacement is only possible after the removal of a portion of one or other of the bones.

Compound Dislocations.—Compound dislocations are usually the result of extreme violence produced by machinery or railway accidents, or by a fall from a height. In the majority of cases they are complicated by fracture of one or more of the constituent bones of the joint, as well as by laceration of muscles, tendons, and blood vessels. In the region of the ankle, wrist, and joints of the thumb, however, compound dislocation is sometimes met with uncomplicated by other lesions. The great risk is infection, which may result in serious impairment of the usefulness of the joint or even in its complete destruction, results towards which the concomitant injuries materially contribute. In many instances where infection has occurred, ankylosis is the best result that can be hoped for.

Treatment.—As a rule, the first question that arises is whether amputation is necessary or not, and the considerations that determine this point are the same as in compound fractures ([p. 26]). If an attempt is to be made to save the limb, the treatment is the same as in compound fracture ([p. 25]).

Dislocation complicated by Fracture.—In certain dislocations the separation of small portions of bones or of epiphyses is of common occurrence—for example, fracture of the tip of the coronoid process in dislocation of the elbow backwards, and chipping off of a portion of the edge of the acetabulum in dislocation of the hip.

The most important example of a fracture complicating a dislocation is fracture of the surgical neck of the humerus coexisting with dislocation of the shoulder. Here the difficulty of diagnosis is greatly increased, and the treatment of both injuries requires to be modified. The dislocation must be reduced—by operation if necessary—before the fracture is treated, and in many cases it is advisable to secure the fragments of the broken bone by pegs, or plates, to admit of movement being commenced early, and so to prevent stiffness of the joint.

Old-standing Dislocations.—When, from want of recognition—and, curiously enough, a dislocation is much more liable to be overlooked than would have been thought possible—or from unsuccessful treatment, a dislocation is left unreduced, changes take place in and around the joint which render reduction increasingly difficult or impossible. The rent in the capsule closes upon the neck of the bone, and fibrous adhesions form between muscles, tendons, and other structures that have been torn. The articular cartilage of the head, being no longer in contact with an opposing cartilage, tends in time to be converted into fibrous tissue, and may become adherent to other fibrous structures in its vicinity. By pressing on adjacent structures it may form for itself a new socket of dense fibrous tissue which in time becomes lined with a secreting membrane. When the displaced head lies against a bone, the continuous pressure produces a new osseous socket, from the margins of which osteophytic outgrowths may spring, and as the surrounding fibrous tissue becomes condensed and forms a strong capsule, a new joint results. The occurrence of these changes in the direction of a new ball-and-socket joint is largely dependent on the behaviour of the patient: a vigorous man, anxious to recover the use of the limb, will employ it with a degree of determination and indifference to pain that could not be expected in a sensitive elderly female. The most perfect example of a new ball-and-socket joint, following upon an unreduced dislocation at the hip, that has come under our observation, was in a hunting dog, given one of us by an Australian pupil, who testified that the animal was as fleet with the new joint as it had been with the original one. Meanwhile the cartilage of the original socket is converted into fibrous tissue, which may come to fill up the cavity. Changes resembling those of arthritis deformans may occur. The large blood vessels and nerves in the vicinity may be pressed upon or stretched by the displaced bone, or may be implicated in fibrous adhesions. In course of time they become lengthened or shortened in accordance with the altered attitude of the limb.

Fig. 12.—Os Innominatum showing new socket formed after old-standing dislocation. The acetabulum is almost obliterated.

In many cases the new joint is remarkably mobile and useful; but in others, pain, limited movement, and atrophy of muscles render it comparatively useless, and surgical intervention is called for.

Treatment.—It is always a difficult problem to determine the date after which it is inadvisable to attempt reduction by manipulation in an old dislocation and no rules can be laid down which will cover all cases. Rather must each case be decided on its own merits, due consideration being had to the risks that attend this line of treatment. The chief of these are: rupture of a large blood vessel or nerve that has formed adhesions with the displaced bone, or has become shortened in adaptation to the altered shape or length of the limb; tearing of muscles or tendons, or even of skin; fracture of the bone, especially in old people; and separation of epiphyses in the young.

Before carrying out the manipulations appropriate to the particular dislocation, all adhesions must first be broken down; and during the proceedings no undue force is to be employed. The first attempt at reduction may fail, and yet subsequent efforts, at intervals of a few days, may ultimately prove successful; the vigorous traction and twisting of the soft parts, matted together as they are by scar-tissue, causes reactive changes in the vessels and tissues which render them more liable to yield on subsequent attempts at reduction. In old people, and where there is an absence of suffering from pressure on nerves or vessels, it may be wiser to leave the dislocation unreduced, and strive rather by massage and movement to obtain a useful variety of false joint. If the conditions are otherwise, it may be better to improve the function of the limb by an open operation. Tight ligaments and other structures are divided, and the socket is cleared out. If reduction is still impossible, a partial excision may be performed and a flap of fascia lata introduced to prevent ankylosis (arthroplasty). In the case of the hip, the dislocation may be left alone and the femur divided below the trochanter, especially if there is pronounced flexion.

Habitual or recurrent dislocation is almost exclusively met with in the shoulder, and will be described with the injuries of that joint.

Pathological Dislocations.—Joints may become dislocated in the course of certain diseases. These pathological dislocations fall into different groups: (1) those due to gradual stretching of the capsular and other ligaments weakened by inflammatory and suppurative processes, such as sometimes follow on typhoid, scarlet fever, or diphtheria, and in pyæmia; (2) those due to destructive changes in the ligaments and bones—typically seen in tuberculous arthritis, in arthritis deformans, in Charcot's disease, and in nerve lesions, e.g. dislocation of the hip in spastic conditions, such as Little's disease; (3) those associated with deformed attitudes of the limb; (4) those due to changes in the articular surfaces, e.g. the phalanges in arthritis deformans. These will be considered with the conditions which give rise to them.

Congenital Dislocations.—Congenital dislocations are believed to be the result of abnormal or arrested development in utero, and are to be distinguished from dislocations occurring during birth, which are essentially traumatic in origin. They will be described along with the Deformities of the Extremities.

CHAPTER III
INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM

• [Surgical Anatomy]
• —[Fractures of Clavicle: Varieties]
• —[Dislocation of Clavicle: Varieties]
• —[Dislocation of Shoulder: Varieties]
• —[Sprains and contusions of shoulder]
• —[Fracture of Scapula: Sites]
• —[Fracture of Upper End of Humerus]:
• [Surgical neck];
• [Separation of epiphysis];
• [Fracture of head, anatomical neck, or tuberosities]
• —[Fractures of Shaft of Humerus].

The injuries met with in the region of the shoulder include fractures and dislocations of the clavicle, fractures of the scapula, dislocations and sprains of the shoulder-joint, and fractures of the upper end of the humerus.

Surgical Anatomy.—For the examination of an injury in the region of the shoulder the patient should be seated on a low stool or chair. After inspecting the parts from the front, the surgeon stands behind the patient and systematically examines by palpation the shoulder girdle and upper end of the humerus. The uninjured side should be examined along with the other for purposes of comparison.

Immediately lateral to the supra-sternal notch, the sterno-clavicular articulation may be felt, the large end of the clavicle projecting to a varying degree beyond the margins of the small and shallow articular surface on the sternum. Any dislocation of this joint is at once recognised. The clavicle being subcutaneous throughout its whole length, any irregularity in its outline can be easily detected. A small tubercle (deltoid tubercle) which frequently exists near the acromial end is liable to suggest the presence of a fracture. The lateral end forms with the acromion the acromio-clavicular joint, which, however, is not always readily identified. The fingers are now carried over the acromion, which often exhibits in the situation of its epiphysial cartilage a prominent ridge, which must not be mistaken for a fracture. The tip of the acromion is usually employed as a fixed point in measuring the length of the upper arm.

The outline of the spine of the scapula can be traced back to the vertebral border; and the body of the bone may be manipulated, and its movements tested by moving the arm.

The coracoid process can be recognised in the upper and lateral angle of the triangular depression bounded by the pectoralis major, the deltoid, and the clavicle.

The head and surgical neck of the humerus may now be felt from the axilla, if the axillary fascia is relaxed by bringing the arm to the side. The great tuberosity can be indistinctly felt on the lateral aspect of the shoulder through the fibres of the deltoid. It lies vertically above the lateral epicondyle, and may be felt to rotate with the shaft. The inter-tubercular (bicipital) groove looks forward, and lies in a line drawn vertically through the biceps muscle.

The subclavian artery, with its vein to the median side and the cords of the brachial plexus to the lateral side, passes under the middle of the clavicle, and may be compressed against the first rib immediately above this bone.

Fracture of the Clavicle

Fracture of the clavicle is one of the commonest injuries met with in practice. As about one-third of the cases occur in children, the fracture is often of the greenstick variety. The fractures are seldom compound or complicated, unless as a result of gun-shot injuries; but occasionally one of the fragments pierces the skin, or comes to press upon the subclavian vessels or the cords of the brachial plexus, arresting the pulsation in the vessels of the limb, and causing severe pain in the arm.

Fig. 13.—Oblique Fracture of Right Clavicle in Middle Third, united.

The most common site of fracture is in the middle third ([Fig. 13]), and this usually results from indirect violence, such as a fall on the outstretched hand, the elbow, or the outer aspect of the shoulder, the force being transmitted through the glenoid cavity to the scapula, and thence by the coraco-clavicular ligaments to the clavicle. The violence is therefore of a twisting character, and the bone gives way near the junction of the lateral and middle thirds, just where the two natural curves of the bone meet, and where the supporting muscular and ligamentous attachments are weakest.

The fracture so produced is usually oblique from above, downwards and inwards. The sternal fragment may be slightly drawn upwards by the clavicular fibres of the sterno-mastoid, while the acromial fragment falls by the weight of the arm, and the fragments usually overlap to the extent of about half an inch. The shoulder, having lost the buttressing support of the clavicle, falls in towards the chest wall, narrowing the axillary space, while the weight of the arm pulls it downward, and the muscles inserted in the region of the bicipital groove pull it forward.

Fracture of the middle third may result also from a direct stroke, such as the recoil of a gun, or from violent muscular contraction, the fracture as a rule being transverse, and the displacement less marked than in fracture by indirect violence.

Clinical Features.—The attitude of the patient is characteristic: the elbow is flexed and is supported by the opposite hand, while the head is inclined towards the affected shoulder to relax the muscles of the neck. Crepitus is elicited on bracing back the shoulders, or on attempting to raise the arm beyond the horizontal, and these movements cause pain. Tenderness is elicited on making pressure over the seat of fracture, and also on distal pressure. The sternal fragment almost invariably overrides the acromial, and can usually be palpated through the skin; on measurement, the clavicle is found to be shortened. When the fracture is incomplete (greenstick) or transverse, the symptoms are less marked.

Fig. 14.—Fracture of Acromial End of Clavicle. Shows forward rotation of lateral fragment, and line of fracture united by bone.

Fracture of the lateral or acromial third of the clavicle is a common form of accident at football matches, and usually results from direct violence, the bone being driven down against the coracoid process, and broken as one breaks a stick over the knee. The fracture may take place through the attachment of the conoid and trapezoid ligaments, in which case the only symptoms are pain and tenderness at the seat of fracture, with impaired movement of the limb. Displacement and crepitus are prevented by the splinting action of the ligaments.

When the break is lateral to the attachment of the trapezoid ligament, the fracture is usually transverse, and is almost always due to a fall on the back of the shoulder—the angle between the spine and the acromion process striking the ground. The acromial fragment rotates forward ([Fig. 14]), sometimes even to a right angle, causing the tip of the shoulder to pass forwards, and so to lie slightly nearer the middle line. The integrity of the coraco-clavicular ligaments prevents any marked drooping of the shoulder. It is noteworthy that the displacement is not always evident at first.

Fractures of the medial or sternal third are rare, are usually oblique, and result either from an indirect force acting in the line of the clavicle, or, less frequently, from direct violence or muscular action. As a rule, the deformity is insignificant, except when the costo-clavicular ligament is torn, in which case the medial end of the distal fragment is tilted up by the weight of the arm. The shoulder passes downwards, forwards, and medially. When close to the sternal end, this fracture may simulate a dislocation of the sterno-clavicular joint or a separation of the clavicular epiphysis. This last is a rare accident, which may occur between the seventeenth and the twenty-fifth years, and is usually the result of violent muscular action. It differs from the other injuries in this region in being more easily reduced and retained in position, the epiphysis lying entirely within the limits of the articular capsule of the sterno-clavicular joint.

Simultaneous fracture of both clavicles usually results from a severe transverse crush of the upper part of the thorax or from a fall on the outstretched hands—for example, in hunting. The middle third of the bone is implicated, and there is marked displacement and overriding. The patient is rendered helpless, and from the extrinsic muscles of respiration being thrown out of action and the weight of the powerless limbs pressing on the chest, there is considerable difficulty in breathing, and this is often increased by the fracture being complicated by injuries of the lung or pleura.

The prognosis as to union in all these injuries is good. Firm bony union usually occurs within twenty-one days. Non-union, false-joint, or fibrous union is but rarely met with. At the same time it is to be borne in mind that, in spite of all precautions, some deformity and shortening may result, without, however, interfering with the usefulness of the limb.

Fig. 15.—Adhesive Plaster applied for Fracture of Clavicle.

Treatment.—The displacement in complete fractures of the clavicle is readily reduced by supporting the elbow, bracing back the shoulders, and levering out the tip of the affected shoulder. In a few cases the interposition of some fibres of the subclavius muscle between the fragments has prevented perfect reduction.

In the greenstick variety the bone may be bent back into its normal position, but no great force should be employed, as, in spite of imperfect reduction, the clavicle usually straightens as it grows, and although some deformity may persist, the function of the limb is not interfered with.

Recumbent Position.—There is little doubt that the most perfect æsthetic results are obtained by treating the patient in the recumbent position. In girls, therefore, in whom it is desired that the shoulders should be perfectly symmetrical, the best results are obtained from placing the patient on a firm mattress, with a narrow, firm cushion between the shoulder-blades, so that the weight of the shoulder may carry the acromial fragment laterally and backwards. A pad is inserted in the axilla, the elbow raised, and the arm placed by the side on a pillow and steadied with sand-bags. Massage is applied daily. As this position must be maintained uninterruptedly for two or three weeks, it proves too irksome for most patients. When both clavicles are fractured, however, it is, short of operation, the only available method of treatment.

In ordinary cases the arm should be placed in that position which gives the best alignment of the fragments and least deformity. A thin layer of wool is placed in the axilla to separate the skin surfaces. A sling, supporting the elbow, is now applied, maintaining the arm in position, and a body bandage fixes the arm to the side. Massage and movement should be commenced at once.

A simple method, which yields satisfactory results, is that suggested by Wharton Hood. The fracture having been reduced, three strips of adhesive plaster, each an inch and a half wide, are applied from a point immediately above the nipple to a point 2 inches below the angle of the scapula ([Fig. 15]). The middle strap covers the seat of fracture, and is applied first: the others, slightly overlapping it, extend about half an inch on either side. The elbow is supported in a sling. This plan has the advantage that it permits of movement of the shoulder being carried out from the first, but the plaster rather interferes with massage.

The Handkerchief Method.—In cases of emergency, one of the best methods applicable to all fractures of the clavicle is to brace back the shoulders by means of two padded handkerchiefs, folded en cravate, placed well over the tips of the shoulders and tied, or interlaced, between the scapulæ. The forearm is then supported by a third handkerchief applied as a sling, the base of which is placed under the elbow, the ends passing over the sound shoulder.

Operative treatment may be called for in compound or comminuted fractures when the fragments have injured, or are likely to injure, the subclavian vessels or the cords of the brachial plexus, or when it is otherwise impossible to reduce the fracture or to retain the fragments in apposition. It is also indicated in some cases of fracture of both clavicles.

These various methods of treatment are not equally applicable to all cases. In our experience, in the circumstances indicated, the following methods have proved the most satisfactory: (1) As a temporary means of retention in emergency cases,—for example, accidents occurring on the football field,—the handkerchief method. (2) In uncomplicated fractures of average severity in any part of the bone, the method of sling and body bandage. (3) In cases where, for æsthetic reasons, the chief consideration is the avoidance of deformity and the maintenance of the symmetry of the shoulders, as in girls, the treatment by recumbency. (4) When retentive apparatus fails, or when the fragments are exerting injurious pressure, operative treatment.

In quite a number of cases, there is an excessive amount of pain, preventing sleep; where this is due to cramp-like contractions of the muscles and movements of the fragments, it is relieved by more accurate fixation, as by strips of plaster; otherwise a hypodermic injection of heroin or morphin is indicated.

Dislocation of the Clavicle

Dislocation of the acromial end—sometimes, and perhaps more correctly, spoken of as dislocation of the scapula—is more frequent than that at the sternal end, and it usually results from a blow from behind, or from a fall on the tip of the shoulder, driving down the scapula, so that the clavicle projects upwards and overrides the acromion process.

Downward displacement of the acromial end of the clavicle is much rarer, and may follow a fall on the elbow or a blow over the clavicle. The end of the bone lies under the acromion process, in contact with the capsule of the shoulder-joint, and the acromion stands out prominently.

The clinical features are so well marked that the diagnosis is unmistakable. The head inclines towards the affected side, and the tip of the shoulder tends to pass slightly downward, forward, and medially. The displaced end of the bone can be seen and felt as a prominence under the skin, or the empty socket can be palpated, while the muscles attached to the displaced clavicle stand out in relief. The movements at the shoulder are restricted, particularly in the direction of abduction above the level of the shoulder. These injuries are sometimes associated with fracture of the ribs, a complication which adds materially to the difficulties of treatment.

Treatment.—Reduction is easily effected by bracing back the shoulders and replacing the bone in its socket by manipulation; but retention is invariably difficult, and in many cases impossible; even when the displacement is permanent, however, the usefulness of the arm is not necessarily impaired.

Treatment is similar to that for fracture of the clavicle by sling and body bandage. Another plan is to place a pad over the acromial end of the clavicle, and fix it in this position by a few turns of elastic bandage carried over the shoulder and under the elbow. The forearm is placed in a sling with the elbow well supported, and the arm is bound to the side by a circular bandage. When the bone cannot be kept in position and the usefulness of the limb is impaired, the joint surfaces may be rawed and the bones wired, with a view to obtaining ankylosis.

The sternal end may be dislocated forwards, backwards, or upwards.

Forward dislocation is the most common; the end of the clavicle lies on the front of the sternum, somewhat below the level of the sterno-clavicular joint, and its articular surface can be distinctly palpated ([Fig. 16]). The inter-articular cartilage sometimes remains attached to one bone, sometimes to the other; the rhomboid ligament is usually intact.

In the backward dislocation the end of the clavicle lies behind the manubrium sterni and the muscles attached to it; there is a marked hollow in the position of the joint, and the facet on the sternum can be felt. In a comparatively small number of cases the bone exerts pressure upon the trachea and œsophagus, producing difficulty in breathing and swallowing. It has also been known to press upon the subclavian artery and on other important structures at the root of the neck.