A text-book of fractures and dislocations

Front matter

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Preface

Ix the preparation of this work the author has carefully culled from the literature the information which seemed most helpful and with it has combined his own ideas and experience in order to cover the field and to present a clear understanding of this important branch of surgery. ]Much of the clinical and all of the statistical material has been obtained at the Cook County Hospital, Chicago. Although the author has personally performed the labor of writing the text and gathering the illustrations, for all of which he alone is responsible, he has been fortunate in receiving the helpful cooperation of his colleagues in the hospitals with which he is connected and of members of the Chicago Surgical Society. He wishes here to express his appreciation of their kindness if at any place in the text he has failed to make more specific acknowledgment.

It has come to be appreciated in all branches of medical teaching and research that a basic knowledge of pathology is of prime importance, so it is believed that clear conception of osseous injuries and their repair is essential to an understanding of fractures. Better treatment results. For this reason the author has selected examples of different types of usual fracture pathology and endeavored to bring them before the reader's eye by means of line drawings which illustrate the essential points. Every illustration of this character is a careful reproduction of a tracing made from a Roentgenogram of an actual case. The Artist, Mr. Streedain, and the author have w^orked for nearly two years preparing these drawings, checking and rechecking each one until it conveyed the author's conception of the lesion. No one can read all roentgenograms with positive assurance. The author's obligations to Dr. Blaine, Roentgenologist to the Cook County Hospital, for his friendly cooperation in this part of the work are gratefully recorded. The Artist has attempted to differentiate the shadows of bones more distant from the observer by lighter lines, and where two shadows overlap has indicated the one more remote by dotted lines. Cutaneous landmarks, lines of incisions with skin clips and plastt^r dressings have been occasionally indicated for obvious reasons.

vi PREFACE

It has seemed unwise to cumber the pages with statistical charts and tables recording all cases of fractures studied by the author; but he has not failed to incorporate freely in the text deductions from many such tables which have been accurately compiled for his private use. The nomenclature employed accords with that used in the Howden edition of Gray's Anatomy.

The author wishes to thank the Publishers for making the book

possible. He is also under obligations to his various House Surgeons

and to those who have helped in the mechanical preparation of the

text. Dr. J. J. Andrews and D. L. have aided greatly by friendly

criticism.

K. S.

Chicago, III., 1916.

Chapter I Bone

Physiology and Physics — Regeneration — Callus Formation — Callus in Joint Fractures — Effects on Callus of Early Motion, Massage, and Foreign Bodies — Bone Transplantation and Fate of Transplants — Bone Repair in Open Fractures and Postoperatively — Clinical Course of Fracture.

Fractures and dislocations deal primarily with bone, and the student and practitioner should have intimate knowledge of the details of osseous gro^^i:h and structures. This chapter aims to deal with the general questions involving bone, largely from a practical and clinical standpoint, because elementary facts concerning bone and its repair become distorted when practical application to fracture is needed.

x\natomical text-books give information in regard to the formation of bone, its deposition in cartilage and membrane, and the present \\Titer has no intention of reiterating. Osseous tissue, the hardest tissue of the human body, is not to be considered as an inert framework on which other important organs and tissues are draped. It possesses elasticity and toughness — that is, power to resist stress and strain — and is consequently governed by the physical laAvs of elastic bodies subject to these forces. Fortunately for animals, and especially for men, bones are also influenced by other factors which govern their appearance, strength, power of recuperation, and regeneration. An analysis from the standpoint of composition, with bone considered as a physical combination of substances, demonstrates that the earthy or hard properties are furnished by calcium phosphate, carbonate, and fluoride, with the addition of some magnesium phosphate. These salts compose about (Hi per cent, of the total bone weight. Adolescent bones contain a smaller percentage of salts, senile bones, a greater percentage. The calcium balance concerns all the skeletal tissues in the builfling-up and tearing-down processes. There is probably a continuous flow of calcium salts both to and from the bone, the amount dependent on the avaihible suj)ply in the food intake and on the metabolic ])rocesses, a matter of such intricate mechanism that it is not thoroughly unrlerstood. Fnder ordinary conditions of food and n.etabolism the supply is sufficient to meet all demands; when the

18 BOME

diet is deprived of calcium salts there is absorption from the bones. This loss by the bones first affects those wfiich can spare calcium best without affecting their tensile strength, namely, the sternum, skull, ribs, etc. Under some conditions the amount of ingested calcium is by no means a measure of that used in bone reconstruction, because other tissues demand these salts. In rickets and osteomalacia there is probably such a diversion to other structures, and perversions with skeletal deformities exist in diseases of the pituitary body and disease or congenital absence of the thyroid or thymus.

While we accept this information as all important in its bearing on the rigidity of osseous material, we must not lose sight of the fact that bone is a living and growing tissue. It varies in size and shape from time to time; it is built up and torn down much as are the skin and epithelial surfaces which are constantly undergoing repair; and it is shaped by the plastic power of growth and force, as are the soft tissues. Wolff's law states the idea thus: the shape of bones is determined by conditions of reactions of bones in structure and shape to the body weight and to stress and strain of muscular action.^

Life and growth of bone are provided for by its division into three parts: the covering or periosteum, the compact tissue or dense ivorylike substance, and the cancellous tissue or softer part found within the compact. Blood supply is rich, furnished by the periosteum, with its vessels penetrating into the compacta and cancellous tissue, and the nutrient and epiphyseal arteries which supply the softer content within the hard outer layer. Blood supply is of the greatest importance in bone regeneration and growth, as it is in any tissue, another factor too frequently overlooked. There are also nerves and lymphatics in bone, delicate and important structures which perform their functions inside the hard covering about them. These functions are easily terminated when the covering is greatly disturbed, as in fracture or other injuries.

It has been determined that the proportion of earthy salts in the bone matrix is a sensitive indication of the life of the bone, that is, of its age or condition of health. W^hen bone is diseased or injured or deprived of its normal function of stress and strain from weight-bearing and muscular action, an atrophy develops within it. The proportion of the salts in its composition is disturbed, and early evidence of this disturbance is found in the character of the shadow cast on the sensitized plate when an exposure is made to the Roentgen rays. Corson^ has stated that the Roentgen-ray shadow of an element is distinctly proportional to its atomic weight. Calcium with an atomic weight of 40 makes a denser shadow than magnesium, weight 24, and because the latter represents only a small percentage of the earthy salts, the main role in shadow density is played by the calcium salts. The best example of this truth lies in the fact that recent callus casts no shadow. No calcifying salts have been deposited. Bone

> Tubby, Brit. Med. Jour., 1908, vii, 25. 2 Ann. Surg., li, 289.

REGENERATION OF BONE 19

atrophy may be the result of a neurotrophic process, or a senile osteoporosis, or of bone cysts affecting small areas, or the hypertrophic syphilitic conditions which leave pits of ulcerating gummatous areas. It also occurs after muscular trauma and inactivity, poliomyelitis or the muscular dystrophies, cerebral palsies, etc. Sensitive bone may show atrophy after nerve injury which involves itself directly or its surrounding soft parts. This pathological fact is of practical bearing in some cases of non-union, or in refracture following clean operative fixation, or in removal of tibial crests for autogenous splints, which may be the result of such nerve disturbance.^ (See Chapter on Operative Treatment.)

Cancellous and compact tissue are much alike, the former being more porous. When it is necessary in body economy that great weight and much stress should be sustained, a bone is composed of more elastic cancellous tissue and less friable and rigid compact tissue. The calcaneus and vertebrse are excellent examples. They have a mere shell of compact tissue about them. Great rigidity and stiffness needed in the limbs is shown by the increased amount of the compact tissue in the shafts of the femur, tibia, humerus, and forearm bones. A vertically sawed section of the tibia shows that the direction of the important bone lamellae is vertical. In the head of the bone these spread out laterally in a direction to take up the strain of weight-bearing. The direction of the main lamellae coincides also with the direction in which muscular strain takes effect. Dixon^ states that the cancellous ends of long bones, in spite of their apparent delicate structure, will resist enormous pressure if the pressure is applied in the normal direction of body weight or muscle strain. (See figure illustrating structure of the calcaneus.)

REGENERATION OF BONE.

How bone grows is an undecided point in pathology. The experimental and clinical observations touching it are of interest here only inasmuch as they cover regeneration after traumatic separation or fracture and its treatment. In the newborn the ends of the long bones entering into joints are round and smooth and separated from each other by cartilage. As age advances, calcium salts are deposited in these cartilaginous areas and cast a shadow in the roentgenogram. The new shadow-casting areas are the epiphyses, the original shaft of the bone the diaphyses, and the remaining clear cartilaginous areas between the two are the epiphyseal lines.

If a sifted resume of the large amount of recent literature on this subject is to be arrived at, it is necessary to consult many authors

1 Die Roentgen Strahlen in Dienste der Neurologic, Fiirnrohr, Berlin, 190G; editorial, Jour. Am. Med, Assn., November 21, 1914; McCrudden, Tr. XVth International Congress on Hygiene, etc., 1913, vol. xi. Part II, p. 424; and Deutsch. Archiv f. klin. Med., Band ex, Heft 1 und 2, p. 90.

2 Manual of Human Osteology.

20 BONE

and recall some of the physical facts in the preceding paragraphs. Little has been said about the periosteum previously, because around this tissue has been waged the war concerning growth of bone, callus formation, delayed and non-union, and necrosis. It must be recalled briefly that the periosteum is derived from fetal mesoderm and mesenchyme, which later become connective tissue. The derivations of this connective tissue are closely allied; they are represented by cartilage, ligaments, tendons, fasciae, and bone, the last of which develops from fibrous tissue as intramembranous bone, or from cartilage as intracartilaginous bone. When the fibrous or cartilaginous tissue becomes bone, cells known as osteoblasts or chondroblasts deposit calcium salts in the fibrous matrix and a bony network results. This network advances in all directions, and later the cells bordering the newly formed osseous tissue condense to make a membrane about it. This is periosteum, and by the time it has become a distinct membrane there is formed beneath it a layer of osteoblasts which proceed to the deposition of the compact bone. The process in cartilage is similar, starting from ossification centres, the perichondrium assuming the function of the periosteum.

Full-developed periosteum is a fibrous membrane closely adhering to the bone circumference except at the cartilaginous ends. The fibers of Sharpey, or fibrous trabeculse, penetrate at right angles from the periosteum into the compact bone. There are also penetrating bloodvessels branching from the periosteal supply into the cancellous tissue. Histologically, there is no distinct line of separation of the periosteum from the compacta.^ When an operator peels the periosteum or strips it with instruments, lines of cleavage are found, close study of which reveals different depths of separation. During a growing stage of bone the periosteum contains the osteoblasts in distinct cellular rows surrounded by a fine network of bloodvessels and fibrils. When adult bone condition is attained, these osteoblasts in the periosseous layer disappear for the most part, and only a few cells remain in an inactive state, their number and physiological activity being governed by the functional and irritative demands of the bone. Consequently this fibrous covering of the bone has three layers : the outer tough fibrous tissue which is highly vascularized, a middle elastic layer of varying thickness which is closely adherent to the compact bone, and enclosed between it and the compacta the third or periosseous layer of fibrils and small cells. This third layer in adult bones is very narrow; in growing bones it is thicker and can be divided into two cellular layers, an outer with flattened nuclei, and an inner with oval or round nuclei of younger cells. There is no distinct and constant line of cleavage from the compacta. Removal of the periosteum by sharp strokes of a periosteotome peels off a thinner layer of tissue than painstaking slow reflection of the membrane. This fact may account for the great variations in experimental results of different

' Smith, Surg,, Gynec. and Obst., No. 5, vol. xv, 550.

REGENERATION OF BONE 21

obseners, because the periosteum must be a varyiug structure, and its removal would not strike the same level of cells or coutain the same proportion of dormant osteoblasts on any two occasions. The age of the bone and its stage of reaction to growth and irritation of metabolic products (alcohol), the amount of blood supply and fibrin present, the mechanical stimuli and destruction, are all variable factors which cause a divergence of experimental results.

Cartilage regenerates largely from the perichondrium, preformed cartilage taking no active part in the new growth.^ IVIoore and Corbett- say that cutting the nutrient artery prevents formation of periosteal bridge, and as this artery supplies medullary bone, they would conclude that medullary bone is responsible for the s.ubperiosteal bridge.

Gallic and Robertson^ agree with Macewen."^

It must be conceded that the osteogenetic cell§ of the periosteum, and in a smaller degree the endosteum, take a very active and earl}^ part in the regeneration of bone. Later a limited regeneration may follow from the compact or medullary portions. This proliferation is in part at least cartilaginous; it later becomes bony; and there may be a great difference in the relative amount of bone and cartilage formed at different periods, depending on the factors mentioned, namely, age, presence or absence of blood-clot and blood supply, nerve, periosteal and mechanical injury, and, according to some experimenters, the amount of tissue to be regenerated. I believe the last makes little difference, if there is an active healthy proliferative process; it does take a long time to produce solid bone transversely, but the whole shaft of a long bone like the humerus may be regenerated in the longitudinal axis in four weeks if removed subperiosteally. This removal I have performed on human beings, the indication being an acute infection. Growing conditions depend also on the force present, and the specific character of the cells predetermine the character of tissue to be formed. Experimental work demonstrates different results concerning the regeneration of bone, possibly for the reasons given previously. Some results show that there is first an active proliferation of the osteoblasts in the third periosteal layer to form cartilage, which is then rapidly transformed into bone. Regenerated cartilage continues to grow as cartilage, rarely becoming bone. Other results show that the bone is formed outside of the cartilage and

' Haas, Surg., Gynec. and Obst., xix, No. 5, also ibid., xvii, 164; Axhausen, Arch. f. klin. Chir., xcix, 1; Davis, Bull. Johns Hopkins Hosp., xxiv, 164; Mallesta, Virchows Arch. f. path. Anat., Berlin, 1906, clxxxiv, 12.3; K. von Korff, Arch. f. mikr. Anat., 1914, Ixxxiv, 26.3, on histological development of cartilage; Mayer and Wehner, Arch. f. klin. Chir., 1914, ciii, 7.32; Ortho. Surg., 1914, p. 213; Hawley, ibid., p. 245.

2 Tr. Western Surg. Assn., 1913.

' Canad. Med. Assn. Jour., iv, 33.

'• Salvetti, Deutsch. Ztschr. f. Chir., cxxviii, 130, Influences of X-rays on Callus; Davis, Ann. Surg., Iv, 781; Wilensky, Am. Jour. Surg., vol. xxviii, No. 2; Murphy, Surg., Gynec. and Obst., 1913, xvi, 493; Jour. Am. Med. Assn., Iviii, 1094; Maccwen, Growth of Bone, 1912; McWilliams, Surg., Gynec. and Ob.st., 1914, p. 159; Jour. Am. Med. Assn., 1914, Ixii, .346.

22 BONE

gradually replaces it, using it as a framework. Newly regenerated bone is cancellous; later the osteoblasts in its spaces are arranged in concentric layers like the Haversian systems and are included as bone corpuscles.^ The i)eriosteinn and perichondrium take analogous parts in new tissue formation, and the osteoblasts tend to revert to the chondroblastic type, and when cartilage regenerates its cells tend to revert to a connective-tissue type.

To understand fracture, its course, pathology, and the latest development of treatment, we must know these conditions and also the normal manner of callus formation, the influence of motion and unwise early use, and of the insertion of foreign bodies or autogenous splints. The fate of bone transplanted into soft parts does not interest us here. It is undoubtedly gradually absorbed, because it has absolutely no functional position to fill,^ and comes to a natural death in accordance with Wolff's law.

Development of bone is of extreme importance, inasmuch as after solution of bone continuity the fragments must be welded and cemented together to reestablish function in the injured part. This is accomplished by callus.

Callus Formation. — -For illustration let us consider a long bone. When it is broken the line of fracture is rarely straight, but is jagged or very irregular, and may include spicules and small loose pieces of osseous tissue between the main fragments. Blood and nerve supply are interfered with, there is a hemorrhagic extravasation, and a clotted mass fills up the space created. The periosteum is torn. Oilier first made clinical note of this fact, but we know now in light of frequent open operations and roentgenographic evidence that this membrane is rarely ruptured completely. It may be stripped up for some distance, or lacerated severely in part of its circumference, but never entirely destroyed. Its quality. of elasticity often saves its continuity. Comminuted fragments of underlying compact bone may be completely separated, but remain attached to the untorn periosteum. A good reposition of alignment in such a case, encased in the guiding vaginal periosteum, would lead to a happy cementing in place with a similarly good functional result. If, however, the periosteum is torn from these fragments, they lose blood supply and may necrose in part. This necrosis takes place in the ends of fragments after all fractures, and is of intense importance. A function of exclusion is also assigned to the periosteum; that is, it holds out of the way the intrusion of the omnipresent connective tissue regenerating in the surrounding soft parts, which would interfere with early bone healing.

Displacement, which removes the fracture ends from contact, usually strips up the periosteum and leaves a bridge joining them. This bridge is of importance because, as we have seen, it contains osteoblastic cells capable of regeneration, and a connecting link of tissue potentially able to form bone still persists between fragments.

1 Gray's Anatomy, Howden edition, p. 59.

2 Phemister, Surg., Gynec. and Obst., No. 3, xix, 303.

REGEXERATIOX OF BOXE 23

The effusion of blood from bone, periosteum, and muscles at the fracture site is absorbed in a few days, and there is a multiplication of small round cells which cause swelling and edema. A viscid, gelatinous, dark-colored fluid mass then exists aroiuid the fracture, which is of practical help in guiding the surgeon to the exact site when he is operating through heavy muscles. The periosteum becomes h^-peremic and thickened, and proliferation of the dormant osteoblasts begins. A soft, whitish, bulbous swelling, which is symmetrical in shape, unites the two fractured bone ends, if there is little lateral displacement. This can be palpated in many bones, even in the femur, inside of twelve or fourteen days. Bone regeneration also takes place slowly from the compact and cancellous tissues and beneath or along the periosteal bridges in the effused blood. The blood-clot may be too extensive, and instead of being a help in bone repair may be so large and cause so much obstruction peripherally that it obstructs the general circulation and chokes the lymphatics. This condition would add to the task of bone repair, which is best and quickest performed in the face of accurate approximation and a minimum amount of coagulated blood.

The compact and cancellous surface ends of the fragments become necrotic after fracture on account of trauma and loss of blood supply. For that reason regeneration from these areas is slow, being preceded by an absorption of this necrotic tissue and creeping proliferation out into it of the new islands of bone from the live Haversian canals beyond it. The mtervening necrotic tissue is slowly replaced by a process of rarefying osteitis, which removes the bone tissue by first making it spongy and cancellous.

The most important element in fracture repair is the absorption of extra vasated blood and the layer of necrotic bone, followed by a reestablishment of vascular conununication between the fragments. This comes from the regenerating and budding vessels in the various bone elements and the erection of new Haversian colimms following on the capillary network. ^Nloore and Corbett in their study of the function of the periosteum showed experimentally that cutting of the nutrient artery in rabbits prevented the formation of the periosteal bridge after fracture. Because this artery supplies medullary bone, they are inclined to believe that it, and not periosteum, is responsible for the periosteal bridge.

As previously stated there is a rarefying osteitis which accompanies this process; that is, a withdrawal of calciimi not only in the immefliate fracture area, but over the body in general. This is probably an adaptive process helping the focal efforts of regeneration through some general stimulative process, and through softening the tissues promoting freer vascular gro\\i:h, the calcium being replaced later when bony repair has been accomplished. When necrotic tissue is organized by the granulations, the productive efforts of the underlying active osteoblasts send projections into them, and new bone with later calcification into permanent tissue forms. Usually this

24 BONE

new bone plugs the medullary canal completely, and, after the provisional callus, thrown out by the periosseous layer and endosteum, has shrunken and permanent union is established, the medullary cavity is reestablished by a further absorption of the blocking tissues. Where the displacement is greater, each division of the bone tends to unite with its separated homologous part. If the union is angular, it may be very thick. When there is lateral separation, the callus attempts to pass in the shortest direction between the ends, taking an oblique angle. Laceration of the periosteum with infolding or loss of continuity precludes the formation of this earl}^ callus. There is a proliferative reaction in the torn periosteal stumps and in the surrounding muscle or connective-tissue layers, but progress is slower and atypical in form. This is called the provisional callus and is cartilaginous and soft in character. Centres of ossification appear and later the whole mass becomes bony.

Bone fragments of various sizes, when remaining attached to the periosteum and blood supply, are often moulded in with the process of callus formation and are of assistance in filling in gaps and acting as centres of regeneration. If they are deprived of circulation they undoubtedly become necrotic, though some peripheral cells may survive if they are bathed in sufficient serum to maintain Hfe. These dead fragments may cause irritation and delay bone union, or on the other hand, may, like an osseous splint, act as a framework for the new capillary and osseous growth and aid in union.

Davis^ believes that the provisional callus may not be important in union. He cited a case in which he cut down on the fracture seven weeks after wiring and found nothing on the outside of the bone in the shape of provisional callus, though there was firm bony union. This w^as probably an exact anatomical reposition with no periosteal laceration.

The effect of Roentgen rays on closed fractures has been studied experimentally on rabbits.^ A daily exposure of ten minutes, 120 amperes at a distance of 30 cm., promoted a quick production of callus, but a slow deposit of calcium salts. FrankeP applied stimulating doses of the Roentgen rays in cases of old unconsolidated fracture, and his results confirm the value of the chemical rays in starting the regeneration of bone tissue and healing the fracture promptly.

From the cancellous and compact tissue small islands of bone project and the proliferation takes place from the cells of the lamellae into the fibrils between the fragments. This is pure bone tissue from the start, and a plug forms, which fills the medullary portion of the bone ends and unites them firmly. This is called the definitive callus, which gives a stable and definite union between the fragments. As the provisional callus calcifies and becomes bony, it shrinks until its size approximates that of the normal bone before fracture. The size

1 Ann. Surg., Iv, 781.

2 Salvetti. Deutsch. Ztschr. f. Chir., cxxviii, 130.

3 Med. klin., Berlin, xi. No. 8.

REGEXERATION OF BOXE 25

is partly governed by the degree of reduction to former alignment. If there is no angular or other disi)laeement, the provisional callus is small and after many months might show no gross evidence of fracture, so closely does it return to the normal contour of the bone. In lateral displacement with oblique lines of deposition the weak side which bears the stress of weight or muscular action fills in firmly and fully, provided the periosteal bridge is present. After function returns this callus becomes permanent, and as the limb is used, there is a natural attempt to restore a good axial line of strength by absorption of the bone on the convex side of the line of greatest functional use and a building up of bone on the concave side. This is particularly noticeable in children, who may thus overcome an angular deformity to an extent which after a few years' time prohibits recognition by comparison with the uninjured limb.

Joint fractures, or those in sites of muscle origin and insertion, where tendon sheaths or fascial layers blend with the periosteum, may cause the formation of callus and permanent bone in the structures mentioned. This is caused by traumatic separation of the periosteum with liberation of cells from the periosseous layer or bone into surroundings favorable for regeneration, or an imbedding of periosteal shreds, membrane-like, about the region of hemorrhage. These areas pass through a cartilaginous stage like ordinary callus, and may later become separated from the neighboring bone and lead to irritative symptoms.^ Traumatic myositis of similar character is seen in cavalrymen, shoemakers, and others whose occupations furnish the constant irritation of one muscle or part of the body. Some of these cases do not represent real bone formation, but are a calcification of infections or hemorrhagic processes.

Permanent repair process in bone is slow. Can the formation of a satisfactory definitive callus be hurried by early use or motion of the part? ^Massage, without gross motions which disturb the healing fragment ends, is of use in promoting better blood supply in the surrounding tissues and possibly aids in hurrying the return of function by a vicarious action of exercise. It may also favor an early absorption of the provisional callus.

If early motion is violent enough to break up the capillary network on which the true bone proliferation proceeds, it will delay the process of repair. If more hemorrhage is caused, greater time will be needed to absorb the extravasated blood and the superficial bone layer which becomes necrotic in consequence of its loss of blood supply. As a rule, it is wise to maintain a relative immobilization for a long period in bones which will be subject to great stress and strain of body weight to avoid both these conditions and the clinical bending of soft callus and subsequent loss of function. Around joints where small exuberances of callus may cause great interference with motion, a long rest is indicated. This does not imply a tight, heavy cast of

20 BONE

])laster, but it does mean quiet, rest without rough manipulation or liaiidHng, until continuity is firmly established. Helpful massage can be given without endangering })rompt union.

Sluggish union, or delayed union from uids:nown causes, is often stinudated by use and mechanical irritation of the fragment ends. This is provided through the application of strains in the normal axis and direction of the limb, especially of the leg, by the operator encasing it in plaster or supporting it in normal position by means of a splint and then encouraging the patient to bear a little weight on it. This gives a slight irritation at the bone ends which stimulates regeneration. Various other means are used to attain the same result. (See Pathology and Ununited Fracture.)