Treatise on fractures in general, industrial, and military practice

Front matter

G)fiyright N l

4&.

COFflUGHT DEPOSIT.

Preface To Second Edition

Many opinions on surgical therapeutics have been modified by the 1 experiences and great clinical opportunities of the World War.

The treatment of gunshot wounds of bones has been revolutionized therebv, because a distinction has been made between contaminated and infected open fractures. Lucas-Championniere's dogma that early mobili- " zation and gentle massage are of value in restoring function and contour in fractures of shafts and joint-ends of bones has been accepted. Lane's insistence that closed fractures need operative fixation with steel plates, as a usual routine, has been found to be an untenable creed. Treatment of fractures of the femur and of the tibia by suspension, long ago advocated by N. R. Smith, Hewson and Hodgen in this country, and by others in Europe, has been reinstated in general favor. Critical, intelligent, and frequent examination of fractures, instead of a too absolute reliance on radiographic interpretations by inexperienced laboratory workers, has become an orthodox requirement. These are a few of the by-products of war surgery brought from the battlefields of Europe.

Another agency forcing a revision of old methods in the treatment of broken bones is the advent in the United States of workmen's compensation laws. The payment, by industrial plants and firms, of money for hospital care and surgical treatment of injured employes, has deepened the sense of responsibility in hospital trustees, surgeons and physicians.

In response to these determining factors, there has been an endeavor to make, in this second edition, a volume of value to all those who treat fractures.

The reader, whether engaged in private, in industrial or in military surgery, will find that the text has been thoroughly revised, particular attention given to differential diagnosis and many valuable illustrations added.

A general view of the contents of the book will be obtained from the following summary of treatment:

i. The treatment of broken flat bones consists in great part of attention to associated injuries of the contents of cranium, thorax, abdomen or pelvis.

2. In fractures of the shafts of long bones, with absence of impaction or entanglement, overriding often may be overcome by means of gentle massage, or moderate traction, aided by rest in bed and anodyne remedies to relieve pain and quiet the patient's nervous system. This statement applies with great force to fractures at upper end of humerus and of femur.

3. Radiographic study, to determine the degree of success obtained iv PEEFACE

by efforts to reconstruct anatomical contour, is not infrequently deceptive. This is due to variations in the relative position of the Crookes tube, the fracture and the photographic plate ; or to faulty interpretation of the skiagraphic negatives.

4. Reduction, often under general anaesthesia, is an essential in fractures, especially in impacted fractures. The exact direction of the reducing force to be applied by the surgeon's hands may be indicated by radiographic examination.

5. Fractures of the maxilla and mandible frequently require that the surgeon have associated with him a competent dentist to prevent faulty occlusion of the teeth after union of the fracture.

6. The doctor should remember that however desirable perfection of anatomical contour may be, a functional restoration of the limb, as a whole, is of major importance. Obtain both, if practicable, but keep the patient alive and give the preference to good function rather than good looks, if either one has to be sacrificed.

7. The majority of closed fractures of long bones may be cured with good function and good anatomical result, without exposing the bone by operation. Some open fractures of these bones, if kept aseptic, may be cured without exposing the bone by operation.

8. A moderate proportion of closed fractures of tubular bones will need operative exposure to correct malposition of fragments, and may require direct fixation.

9. Many open fractures, especially gunshot injuries, will require operation to convert contaminated fractures into aseptic fractures, and to permit primary closure of the wounds. Some of these open fractures will also need readjustment and possibly direct fixation of fragments.

10. Conversion of contaminated open fractures into aseptic fractures should be done within the first eight or ten hours, by removal of foreign bodies and excision of debatable soft parts. The wounds should then be closed by primary suture and the bones given external rigid support : and the patient kept under careful surgical observation for advent of sepsis.

11. Closed fractures, needing exposure of bone for readjustment of fragments, will probably escape operative sepsis more frequently if operation is delayed about seven days after injury.

12.. Comminution of bone in closed fractures does not add much to the severity of the injury, but it requires that the accuracy of coaptation and of external support receive vigilant attention.

13. Comminuted open fractures, if kept aseptic or early rendered aseptic, do well, because the small fragments furnish many centres of callus deposition.

14. Nearly all closed fractures, and many open ones of the upper limb, may be successfully treated as to functional ability and anatomical integrity by means of ambulatory dressings.

PREFACE v

15. Nearly all fractures of the lower extremity, whether open or closed, do better when treated in bed with suspension of the limb and more or less continuous traction. Surgeons, however, are apt to forget that increased overriding of fragments is often caused by muscular spasm, due to pain or insufficient repose of mind and limb. Continuous moderate traction, with lateral support at seat of fracture, with opiates and bromides internally, may be better than great addition to traction weights.

16. An exception to the rule of treating fractures of the lower limb in bed may occur in fractures of the fibula and of bones of the foot.

17. Most fractures of the femur, and a considerable number of the tibia, must have traction added to suspension of the external fixation apparatus.

18. A few fractures of the upper limb, closed and open, require suspension with traction. This is particularly true in fractures near the upper end of the humerus, and is more frequently needed for infected than closed fractures in this site.

19. Fixation by external splinting is best given to the upper limb by using the thorax as a splint for fractures of upper part of the humerus, and some form of plastic material moulded to the surface for fractures of lower part and for the forearm. Encircling the arm or forearm by gypsum encasements is dangerous in early stages of the treatment. Fractures of the internal condyle often do well with full flexion of the elbow.

20. When suspension and traction are required for upper-limb fractures, the patient should be kept in bed for a time. Traction and splinting should usually be obtained with steel rods similar in form to the splints and braces used in fractures of the lower limb or with a modified Buck's traction apparatus.

21. The suspension and traction so valuable in fractures of the femur may best be obtained with the suspended N. R. Smith or Hodgen anterior heavy wire splint, a modified Thomas splint, or with traction by the Buck's traction method, with or without suspension, or by use of the Bradford frame.

22. The Thomas splint is probably the best of these methods in adults with great overriding of the fragments. It is particularly valuable when the patient must be subjected to transportation. The open ring Thomas splint and the one with movable footpiece are improvements over the earliest forms.

23. The joints, muscles and skin in fractures should be given attention from beginning to end of treatment by mobilization and gentle massage, if the best results are to be obtained.

24. Joint fractures should not be kept immobile longer than one or two days. Careful passive and active movements usually should be allowed within the first few days, and frequently repeated during the course of treatment.

VI

PBEFACE

25. It is a common practice to permit weight-bearing on fractures of the lower extremity too soon. Secondary deformity is frequently caused by this error. Crutches, braces and other devices often should be used after union to prevent such deformities.

26. No special form of splint or apparatus may be substituted with safety for the requisite knowledge of anatomy, pathology and mechanics. It is acquaintance with these subjects which constitutes a surgical grasp of the particular fracture needing intelligent care. These propositions are the essence of the teaching which it is hoped this volume will impart.

Thanks are due to Dr. Wm, H. L. Hale for much labor devoted to proof reading and preparing index.

J. B. R.

J. A. K.

February 21, 1921.

Preface To First Edition

The object of this book is to supply student and medical practitioner with a clear, concise, and systematic presentation of the subject of fractures.

In the following pages, a careful classification of the varieties of fracture occurring in each bone is given, together with statistics, symptomatology, diagnosis, prognosis and treatment. The varieties of fracture are shown by well-selected radiograms, the displacement of fragments is illustrated by accurate drawings, and when possible the methods of reduction and the application of retentive apparatus are presented by photographs.

The universal use of the Rontgen ray as a means of accurate diagnosis has brought about greater success in the recognition of fractures and has shown that many received methods of treatment are faulty or imperfectly understood. As a result, many fractures have been operated upon in which good anatomical and functional results could have been obtained by more conservative measures.

The purpose of the authors is to present a lucid view of the subject in the light of recent discoveries, to point out an accurate scientific procedure, whether operative or otherwise, according to the character of individual injuries, and to urge the general practitioner, as well as the surgical specialist, to the study of methods, operative or non-operative, with augury of propitious result.

The authors are indebted to Drs. M. B. Miller, J. H. Jopson, G. G. Davis, G. P. Muller, J. H. Hutchinson, J. M. Spellissy, L. J. Hammond, J. T. Rugh, E. R. Kirby, J. H. Ross, J. A. Boger, A. C. Wood, H. S. Carmany, A. Hewson, O. A. Rath, J. Chalmers Da Costa, C. F. Nassau, M. M. Franklin, J. F. X. Jones, A. A. Sender, F. C. Hutton, and M. F. Percival, for many roentgenograms.

The photographs of specimens, patients, dressings, and copies of skiagrams were made by Mr. Meyer S. Lentz, the original drawings by Mr. Erwin F. Faber, to both of whom the authors are grateful for skill, patience, and untiring energy.

vii viii PREFACE

In all instances an endeavor has been made to give proper credit in the text and illustrations to the work of other writers.

Finally they wish to thank the publishers for many helpful suggestions and active cooperation in the presentation of this volume to the medical profession in such an attractive form.

John B. Roberts James A. Kelly

Philadelphia, January, 1916.

Contents

CHAPTER PAGE

I. General Considerations i

Causes, Varieties, Symptoms, Diagnosis, Repair, Complications, Anaemic Myositis, Prognos : s.

Chapter I

Definitions. — A fracture is a sudden separation of osseous fibres due to injury ; in a general way it refers to the breaking of a bone or cartilage. It is applied somewhat incorrectly to a traumatic separation of an epiphysis from its diaphysis, though that lesion is properly called a diastasis.

A dislocation or luxation is the sudden displacement of the articular surfaces of the adjoining bones from their normal relation. The term is also used to describe the displacement of an articular or intra-articular fibrocartilage from its normal relations. A dislocation is complete when the normal articular surfaces of the bone involved are entirely displaced; incomplete when the articular surfaces of the bone involved still retain partial contact. The latter condition is more properly termed a subluxation.

A sprain or distortion may be described as an injury to a joint or the structures in proximity to a joint, in which the joint motions have been forcibly carried beyond normal physiological limits. Sprains are usually the result of indirect violence, although they may be produced by muscular action alone. The force would probably result in a fracture or dislocation if the violence were greater. The injury generally consists in partial or minute tearing of portions of ligaments, tendons, or fascias, or the bruising of the articular cartilages.

A sprain-fracture is the partial or complete separation of a small portion of a bone near a joint to which a tendon or ligament is attached, as a result of sudden violence acting upon the tendon or ligament involved.

Statistics. — Examination of statistics showing the liability of individual bones to fracture proves that, as a rule, such statistics are incomplete as to classification or that the exact site of fractures of individual bones is not given. Another source of error is the fact that many fractures are omitted entirely, some are diagnosed as subluxations, and others as sprains. These defects cause the average statistics to be worthless.

The combined statistics of Bruns, Chudowsky, Immelmann and those of Plagemann are, however, of considerable value. The records of Plagemann from the Rostock clinic are probably among the most accurate that have been published.

Relationship of Fractures to Age, Sex and Season. — The influence of age upon the production of fractures is shown by Plagemann, both

l relative to the periods of life in which fractures are most frequently seen, and regarding the types of fracture which are most frequent at certain ages. In the first and second decades the most frequent fractures are the incomplete, the subperiosteal and epiphyseal separations. The bones most frequently involved are the clavicle, the lower end of the humerus, and the lower end of the radius. During the third, fourth, and fifth decades, the fractures most frequently met are those from an occupational cause and those from direct violence ; the bones most frequently affected are those of the leg, femur, humerus and skull. During the sixth and seventh decades other influences are at w T ork. In this period the bones are more brittle, the muscular tone of the body diminished, the special senses not so acute ; and as a result the most frequent fractures occur at the upper end of the femur, the upper end of the humerus, and the lower end of the radius. It may be stated that, as a general rule, fractures occur in the greatest number during the second, third, and fourth decades of life.

Fractures are apparently more frequently seen in men than in women. They are said to occur in the proportion of about 4 to 1. This disproportion is due to the more active life of the male at all ages, to the occupations assumed by the male, and to the fact that men spend so much more time out of doors. During the third, fourth, and fifth decades fractures occur among men six or seven times more frequently than in women. In infancy and old age the proportion of fractures occurring in the two sexes is about equal. In old age fractures are a little more frequent in the female, and are most often fractures of the upper end of the femur.

The influence of season in the occurrence of fractures is shown in the frequency of fractures seen in the summer season as compared with the winter season. This is due entirely to the fact that we are more active, spend more time out of doors, and that the various building trades and all business, in fact, are carried on more actively in the summer season. The occurrence of ice and snow in winter may perhaps modify these conclusions in some places.

Etiology of Fractures. — For the production of a fracture certain etiological factors must be present. These may be divided into ( 1 ) predisposing causes, and (2) the exciting or determining causes. Fractures may be divided into (1) traumatic and (2) pathologic fractures.

Predisposing Causes. — Certain bones are predisposed to fracture on account of their exposed position, shape, their function as levers, or the small proportion of osseous tissue in their composition. Other bones are less liable to fracture owing to their unexposed position, their mobility, and the protection afforded by overlying muscles. Other factors are the elastic and yielding character of bones in infancy and adolescence; and the brittle character of the bones in the aged, from senile atrophy and thinning of the cortex.

A predisposing factor of diastasis, or epiphyseal rupture, in early

GEXEKAL CONSIDERATIONS 3

age is the presence of the epiphyseal cartilages; epiphyseal separations occur only at this period of life.

Exciting Causes of Fracture. — The exciting causes of fracture are (i) external violence, and (2) muscular action.

Fractures by External Violence. — These may be divided by the mechanical modes of their production, and by the clinical difference, into two classes — fractures by direct violence and fractures by indirect violence. In fractures by direct violence the bone is broken immediately beneath the site of impact of the fracturing force. In injury by indirect violence the fracture does not occur at the site of the blow, but at a point distant. Fractures by direct violence may be complicated by extensive injury to the overlying soft parts, and secondary sloughing of tissues; or by the production of a wound leading to the seat of break in the bone, thus constituting a so-called open or compound fracture. Examples of fracture by direct violence are fractures of the calcaneum by falls upon the feet, fractures due to kicks, or falling timbers, or to being struck with a heavy instrument; and gunshot fractures. Direct fractures of shafts of long bones are quite often transverse to the axis of the bone broken. In fractures by indirect violence the fracturing force is conveyed through the intervening bones ; and the break occurs by leverage, torsion, or traction. Such forces may produce transverse fractures, but more generally, oblique, spiral, or comminuted fractures. Examples of fractures by indirect violence are those of the clavicle from a fall upon the hand, oblique or spiral fractures of the tibia and fibula, fractures by torsion of the humerus in the so-called strength test, and fractures by traction at lower end of elbow and at ankle in forced flexion, extension, adduction, or abduction.

Fractures by indirect violence more frequently involve the long than short bones because of their length, shape, and muscular and ligamentous attachments. Such injuries are modified according to the condition of the muscles of the part, the direction of the fracturing force, the position of the parts at the time of injury, and the anatomical structure of the bone involved. Thus from falls upon the palm of the hand are caused varying fracture lesions of the clavicle, humerus, or radius. Fracture through the base or lower end of the radius is the most common.

Fractures by Muscular Action. — Bones may be fractured by the sudden contraction of muscles; by contraction of muscles when a part of the bone is fixed so that leverage is produced; and by sudden muscular action producing abrupt arrest of the moving bone. Examples of the first class are fractures of the patella, of the olecranon, of the tuberosity of the calcaneum; examples of the second class are spiral or oblique fractures of the humerus in wringing out clothes, and in the so-called strength test with clasped hands of the contestants; examples of the third class are fractures produced by throwing, lifting, and shovelling. Other illustrations of fractures produced by muscular action are fractures of the ribs from violent coughing, fractures of the bones of the leg in missing steps, fractures of long bones during the muscular convulsions of tetanus.

The patella is the bone most frequently fractured by muscular action. Next in order are the olecranon of the ulna, the greater tuberosity of the humerus, occasionally the coracoid and acromion processes of the scapula, and many atypical fractures at the site of insertion of powerful muscles. Sprain fractures are often produced by muscular action.

Gunshot Fractures. — In considering the etiology of gunshot fractures, one must bear in mind that the resulting lesions vary greatly, depending upon the velocity of the bullet, its size, the part of the bone involved, and upon whether the lesions are produced in military or civil life. The character of the fracture produced by the high-velocity bullet of war is entirely different from that produced in the ordinary revolver wound. Various degrees of bone lesion may occur. These may be classified as : (i) A fissured fracture of one side of the cortex. (2) A depression of the cortex. (3) A transverse comminuted or fissured fracture without perforation of the bone. (4) A perforation of the bone. When this last form occurs in the spongy bone near the articular end of long bones or in flat bones, there is generally no comminution. When the shaft of the bone is involved there is generally extensive Assuring, comminution and destruction dependent upon the line of the projectile. (5) Guttered or notched fractures may be produced when only a small portion of the circumference of the bone is involved.

Fractures produced in military life with jacketed bullets are generally less extensive and less complicated by injury to soft parts than those caused by soft-nosed bullets, and by such missiles as were formerly used in war, and still are commonly fired in civilian gunnery. This is due to the high velocity of the bullet, its decreased size, its tendency to perforate without extensive comminution, and to the fact that wounds produced by it are, as a rule, aseptic. Disablement is produced by such small-calibre jacketed bullets, but mortality is less great. The aseptic condition of a wound or fracture depends, however, to a great extent, upon the relative cleanliness of the wounded man's skin and whether pieces of clothing have been carried into the soft parts. A missile which has struck the soldier after ricocheting may be highly infective. The South African war between the Boers and the British seemed to establish these conclusions. The Great War in Europe between the German Empire and the allied powers seemed to prove the great difference between wounds contaminated with highly cultivated, and therefore frequently manured, soil and those which had come in contact with the earth in the sparsely peopled South African veldt. Fractures produced in civil life by the ordinary low-velocity large-sized bullet are generally more comminuted, the destruction of the bone is greater, injury to the overlying soft parts is more extensive, and infection is more frequent. Fractures produced bv bird-shot are rare, and are only possible when the distance is short, or the bone injured is very thin. The associated lesion of the soft parts is the chief characteristic, but in some the associated injuries to viscera are very important. Shrapnel causes great mutilation of all structures. Gunshot fractures due to exploding shells, or blows from heavy pieces of metal, are often greatly comminuted and may be accompanied by wide contusion and laceration of soft tissues. Infective osteomyelitis in such injuries therefore is almost certain, unless prompt removal of contaminated structures is accomplished and the sterilization assured.

Pathological Fractures. — This name is given to fractures, which follow some slight injury or only moderate muscular action, because of of the Pathologic fractures occur a pathologic condition bone

in bones in which there is. a brittleness or lack of resistance due to a local lesion or to a general disease producing a general fragility of the osseous structures.

These fractures are sometimes termed spontaneous fractures.

It can be readily understood that fracture may occur, under slight strain, in bones the seat of local lesions by which osseous tissue is softened, destroyed or replaced by other forms of tissue.

It has been observed by several authors that in patients, in which spontaneous fractures occur, there have been found varying quantities of phosphoric acid in the urine. It has been suggested that this is the result of decalcification of the bone by some metabolic process, the exact nature of which has not yet been determined by pathologists. These changes have been observed in cases of cancer and diabetes.

Pathologic fractures may be classified as follows: (A) Fractures the result of local bone disease; and (B) fractures in which the rarefaction of the bone is the result of a general disease.

A. Of the first class pathologic fractures have been observed in the following conditions :

a. Inflammatory processes : infectious osteomyelitis ; tuberculous osteomyelitis.

mm

Fig. i.-

Osteomyelitis (typhoid) of femur. Pathologic Patient fell while wearing a brace.

fracture b. New growths of bone: Sarcoma, primary (Fig. 4), and metastatic; carcinoma, metastatic (Figs. 5 and 6); benign bone cysts; myeloma (albumosa) ; lymphomata, malignant, metastatic; metastatic tumors, thyroid in origin ; metastatic tumors from the adrenal ; echinococcus cysts.

Pig. 2. — Cystic degeneration of humerus permitting pathological fracture. A man, aged 32 years, sustained fracture by fall against a chain; not a heavy blow. Had had pain in right humerus previously. Fracture was diagnosed by preternatural mobility with soft or almost no crepitus. Wassermann negative. Bone united without difficulty, though patient was given potassium iodide with mercury. Case may prove

to be sarcoma.

c. Aneurisms.

d. Fracture the result of fragility of bones due to a general disease. B. Of the second class fractures have been observed as follows :

a. Disease of the nervous system: locomotor ataxia; syringomyelia.

b. Rickets, syphilis, scurvy, diabetes.

G-EXERAL CONSIDERATIONS c. Osteomalacia, osteitis deformans, imperfect osteogenesis of unknown origin.

d. Rarefaction from chronic diseases affecting metabolism. Fractures in Utero. — Intra-uterine fractures are chiefly fractures

and pathologic fractures. The traumatic fractures are the result of external violence. Pathologic intra-uterine fractures are generally the of the mother. Children have been born with one or more fractures, some in a state of partial union in which there has been no history of

external violence. Pathologic intra-uterine fractures are generally the result of syphilis, rickets, osteochondrosis, parenchyma-

Fig. 3. — Pathologic fracture of humerus. After treatment. (See Fig. 2.)

-Sarcoma of right humerus. Pathologic fracture.

tous osteitis or amniotic adhesions. Very often it is difficult to differentiate intra-uterine from intrapartum fractures. Imperfect development of the skeleton may cause defects resembling fractures of the long bones.

Intrapartum Fractures. — Fractures may occur during delivery. They, as a general rule, are the result of disproportion in the size of the foetus and the pelvis, unusual position of the foetus, or undue haste or faulty management of the delivery. The bones most frequently fractured are the femur, humerus, clavicle, tibia and fibula, radius and ulna. The most common lesion is epiphyseal separation, although fractures of the shaft of the bone may occur.

Varieties of Fractures. — Fractures should be classified as to variety as follows :

A. Fractures considered in relation to the condition of the surrounding soft parts: Fractures are divided into two classes : ( i ) closed fractures; and (2) open fractures. A closed fracture is one in which there is no communication between the outside air and the seat of fracture. They are sometimes designated as simple or subcutaneous fractures. An open fracture is one in which the seat of fracture is exposed to atmospheric contact through a wound of the muscles, fascia and skin. These fractures are sometimes called compound fractures. The open

Pig. 5.

Fig. 6.

ogic fracture of right femur, due to metastasis from carcinoma of left breast, operated two years previously; local recurrence in scar, left axillary and supraclavicular regions. Fig. 6. — Pathologic fracture of right humerus due to metastatic growth from primary carcinoma of

prostate gland.

character of the fracture may be caused by the direct vulnerating force, by thrust of the end of a fragment through the soft parts by the fracturing force or by the weight of the unsupported limb, or by subsequent ulceration or sloughing of the overlying soft parts. It can be readily understood that open fractures are more dangerous and may lead to more complications than closed fractures, because of the ease of entrance of infecting organisms. If contamination is averted or aseptic closure attained, before contamination has become infection, open fractures heal and become united almost as readily as closed injuries of bone. Infection followed by osteomyelitis and septicaemia may occur, necessitating amputation occasionally as a last resort. Death is not unusual in infected fractures, unless the lesion is treated with an aseptic or antiseptic technic and great surgical skill. Industrial and military fractures are especially liable to be both open and infected.

B. Fractures classified according to degree: Fractures may be classified as (i) incomplete, and (2) complete.

1. Of the incomplete fractures (Fig. 8) there are:

(a) Fissures. This form of fracture consists in a linear break without separation of the fragments to any appreciable extent. The most frequent sites are the vault and base of the skull; and the humerus and tibia. When they involve the long bones they as a rule begin at the articular surface.

(b) Infraction; green-stick or true incomplete fracture. This is a

Fig.

7. — Showing result of too early weight bearing after cure of syphilitic fracture of tibia and fibula at ankle. Patient also has Charcot knee-joints.

fracture involving only a portion of the diameter of the shaft with bending or angulation of the remaining fibres at the point of fracture. It occurs in children, whose bones are normally elastic from a relatively large amount of organic material in their composition. It happens most frequently in the bones of the forearm, clavicle, tibia, femur and humerus. Such fractures may happen in softened bone of adults.

(c) Depressions or indentations. This variety of fracture is a driving in of the cortex of the bone, without complete fracture, as a result of direct external violence. It is most commonly observed in the skull, involving the outer table, and in the spongy bones.