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Fracture

fracture. A break, as of a bone.
Symptoms of a Recent Fracture. In the examination of a patient who has sustained a recent fracture, procedure should be as follows: the history of the patient and of the accident should be taken; an examination should be made for objective signs, like deformity, abnormal mobility, crepitus, and ecchymosis; subjective symptoms, such as pain and loss of function of the limb should be ascertained; an X-ray picture should be taken and every possible precaution observed to exclude distortion or exaggeration.

Incomplete Fractures

Among the varieties of incomplete fracture are: greenstick; fissured; depressed.

Greenstick Fractures  (really a bending rather than a break of the bone) are mostly seen under the age of fifteen, and the bones of the leg are rarely affected.

Fissured Fractures  are those in which there is a split or crack in the bones; they are very rare in the bones of the lower extremity.

Depressed Fractures  are fractures in which one or more segments of broken bone are depressed; they are most common in fractures of the skull.

Classification of Fractures

Comminuted , when there is extensive splintering of the bone adjoining the fracture or one of the fragments.

Impacted , when the fragments are driven into each other. This variety usually occurs in the neck of the femur.

Compression, or Crushing Fractures , when the broken bones are compressed or crushed; this variety usually occurs in the tarsal bones. The spongy portion and cortical layer are both crushed. In some cases there is a perfect pulpification of these bones. This condition occurs after falls from a height upon the sole of the foot.

Fractures

A fracture may be defined as a broken bone. Fractures are classified as follows:

1. As to their degree.
2. As to the direction of the line of fracture.
3. As to their location.
4. As to the etiology.
5. As to their relation to the overlying skin.
6. As to the number of fragments.
7. As to whether they are complicated or not.

Degree of Fracture. A fracture which only involves a portion of the thickness of the bones, so that its continuity has not been entirely lost or a fragment has not been completely detached, is called an incomplete fracture. A fracture which involves the entire thickness of the bone, so that it is divided into two or more distinct fragments, is called a complete fracture.

Further Classification of Fractures

Fracture. In the ordinary use of the term “fracture” is understood to indicate a complete  or incomplete separation of the bone into two or more fragments, the lines of which are continuous with each other.

Multiple Fracture. The term multiple fracture  is applied to the simultaneous fracture of two or more non-adjacent bones, and also to those cases in which two or more fractures of the same bone exist, and the lines are not continuous with each other. Such multiple fractures are usually the result of direct violence.

Complicated Fracture. When a fracture is accompanied by injuries of the viscera, nerves, etc., the term complicated fracture  is applied. Such a fracture may be simple or compound. The term complicated, as ordinarily employed, is limited to those fractures which are accompanied by local, rather than by general complications.

Classification and Relation of Fractures to the Overlying Skin

Fractures are divided into compound, or open  and simple, or subcutaneous, according to whether a communication does or does not exist between the seat of fracture and a wound of the skin.

A compound fracture is one in which the cutaneous wound communicates with the seat of the fracture.

A simple fracture is one in which a wound of the skin is absent, or, if present, no communication exists between it and the seat of the fracture.

The majority of compound fractures are the result of direct violence, and the injuries of the soft parts, are, as a rule, far more extensive and serious than in a simple fracture. A fracture which is simple at first, may become compound as a result of necrosis of the skin lying over it; or as a consequence of the original injury; or of pressure upon it by a displaced fragment; or by penetration of the skin, in efforts to use the limb.

Treatment of Fractures of the Leg. The treatment of a simple fracture of one or of both bones of the leg depends first, upon whether or not swelling is present, and second, upon the amount of displacement of fragments and our ability to keep them in apposition after reduction. If the case is seen within a few hours after the injury and but little, if any, swelling be present, the following is a perfectly safe and justifiable method of treatment:

The limb is wrapped with strips of sheet-wadding from the toes to the middle of the thigh, and a circular plaster of Paris cast is applied extending over the same area. Before the cast is dry, it is cut open along the median line, in front, to allow for any swelling. The cast is best applied while the patient is under the influence of an anesthetic, so as to permit reduction of the fragments by traction upon the foot. In from ten days to two weeks the cast should be removed and a fresh one applied. The second cast does not require to be cut open, and can be left on the limb until the end of the fourth week. It is then removed and if union be complete, no further cast need be worn. Massage of the limb and passive and active motion are now begun.

Complete Fractures

Complete Fractures  are divided according to the line and the seat of the breech of bone continuity.

Directions of the Lines of Fractures

Transverse , when the line of fracture does not deviate more than ten to fifteen degrees from that of the transverse axis. This variety is rare in the shaft of the long bones. It is usually found at the lower end of the radius or of the femur, and in the short bones.

Longitudinal , when the break is parallel to the long diameter of the bone; very few cases of this variety are seen.

Oblique , when the direction of the line of fracture may form any angle with the transverse axis of the bone up to a right angle. When it approaches the latter, it belongs to the group of longitudinal fractures. In the oblique variety, the line of fracture may be single or multiple. This and the spiral form are most frequent in the shafts of the long bones.

Spiral , when the break line is spiral. This variety of fracture was formerly considered to be very rare. The more systematic use of the X-ray as part of the routine of diagnosis has shown that spiral fractures are quite frequent in the shafts of the tibia and fibula. They are usually the result of a rotating or twisting force.

Diagnosis. The diagnosis is usually easy to make. The ankle joint is greatly swollen, the depression, normally present in front of and behind the malleoli, being obliterated. The foot is displaced outward, and the internal malleolus is prominent. This deformity will often persist and become a cause of disability after healing of the fracture.

There is also backward displacement of the foot. These displacements may be so marked as, at first glance, to resemble a true dislocation of the ankle.

Abnormal lateral and anteroposterior mobility may be ascertained by grasping the sole of the foot with one hand and moving it inward and outward, or backward and forward, while the other hand steadies the leg. There is great tenderness between the tibia and fibula at the front of the ankle, and over the points of fracture in the malleoli.

If the fibula alone be broken, abnormal mobility and crepitus may be elicited by pressing its tip inward with the index finger of the one hand while a finger of the other hand is placed at the seat of fracture.

In some cases of Pott's fracture the foot will move inward instead of outward. The degree of outward displacement can be measured by the difference in the distance from the front of the ankle to the cleft between the first and second toes, as measured on the sound and injured foot. There is not always complete loss of function. In fractures of the external malleolus alone, the patient may walk quite well.

Fractures of the Tarsal Bones. Fractures of these bones have been found far more frequently than was thought before the use of the X-ray. Many cases of tarsal fracture have been treated for sprains of the ankle. It is only when the recovery is slow or the injury is followed by a traumatic flat foot that the surgeon begins to suspect that a more serious condition was present at the time of the original injury.

The astragalus and os calcis are the tarsal bones that are usually affected. Fractures of the os calcis, in the majority of cases, are due to compression. The patient falls from a height to the ground, on a hard substance. The os calcis is crushed between the astragalus and the ground.

There are three general types of fracture of the os calcis:

1. That in which the fracture has been confined largely to that portion lying behind a vertical plane through the middle of the body of the astragalus. There are three varieties of this heel fragment type: (a ) cases with one large heel fragment; (b ) cases of small heel fragments (in this variety, also called avulsion fracture, the sudden contraction of the calf muscles pulls the fragment off; at times the tendo Achillis itself is torn off from the attachment to the os calcis at the same time); (c ) cases showing only fissures in the bone.

2. Comminution of the anterior half of the os calcis.

3. All the cases of extensive comminution of the bones; the bone is literally shattered.

Fractures of the Metatarsal Bones. These are usually due to direct violence, as occurs when a heavy weight falls upon the dorsum of the foot. Another example of direct violence is a fracture following a crushing injury, as in being run over.

In indirect violence, such as follows dancing, jumping, or sudden twists of the foot, the fifth metatarsal bone is the one most often involved. There is but little tendency to displacement except when several bones are broken at the same time, and then it is toward the dorsum of the foot.

The diagnosis in fractures produced by direct violence is made from the following: presence of severe localized pain; swelling; and, not infrequently, crepitus and abnormal mobility. In those fractures due to indirect violence (second, third and fifth metatarsals), there is pain when the patient endeavors to put pressure upon the toes or tries to invert the foot. The usual signs of fracture are absent. A skiagraph should be made in every case.

Fracture of the metatarsal bones is liable to be followed by traumatic flat foot, on account of the sinking of the arch, or painful large calluses forming on the sole of the foot may interfere with walking.

Treatment. The treatment in such fractures is by immobilization in a posterior metal or plaster splint, for four weeks. If there is continual pain upon walking after the injury, a steel insole will often give relief. The treatment of compound fractures of the metatarsal bones does not differ from that of other bones.

Existing or Determining Causes of Fractures

Fractures by External Violence  are divided both clinically and from a mechanic standpoint into two classes:direct  and indirect. In fractures by direct violence the bone breaks immediately under the point where the force has been applied. In this class of fractures there is more damage to the soft tissues and this damage is generally more serious than in indirect fractures. Direct fractures are more likely to occur in exposed bones like the clavicle, os calcis, etc.

An example of fracture by direct violence is found in fractures of the tarsal bones after a fall upon the feet from a height.

Under the head of fractures by indirect violence belong (a) those which occur as the result of a rotary or twisting force (spiral fracture of the tibia or fibula, for example); (b) those which are produced by compression; (for example, a fall upon the feet may cause an impacted fracture of the upper end of the tibia); (c) those which are the result of a tearing force.

Fractures resulting from a tearing force occur when a joint is suddenly moved beyond its normal range of excursion. The firmly attached ligaments being a fixed point, the ends or some process of the bones composing the joint are torn off from the remainder of the bone. Examples of this are fractures of the internal or external malleoli, following forcible eversion or inversion of the foot.

Fractures are also caused by muscular action and by gunshot injuries.

Pathologic  (spontaneous fractures):

1. Fractures resulting from bone fragility of local origin as for example, tumors, osteomyelitis, aneurisms.

2. Fractures resulting from bone fragility due to some general disease, as for example, tabes dorsalis, paresis, rachitis, osteomalacia, and exhausting chronic diseases.

Fractures of the Astragalus. These can be divided into: (a ) those of the neck; (b ) those of the body. The former are the most common fractures of the astragalus. They may follow sudden dorsal flexion, or forced supination, or pronation of the foot. They may be due to a fall from a height or from direct violence. Fractures of the body of the astragalus are usually the result of a crushing force which ordinarily have a like effect on the body of the os calcis, and are often associated with fractures of the latter bone. The variety of fractures is considerable, varying from two large fragments, to complete comminution of the bone.

A fact of considerable importance in the interpretation of skiagraphs of fractures of the astragalus, is a knowledge of the presence in many normal individuals of a little bone known as the os trigonum. It may occur detached from the astragalus or may be attached to it as a process, on its posterior aspect, and on account of the swelling and pain around the ankle, a diagnosis can seldom be made without the routine use of the X-ray in every injury in this region.

The swelling, with obliteration of the depressions normally present around the ankle, does not differ from that characteristic of a sprain of the ankle or of a Pott's fracture. If there is extensive comminution of the os calcis or astragalus, the malleoli may be a little lower than normal.

The X-ray must always remain our most reliable means of diagnosis at the time of the injury. At a later period the chief symptoms are a painful flat foot, ankylosis of the ankle joint, pain and difficulty in pronating and supinating the foot.

The prognosis of fractures of the tarsal bones is not favorable, even though the lesion has been recognized at the time of injury. Even in the most favorable cases there is some limitation of lateral motion. The outlook is better in those cases of fracture of the os calcis in which there is a large heel fragment, than if the fracture is comminuted. The most frequent sequel is stiffness of the ankle-joint and traumatic pes valgus. Infection is frequent in compound fractures.

Treatment. This does not differ from that of a Pott's fracture until the greater part of the swelling has disappeared. The skin of the foot and lower portion of the leg should be thoroughly cleansed and covered with gauze. This is necessary on account of the possibility of necrosis of the skin of the heel, and the danger of infection of the bruised soft tissues around the heel.

The foot should be placed in a well-padded box or in a posterior splint of the Volkman type. Ice bags should be applied over the sides of the heel.

After from eight to ten days, a circular plaster cast can be applied, extending from the toes to the knee. An anesthetic should be given during the application of the cast, the foot being held flexed at right angles and sheet wadding freely used around the ankle. The cast should be worn for seven weeks. At the end of this time the patient is gradually permitted to step upon the injured foot. Passive and active motion are also now employed.

Fractures of the neck of the astragalus, with rotation of the posterior fragment, are usually followed by great limitation of the movements of the ankle joint. This condition might be greatly improved by an open operation.

Location of Fracture

In the Diaphysis of a Bone. Breaks in the diaphysis of a bone are spoken of as fractures of the shaft, and to be still more exact, it is stated whether of the upper, middle, or lower third.

At the Ends of Bones. Fractures occurring at the ends of bones receive the name of the part which the line of fracture transverses; for example, fractures of the neck  of a bone, of a tuberosity, of a process, of a condyle, etc.

There are two forms of fracture that require special mention in connection with their location. These are epiphyseal separations  and articular fractures.

Epiphyseal Separations. The union of the epiphysis to the diaphysis commences during puberty, hence these fractures are less common in childhood than after the ages of eleven or twelve. As a rule, they can only occur before the twentieth year. The periosteum is more resisting and tougher during the early years of life than later on.

Articular Fracture  (joint fractures ). Like epiphyseal separations, recognition and proper treatment of these fractures have assumed great importance.

Articular fractures may be divided into three classes:

1. Intra-articular. In these the line of fracture lies entirely within the joint. Such fractures are most frequently found in the elbow and knee joint.

2. Para articular. In these the line of fracture extends close to the joint but not into it. An example of this class is the supracondyloid  fracture of the humerus.

3. Articular fractures proper. The majority of joint fractures belong to this class. The line of fracture either extends into the joint from without or it extends from the joint outward. As example, the ankle joint; the majority of the typical supramalleolar, malleolar, and spiral fractures of the tibia and fibula.

Etiology. Fractures may be divided into two groups: the traumatic  and the pathologic  or spontaneous. In the traumatic, the fracture is the result of violence acting upon a bone which is either normal or shows slight changes due to the physiologic causes mentioned. A pathologic or spontaneous fracture is one which occurs in a bone, the strength of which has been diminished by some preceding abnormal or pathologic changes. In this variety the degree of force which produced the fracture would not be sufficient to cause a fracture in a healthy bone.

The causes of traumatic fractures may be either predisposing or exciting.

Predisposing Causes. The bones of the human body attain their greatest strength toward middle age. From infancy up to that time the bones are very elastic and yielding. Toward old age an interstitial atrophy occurs. It causes a thinning of the cortex of the shafts and of the trabeculae of the spongy portions of the long and short bones. It is an actual diminution of the bone substance and a corresponding increase of the fat. This is especially seen in the neck of the femur. When it occurs in old age, it acts as a predisposing cause, but when it occurs prematurely or reaches an extreme degree, it must be considered as pathologic.

Treatment of Fractures. First Aid. The treatment of fracture may be said to begin from the moment of its occurrence. Much can be done for the comfort of the patient and correct union of the fracture by intelligent treatment during the first hours.

The proper temporary fixation of the limb, the mode of transportation, and the removal of the clothing, all require special mention.

The use of first aid dressings, those which can be used until more permanent and suitable ones can be applied, varies, of course, with the individual bone affected. In fractures of the tibia, fibula and foot, as well as in those of the lower half of the femur, the use of the blanket splint will be found of great aid. Instead of a blanket, a long pillow or soft cushion can be employed in the same manner.

The “blanket splint” can be readily made by folding a blanket in such a manner that it extends from the middle of the injured thigh to below the foot. Two pieces of narrow, strong board, or better still, two broomsticks are rolled up in the blanket, one at either end. The rolled-up blanket is now turned in so that the board supports with their enveloping turns of blanket, lie upon the posterior surface. Thus, a trough is formed in which the limb is placed and firmly secured by loops of bandage, one below the foot, the second just above the ankle, the third below the knee, and the fourth near the upper end of the blanket.

In fractures of the leg, after the application of the emergency splint, the patient should be transported in a recumbent position, the support being as firm as possible, a wide board, shutter or a wooden rail being preferable. If such supports are not at hand, and the patient is to be moved without their use, the persons transporting the invalid should be distributed in the following manner: one supporting the head and shoulders, a second the pelvis, and the third the two limbs.

Reduction. The reduction of a fracture is the effort made by the surgeon to overcome any tendency to displacement, and thus to place the fragments in such close apposition that an accurate and firm union is possible. The best time in general for the reduction of a fracture is as soon as possible after the accident, if the patient's general condition will permit. If there is marked displacement of fragments, so that there is danger of necrosis of the overlying skin or of damage to the adjacent vessels or nerves, an early reduction is imperative.

In all cases in which reduction is very painful or difficult, whether performed shortly after the accident or at a later period, it is best to administer an anesthetic to overcome muscular contraction and to decrease the amount of pain. After reduction of a fracture, retentive apparatus is indicated in order to maintain apposition. In the use of dressings there will be two kinds, those which are temporary and those which are permanent. The former are employed where the swelling of the limb is such that some dressing can be employed which will not cause pressure.

Certain general principles should be followed in the use of splints; for instance, a splint, after being applied, should not interfere with the circulation, allowance always being made for the swelling of the limb, which almost invariably occurs during the first week. The splint, if flat, should be wide enough to obviate the possibility of pressure against the point of fracture; also, it should project a little beyond the limb.

In general, it is best to immobilize the adjacent joints, above and below the seat of fracture, but no dressing should be permitted to remain so long as to produce stiffness of the joints and muscular atrophy.

The skin, even in simple fractures, must be cleansed with green soap, water and alcohol. If blebs or an area of threatening necrosis of the skin exist, they should be freely dusted with powdered boric acid and a few layers of aseptic gauze applied.

The form of retentive apparatus to be employed will vary, of course, with the individual bone requiring treatment.

The most important articles of a fracture equipment are as follows:

1. Plaster of Paris bandages for making molded splints and circular casts.

2. A stock of basswood, three-sixteenths of an inch thick, for making wooden splints.

3. An assortment of metal splints or materials for making them.

4. Muslin for bandages and slings.

5. Five yard rolls of ordinary and zinc oxide adhesive plaster, three inches wide.

6. Cotton batting and sheet wadding for padding splints.

7. Strips of tin or thin cypress for strengthening plaster casts.

The selection of a dressing for the immobilization of a fracture depends upon, first, the particular bone involved and whether apposition can be maintained with or without extension; second, whether great swelling be present or not; third, whether the fracture be simple or compound; and last, whether ambulatory treatment be preferable to that in the recumbent position. This latter applies, of course, only to fractures of the lower extremity.

Operative Treatment of Simple Fractures. Operative treatment of a recent simple fracture is indicated in general, when reduction cannot be completely made; when correct apposition cannot be maintained; when there is interposition of bone or soft parts; when the fracture is a spiral one with considerable displacement of the fragments; when fragments are rotated upon each other, and when there are multiple fractures.

The most favorable time to operate in recent simple fractures is at the end of the first or beginning of the second week. At this time the process of callus formation is most active. The blood clots and loose shreds of tissue have begun to be absorbed, so that the fragments are more easily accessible.

Methods of Fixation of the Fragments. In the majority of cases the reposition of the fragments alone is not sufficient to maintain accurate apposition. It is usually necessary to employ some means of mechanical fixation. In all the methods employed, the preparation of the parts is the same as for any aseptic operation. The opportunity for serious complications resulting from septic infection, is greater than in any other class of operations. It is for this reason that extraordinary caution must be exercised. The incision should be large enough to expose the seat of the fracture thoroughly.

The materials used to secure fixation are: absorbable sutures, such as chromicized catgut or kangaroo tendon; metal suture of silver or bronze aluminum wire; screws, nails, plates, clamps, etc.

Injuries in the Vicinity of the Ankle Joint. In the examination of a patient who shows evidence of injury in the vicinity of the ankle joint, such as swelling, deformity, loss of function, etc., the following conditions must be thought of, in the order given:

1. Fractures of the lower ends of the tibia and fibula (Pott's Fracture).
2. Dislocation at or near the ankle.
3. Fractures of the tarsal bones.
4. Rupture of the tendon Achillis.
5. Sprains of the ankle.

Fractures of the Lower Ends of the Tibia and Fibula. Commonly given the name of Pott's Fracture. They may be the result either of forcible abduction or eversion of the foot, or of inversion or adduction. If the sole or main movement is eversion, the internal  malleolus is broken, and if the force continues to act, it also causes the external  malleolus to be broken. In the second variety, fracture by inversion, the first effect of the force is to break the fibula at the external malleolus. If the movement continues, the internal malleolus or a greater portion of the tibia is broken off.