Compound fracture

“ Lastly, with regard to suppuration, only a small proportion of the fractures, accompanied by the presence of large wounds, escaped infection. When infection did occur, the results offered some special features dependent on the small relative amount of damage to the soft tissues, compared with that suffered by the bone. In an ordinary compound fracture, such as we meet with in civil practice, whether the result of direct or indirect violence, a considerable amount of contusion or laceration, as the case may be, accompanies the injury to the bone. ”

“ In compound fracture the prognosis is always unfavourable. Means must be taken to avert incited action—the limb must be properly placed without delay, the edges of the wound accurately approximated, and antiphlogistic measures pursued. Purulent collections must be opened early. Rest of the joint is to be insured, and support afforded, by bandaging and by the application of a splint. The patient will be fortunate if he escape mutilation by the amputating knife ”

“ Thus, the smaller the weapon, the greater the violence, the nearer the site of application to the vertex, the more direct the blow, the greater is the tendency to vault limitation. Again, compound fractures are much more liable to vault limitation than simple fractures, as is proved, for instance, by the reports of Sir Prescott Hewitt—20 compound fractures in which the fracture was restricted to the vault of the skull, and 56 simple fractures in which the base was involved in all but one. ”

“ It has been said that we must be regulated in our proceedings very much by the existence or not of external wound; that we must be cautious in cutting down upon fractures of the cranium where there is no wound, and so converting a simple into a compound fracture. In fact, so much is the danger increased, it is alleged, by the existence of wound, that the symptoms must be very urgent indeed which would demand division of the integuments in order to admit of examination of the fracture, the application of the trephine, or the elevation of the bone ”

“ The deformity is usually angular, with the apex towards the palm, and if union takes place in this position, the power of grasping is interfered with. Unnatural mobility and crepitus can usually be recognised, but, on account of the swelling and tenderness, the fracture is apt to be overlooked. Firm union takes place in two or three weeks. In oblique and comminuted fractures, union may take place with overlapping, producing a deformity which may prevent the wearing of a glove or of rings. In compound fractures, non-union sometimes occurs, and causes persistent disability. ”

“ In cases of fracture of the arm, either above or below the elbow, the injured person can make himself quite comfortable by18 pinning the bottom of his coat to his shoulder and placing the injured arm in the V-shaped sling thus formed.
The treatment of compound fractures is one that requires some "nerve" on the part of the acting surgeon and a great deal of fortitude in the injured person. A compound fracture of the leg or thigh is the most terrible accident, short of death, that can befall a man in the woods. ”

“ Fractures are partial or complete, the former when the bone is broken only part way through; simple, when the fracture is a mere break of the bone, and compound, when the end of one or both fragments push through the skin, allowing the air with its germs to come in contact with the wound, thus greatly increasing the danger. To be sure that a bone is broken we must consider several points. The patient has usually fallen or has received a severe blow upon the part. This is not necessarily true, for old people often break the thigh bone at the hip joint by simply making a false step. ”

“ Surgeons divide fractures into: simple, those where there is a simple separation of the bone without injury to the flesh; compound, where in addition to the separation of the bone there is laceration of the flesh and one or both ends of the bone are driven out through the skin; and comminuted, where the bone is in several fragments. A comminuted fracture may be either simple or compound, according as it does or does not penetrate the flesh. ”

“ In either case there is a communication between the external air and injured bone, and the probability arises of the germs of suppuration finding their way to the seat of fracture. This greatly increases the risks of the case, for septic inflammation and suppuration may lead to delayed union, to death of large pieces of the bone (necrosis) , and to osteomyelitis and to blood-poisoning. In the treatment of a fracture, every care should be taken to prevent any sharp fragment coming near the skin. Careless handling has often been the means of a simple fracture being converted into a compound one. ”

“ A fracture of a bone, however simple it may be in its nature, is said to be compound when accompanied by an external opening in, or a wound of, the soft parts, communicating with the broken bone—a complication which usually gives rise to ulcerative inflammation and suppuration throughout the whole extent of the injury, preventing thereby those milder processes being effected which, under the more favorable circumstances of the skin being unbroken, lead to a speedy union of the broken parts ”

“ Fig. 75.—Longitudinal section of Femur showing recent Fracture of Shaft with overriding of Fragments.
In adults, when due to direct violence, the fracture is usually transverse, and may be attended with comparatively little displacement. Indirect violence, on the other hand, usually produces an oblique fracture, which is frequently comminuted and often compound. The break is most commonly situated a little above the middle of the shaft, the obliquity being downward, forward, and medially, and of such a nature that the fragments tend to override one another (Fig. 75) . ”

“ One reason why compound fractures are so dangerous, is because, the skin being broken, the air obtains access to the wound, bringing with it innumerable germs, which too often set up putrefying action. ”

“ Bandages will do nearly as much harm as good in fractures of the os femoris, if, as was practised by the ancients, they be formed by a single roller surrounding the limb: in such a case, the limb being necessarily raised up at each time of their reapplication, will be exposed to continual displacements. Hence the ingenious idea of applying to simple fractures of the lower extremities the eighteen-tailed bandage, invented for compound fractures, and by means of which the thigh may be suffered to remain at rest. ”

“ Beach speaks of an individual who suffered fracture of both thighs, and compound comminuted fracture of the tibia, fibula, and tarsal bones into the ankle-joint, necessitating amputation of the leg. The patient not only survived the operation, but recovered with good union in both thighs. As illustrative of the numerous fractures a person may sustain at one time, the London Medical Gazette mentions an injury to a girl of fourteen, which resulted in 31 fractures. ”

“ In carrying out their operations, they often run great dangers. They are sometimes so seriously injured by wounds and fractures as to be disabled for life. For instance, in carrying out the works of the Manchester, Sheffield, and Lincolnshire Railway, there were twenty-two cases of compound fractures seventy-four simple fractures, besides burns from blasts, severe contusions, lacerations, and dislocations. One man lost both his eyes by a blast, another had his arm broken by a blast. ”

“ Fractures of the great trochanter are the effect either of falls on that protuberance, or of the action of bodies striking against it. Oblique or transverse, situated sometimes at its summit, and sometimes at its base, these fractures may be either simple or complicated. They are rendered complicated sometimes by splinters and a swelling, as happens when a ball produces the division, and at other times by a fracture of the neck of the bone, an example of which we find in the Journal of Surgery, in the case of a man seventy years of age, who had been long subject to the itch. ”

“ It may be important to determine whether a bone was fractured before or after death. This point can not always be decided. Fractures inflicted during life are, as a rule, attended with more extravasation of blood and evidences of reaction in the surrounding tissues; but fractures produced within a few hours after death may resemble these very closely. Usually a greater degree of force is necessary to fracture bones in the dead than in the living body. ”

“ 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. ”

“ Fractures are generally the result of great force applied directly to the shaft of a bone, or to its extremity; but they are also not unfrequently caused by twisting of the limb whilst the muscles are in a powerful action. Bones are broken transversely; but more frequently there is a degree of obliquity in the fracture, and the fragments are generally detached. A bone may be split longitudinally, as from a musket-ball striking its shaft in the centre ”

“ Most of the phenomena which accompany fractures of the fore-arm (5) , are evidently the result of a displacement of the fragments; a displacement, not, in general, very perceptible in the longitudinal direction of the bones, because the muscular action, tending to produce it in that direction, is not very powerful. When it does occur in this way, it is most frequently the immediate effect of the stroke that produced the fracture. ”

“ For instance, the line of gravity of the body is, by some cause, removed behind it; the anterior muscles contract themselves to bring it forward again; the extensors act on the rotula; it is broken, and a fall ensues. Again, the leg is suddenly thrown into a state of violent extension; the extensors act with great force; a fracture is the consequence, and the patient falls. A soldier once fractured his rotula in kicking at his serjeant; thus the olecranon, in like manner, has been broken by throwing a stone. ”

“ Consequences dreadful to the patient have too often followed blunders in diagnosis. As in the accidents of the shoulder-joint, some idea as to the exact injury may be formed by ascertaining how the force was applied; but this, alone, may sometimes mislead. Careful manipulation is to be chiefly trusted to.
Fracture within the capsule is met with most frequently in those of advanced age, when the form of the neck of the bone has been altered,—when it has become shorter, and attached less obliquely to the shaft, as is sometimes the case; the bones, too, are then more brittle than in earlier life. ”

“ 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. ”

“ To burst is to break by pressure from within, as a bombshell, but it is used also for the result of violent force otherwise exerted; as, to burst in a door, where the door yields as if to an explosion. To crush is to break by pressure from without, as an egg-shell. To crack is to break without complete severance of parts; a cracked cup or mirror may still hold together. Fracture has a somewhat similar sense. In a fractured limb, the ends of the broken bone may be separated, tho both portions are still retained within the common muscular tissue. ”

“ Whenever it sustains a fracture, it is always by a true counter-stroke, resulting from a fall, sometimes on the great trochanter, and at other times on the sole of the foot or the knee. But fractures produced in the first mode, are much more frequently met with in practice, than those produced in the second, doubtless because, in the latter, the motion is weakened by the extent of parts through which it is distributed, previously to its arrival at the neck of the os femoris. ”

“ Some enumerate also the capillary fracture, but it is a very narrow fissure which eludes the senses, and therefore, being often overlooked owing to the symptoms of it not being obvious, it occasions death. An indentation is not a division of a bone, and, therefore, such an injury is not properly called a fracture, but is, as it were, a protrusion and bending of the skull inwardly, forming a hollow without a solution of continuity, as when vessels made of copper, or the raw hide of an ox, are struck on the outside. ”

“ The old dictum of Nélaton, that the treatment of fracture of the thigh should last for a hundred days, is a safe working-rule. In fractures of the shaft an ordinary Thomas' knee splint, or a “walking calliper splint” which is fixed to the heel of the boot, may be worn when the patient gets up.
Union may be exceedingly slow in fracture of the femur, and may even be delayed for months. Mal-union sometimes occurs, the fracture uniting with an angular deformity outward and forward.
Re-fracture is liable to occur if the patient falls or twists the limb within a few months of the original injury. ”