FRACTURES. A fracture is a break, more especially of a bone or cartilage. The bone may be broken at the part where it is struck (fracture from direct violence), or may break in con sequence • of a strain applied to two levels of the bone at some distance apart (fracture from indirect violence). The actual form of the fracture of a long bone is classified in accordance with whether it is transverse, oblique, comminuted or impacted. The first two terms explain themselves. A comminuted fracture is one in which there is fragmentation of the bone at the site of injury ; an impacted fracture is one in which the broken ends are driven together by the causative violence in such a way as to become locked. A type known as the greenstick variety is met with in children ; the fracture does not extend right across the bone, and angulation is therefore the only possible displacement.
Fractures of all types are subdi vided into those which are simple (or closed), or compound (or open) . The term simple means that the skin over the fracture remains intact. A compound fracture is one in which the skin is broken, either by protusion of the bones through the skin after the break has occurred, or by the direct action of the violence which caused it ; this latter condition is seen as a result of missile injuries and run-over accidents. A compound fracture is always a serious condition on account of the possibility of infection of the wound by micro-organisms. If germs are introduced into the wound suppuration will occur, and when this process invades the broken surfaces of bone it is a dangerous complication; in its most severe forms it may necessitate amputation in order to stop blood poisoning which may threaten the patient's life. In any case infection will delay union, and very likely lead to the death of fragments of bone in the neighbourhood of the fracture.
The experience of the Great War was largely in relation to fractures of this nature, and a very definite advance was made in the treatment of these cases. It was found that no chemical anti septic was effective in disinfecting a lacerated wound; the only effective procedure is the clean excision of the wound track, in volving the removal of all contaminated tissues. The application of this process of wound excision or debrideTuent in severe com pound fractures has greatly improved the results and minimized the number of cases of serious infection. To have a proper hope of success the procedure should be carried out within twelve hours of infliction of the injury. So long as infection does not occur, or once it has been eradicated, the treatment of a com pound fracture is on the same lines as a simple one.
The diagnosis of a fracture can usually be made on the history of an injury followed by acute pain in a bone and the loss of function of the limb affected. In many cases there is gross deformity which can be recognized by comparing the in jured limb with the sound side and can be confirmed by measure ments taken between known bony points. A sensation of grating (crepitus) between the broken bone ends is characteristic in cases which are not impacted. Nowadays, however, radiological exam ination is essential if a full appreciation of the position of the fragments is to be obtained, and few fractures can be treated up to the highest current standard without the aid of this procedure. Radiology is also of great value in observing the progress of the case towards repair.
Bones unite by a process of repair comparable to that observed in any other tissue of the body. After the primary effu sion of blood arid serum which follows the injury the swelling so formed is gradually absorbed and replaced by granulation tissue. The granulation tissue laid down about broken bone differs from that in the soft parts in that it becomes calcified, and finally is converted into true bone. The term callus is applied to this type of repair tissue. Finally, if the bones are in good alignment the normal structure is completely restored. The speed of union varies with individual fractures and with individual patients in a way and to a degree which cannot be explained on any simple grounds. In general the process is more rapid in children. In the adult the age of the patient does not have a very great influence on the process.
of a fracture in which there is any serious dis placement will in the first place involve setting the bones, that is to say, putting the fragments in as nearly normal a position as circumstances permit. This is effected or attempted by manipu lation under an anaesthetic. In many cases, however, of fractures of long bones in which there is overlap, satisfactory reposition cannot be obtained by this means, and the adjustment of the ends is effected by gradual weight extension or traction which stretches the muscles and tends to draw the bones into their nor mal alignment.
Should it be impossible to get satisfactory apposition of the fragments by one of these methods, open opera tion is justifiable and may be the only method of obtaining a first-class result. The aim of surgical technique in relation to bone work for which Lane was mainly responsible, has rendered these operations a safe and straightforward proposition. When the fracture has been exposed and adjusted, some method of in ternal fixation is often employed, the bones being joined together by metal or bone plates, or sutured by wire. There is a tendency at the present day to avoid the use of metal in these open opera tions and to employ instead slats of bone which may be obtained from the patient or from some other source.
The next step in treatment after reduction of de formity is the maintenance of position of the reduced frag ments. This can be effected by various forms of external splintage. Plaster of Paris is the most effective method of fitting a firm splint to a limb, but it can only be applied to a limited group of cases. Wire skeleton splints which are completed by fabric slings are popular for the lower extremity. Aluminium gutter splints are of value in some cases on account of their malleability and translu cence to X-rays. The period during which splints are kept applied varies widely in accordance with the nature of each fracture. In general they are not removed till union is so far advanced that their absence does not cause a risk of displacement.
Restoration of Function.—In every fracture the neighbour ing muscles, tendons, and very of ten joints, are damaged in some degree. The disabilities which may follow a fracture are most often the result of these latter injuries, and after-treatment is directed to the restoration of full function and movement of mus cles and joints. Massage can be employed from an early stage, though it may be impossible in circumstances in which rigid fixa tion of the bones has to be' maintained. It is of value in pro moting absorption of swelling, and thereby promotes repair. Passive and active movement of joints near the fracture is car ried out as soon as the stability of the broken bone will permit. Electrical methods of various kinds are employed to exercise and repair muscles, and have considerable value in properly selected cases. In general it may be said that in fractures of the upper ex tremity the main aim should be to restore full and early move ment of joints and muscles, even at the expense of imperfect reposition of the broken bone. In the lower extremity perfect alignment of the bones is the first necessity if secondary joint troubles are to be avoided.
Delayed or Un-united Fractures.—Delay in the process of union is common enough for several reasons, the commonest being probably the interposition of soft structures between the broken ends. The presence of syphilis in the system and certain wasting diseases are also deterrent factors. Failure of bones to unite firmly in healthy individuals is rare. It is, however, met with in those cases in which a large part of the bone substance has been de stroyed or damaged by the primary injury or subsequent infec tion. These cases are now treated in suitable subjects with a high measure of success by bone grafting. Fresh bone taken from the patient himself gives the most reliable results. In cases in which the original broken bone ends can actually be brought together, a beef bone and preserved human bone have been employed with some measure of success. As to the degree to which the grafted bone replaces normal bone, the consensus of opinion is that the graft acts as a scaffold along which new bone grows, rather than that it becomes a part of the host skeleton. At any rate it forms a firm bond about which, under suitable conditions, new bone formation takes place. (C. M. P.)
