and crepitus are the two other objective symptoms of fracture and are pathognomonic. In ex posed positions the former sign may be elicited by directly grasping the segments of the bone and moving either upon the other; in other cases (fracture of the sur gical neck of the humerus) the surgeon must be satisfied with determining that the motions (rotation) of one fragment (the shaft) are not imparted to the other, as indicated by the immobility of one of its bony points (the greater tuberosity) Again, abnormal mobility near a joint may simulate abnormal mobility of the joint itself, and special care be necessary to differentiate between fracture and dis location.
is the grating sensation heard or felt when the two rough bone ends rub against each other. The inter vention of soft parts between the bone ends, of course, prevents crepitus, which may, on the other hand, be simulated by crackling of coagulated blood, by rough ened joint-surfaces, by teno-svnovitis, and by emphysema. Finally, be it espe cially noted that although abnormal mo bility and crepitus are pathognomonic, they are often by no means necessary to the diagnosis of fracture, and the manip ulations which they require may be not only extremely painful, but also, by pro ducing further lacerations of the soft parts, positively harmful to the patient.
Loss OF FUNCTION is usually present to a greater or less degree and is due to the weakness of the part or to the pain evoked by motion or pressure; but this symptom is liable to be misleading, for, while one patient may use a fractured limb with great freedom, another may be totally disabled by a mere contusion.
PAIN.—This is always present, except when the patient is unconscious, and is either spontaneous or aroused by press ure or movement. The characteristic pain of a fracture is localized over the point of fracture and may be elicited, not only by pressure over this point, but also by pressure at other points along the fractured bone. Such a pain, together with a history of injury, may sometimes constitute sufficient evidence of fracture, notably in fracture of the ribs or of the fibula.
— Immediately after the accident the torn vessels pour out their blood into the tissues, and within a few hours oedema sets in on account of the occlusion of the lacerated veins and lymphatics and the obstruction of others by the pressure of the extrava sated blood. The temperature may rise a degree or two, blebs appear on the sur face, and the tense skin discolored by ecchymoses. The discoloration which may appear a few days later, as the blood extravasated among the deeper tissues makes its way to the surface, perhaps at some distance from the point of fracture, is a presumptive sign that a bone-lesion exists. In from one to five days—more
rapidly under appropriate treatment— the oedema subsides and the swelling is reduced to a hard lump, the mobility of the fracture becomes less, crepitus is no longer obtainable as the fractured bone ends become covered with granulations, and, finally, after a few weeks abnormal mobility entirely disappears and the fracture is said to be united. But the patient is not yet well. Disease has stiffened the joints and weakened the muscles so that several weeks or months will be required before the limb regains its usefulness, while in cases where the proper care of the joints has been ne glected they may remain permanently stiffened.
Diagnosis.—The degree of fracture should always be made with the least possible manipulation. A consideration of the patient's history, together with careful inspection, gentle palpation, and accurate measuring will usually suffice. If not, gentle manipulation of the in jured part may be made use of for the purpose of eliciting abnormal mobility or crepitus. To this end general anes thesia is of great assistance by relaxing muscular spasm and removing pain; but with these safeguards against further laceration thus removed, manipulation should be doubly gentle. Moreover, a slight, gentle movement will often be of service when a brusque or violent one will fail.
In obscure cases the use of the X-rays by fluoroscope or sciagraph may be re sorted to instead of anesthesia; but when operative interference is necessary, or when complete insensibility is requi site for the "setting" of the fragments, the use of the rays is not called for. In fact, the safe rule is to use the rays for diagnosis as little as possible, for depend ence upon the ordinary clinical data and the careful use of trained eyes and fin gers are productive of far better clinical results than is the use of an instrument whose finding may be misleading and which tends to shroud the clinical aspect of the case in the silvered cloud of scien tific accuracy. In doubtful lesions about joints, however (notably the hip and shoulder), and in supposed fractures of the spine or pelvis, the rays may be of great service, and they are of undoubted use also in some cases where operation for non-union is contemplated, and occa sionally to determine the condition of the bones of a limb in fixed splint. Their application to scientific and statistical investigation is beside our subject.