Local sloughing of the tissues may occur from the pressure of a sharp point of bone, or, more commonly, by extrava sated blood. The reduction of the fract ure, followed by the application of heat and pressure and the elevation of the limb, constitute the elements of prophy laxis in such cases, to which must be rarely added incisions for the evacuation of clots or the ligature of bleeding-points.
Other early complications are the sec ondary compounding of the fracture by a sharp point of bone, and the formation of a traumatic aneurism in a lacerated artery.
Complete recovery may be delayed or prevented by exuberant, painful, or weak callus. The callus always is "exuberant" at first, and may be expected to grow somewhat smaller even after bony union has taken place, but experience has proved that large masses of callus that impair function will not disappear in the course of nature nor under any medical, mechanical, or electrical treatment. They must be exposed and chiseled away, and in this connection it is well to re mark that in old cases it may be impos sible to tell before operation whether the offending mass is a badly-reduced frag ment or exuberant callus. Persistent pain in the callus may be due to pressure on a nerve or the inclusion of nerve-fila ments in the callus, or to suppuration about a sequestrum. If the pain cannot be explained, it is called "osteoneural gia." Weakness of the callus, if not caused by undue separation of the frag ments or constitutional debility, is usu ally due to inefficient immobilization. It is not an uncommon consequence of suppuration in a compound fracture.
Stiffness of the joints is, to a certain extent, the natural result of the immo bilization necessary to secure union in the fracture. But this stiffness should be transitory except in the old and rheu matic, or unless the joints are sprained or involved in the fracture. In this last event permanent bony union of the op posed bone-surfaces may occur, or exu berant callus may interfere with the movements of the joints. The joints of the fingers, however, are very liable to remain stiff if they are immobilized for more than two weeks, especially if in the position of extension.
Atrophy of the muscles may be per manent in old and debilitated persons. In whom also spontaneous dislocations and fragility of the bones may result from disease.
Tumors—primary sarcoma and sec ondary carcinoma—may occur at the seat of fracture, and secondary carcinoma may occur in the epithelium lining of the old sinuses of compound fractures.
Permanent paralysis may result from laceration of or pressure on the nerves.
Treatment. -REDUCTION. - The sur geon's first duty, unless the associated injuries or shock demand immediate at tention, is to "reduce" or "set" the fract ure; that is, to restore the fragments to their normal position, or at least to that position in which he intends them to unite. This first step in the treatment, and the next one, immobilization, must be carried out as soon as possible in order that the displaced fragments shall do no further damage to the soft parts. Of course, in such fractures as do not need reduction (e.g., ribs) immobilization is alone required. If the patient's general condition contra-indicates such extensive manipulations as are required to reduce a complicated fracture, the bones must be immobilized as completely as possible in their abnormal positions. In com pound fractures, moreover, special indi cations exist for primary immobilization. These will be discussed in a subsequent paragraph. Reduction should not be made if the spongy tissue of the bone has been crushed so severely that if the distal fragment were replaced in its normal position a gap would exist between the fragments.
To effect reduction the least possible force must be applied. Ordinarily speak ing, gentle traction is made upon the distal fragment by the hands of an as sistant, while the surgeon manipulates the broken ends, bringing them gently into position. General anmsthesia may rarely be necessary to relax the mus cles.
Immobilization is effected by means of splints. Any dressing used to immobil ize a fracture is called a splint. Of tem porary emergency splints, the simplest and most generally applicable are made of wood. They should be broader than the limb to prevent constriction when they are bandaged to it, and, generally speaking, longer than the fractured bone. They should be padded on the side next to the limb and should be light and yet strong enough to maintain the bones in their proper positions. These splints are held in place by a roller bandage or strips of adhesive plaster.