FRACTURES.
The general principles of treatment only need be detailed. These consist in the reduction of the deformity by placing the fragments of bone in their normal position, the application of such simple mechanical contrivances as will maintain their apposition till union occurs, and when necessary the use of appliances to keep up such extension as will overcome spasm of the muscles tending to cause over-riding of the broken bones, and at the same time to employ such local measures as will keep the joints and muscles in their normal healthy state.
When a fracture comes under the care of the surgeon, no time should be lost in carrying out these principles. As in the case of dislocations, the great harrier to reduction is the reflex contraction of the muscles. and the sooner the attempt at restoration of the broken fragments to their normal position, the easier will the operation become. The popular idea of the importance of " setting " a fracture as soon as possible after its occurrence is therefore based upon sound pathology, and the surgeon is liable to blame if he delays the.reduction till an ideal form of splint or apparatus is at hand; it is thus wise to extemporise splints till more suitable appliances can be obtained.
The patient's clothing should be carefully removed by slitting up the seams in order to cause as little movement as possible of the broken fragments, otherwise a sharp spicula of bone may cause much injury of the soft tissues or even be made to perforate the skin, changing a simple into a dangerous compound fracture. lle should be placed upon a firm hair mattress, and the most gentle and thorough examination of the injured limb should be carried out, after which the surgeon, when his appliances are at hand, proceeds to reduce the deformity. This should in all cases be achieved without the use of force, b) so arranging the position of the limb as to cause the most complete relaxation of all its muscles and joints in order that the fragments may be brought into accurate apposition without rough pulling or hauling, which only excites reflex spasm and thwarts his efforts at reduction.
This is achieved by an assistant grasping the limb firmly above the seat of fracture, whilst the surgeon makes very gentle steady traction in the line of the axis of the limb upon the lower part, during which the bones come into apposition, guided by the gentlest pressure of the fingers when necessary. Care must be taken that no muscle, fascia or tendon is left
interposed between the divided ends, and if any great difficulty be experi enced from muscular spasm an anesthetic should be administered.
Accurate adjustment of the bones having been secured, a well-padded splint of wood, gutta-percha, leather, poroplastic felt, wire gauze, perfor ated tin ur zinc is applied on each aspect of the limb. These splints should be so shaped, moulded, or lined with padding as to apply when bandaged an even pressure over the limb. As they are adjusted to the fractured member gentle extension or traction is to be kept up until the whole is enveloped in a good calico bandage. The use of a few straps and buckles, or better still a broad piece of adhesive plaster, to secure the splints in position before the application of the bandage is a great con venience. Buckles should always rest upon the splints, and not upon the skin. Much skill and experience is required in graduating the pressure of the bandage, which should not be tight, and the seat of fracture should be left free and exposed when possible.
Before completing the bandaging the limb should be carefully measured and contrasted with its fellow in order to demonstrate that full reduction has been accomplished, and it is a good rule in all cases to obtain a skiagram after the setting operation has been completed.
The limb should be maintained in the position which affords the most complete relaxation of the muscles. The less it is interfered with the better, though careful inspection is to he constantly maintained, especially after the first 24 hums, lest the bandages might get tight from subsequent swelling, as gangrene might thereby result. The surgeon satisfies himself from time to time by passing his finger over the scat of fracture that the fragments are kept in position, and by passing his eye over the entire limb, and contrasting it with its fellow on the sound side, he sees that no rotation or deformity arises.