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FRACTURE. 



FRACTURK. 



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of UM utmost care and skill ; and MOM distortion and ihortaning of 

 the limb U inevitable in severe OWN. 



Oommixulai fracture. When a bone in crushed, or fissured in mure 

 than one direction, * that portions of it are detached from the rout, 

 the fracture U said to comminuted. From the facility generally expe- 

 rienced in replacing the bone, or at least in straightening and ip|><>rtiug 

 the limb in theae raias, they often end better than apparently lew 

 serious oblique fracture*. Perhaps one reason may be that the direct 

 application of force, by which they are generally produced, has some 

 fleet in stunning the muscles and deadening the injurioua influence of 

 their contraction. If there be much contusion of the soft parts, con- 

 siderable inflammation and fever may supervene, and the recovery will 

 be tedious in proportion ; but the eventual restoration of the natural 

 shape and length of the limb is frequently more complete than might 

 be expected. 



fracture ejctending into a joiiil. A bone may of course be broken in 

 Uu situation of a joint ; or, if the fracture occur at some distance, a 

 fissure may extend longitudinally into one of these cavities. This cir- 

 cumstance i a very important aggravation of the injury. The 

 nynovial membranes which line the joints are peculiarly impatient 

 of irritation, and when they become inflamed, the constitutional dis- 

 turbance is often considerable, and the attendant, or, as it is called, 

 the $ym}itomati<- fever, is of a very acute type. When the larger 

 joints, such as the knee, are concerned in injuries of this kind, 

 the old surgeons frequently recommended amputation of the limb. 

 Modern experience has shown that this may generally be dispensed 

 with ; but the greatest skill and watchfulness are required and often 

 baffled in endeavouring to prevent the occurrence of a stiff joint 

 (oaeA.vfomi), and to keep the limb in the most useful position, if it 

 should occur ; a position which is not always the most conducive to 

 the ease, or indeed to the recovery, of the patient, and therefore not 

 always eligible. 



Fraetnrr complicated iritk ditlocalion. If a bone be dislocated as 

 well as broken, it may be difficult or impossible to carry into effect 

 the measures which are necessary for the satisfactory treatment of 

 either injury, and the result is permanent distortion and crippling of 

 the limb. This is of course an extreme case, and is not likely to 

 happen unless the fracture take place very near the dislocated joint, 

 so that a firm hold cannot be taken of the detached end of the bone. 

 If, however, the fissure in the bone does not extend to the joint, the 

 constitution does not, upon the whole, Buffer so materially as might be 

 expected in consequence of the double injury, except in particular 

 rannii, such as those complicated with traumatic delirium, on which, a 

 the subject is curious, we shall here take occasion to say a few words. 



Traumatic dtlirium (Tfavpa, a vonnd). This affection is by no 

 means confined to fractures with dislocation, or to injuries of which 

 fracture forms a part. It appears however to be more frequently a 

 consequence of injuries of this nature than of others, and particularly 

 of the fracture of the fibula immediately above the ancle, which u 

 often followed by dislocation of the foot. [Fraui.A, in NAT. HIST. Div/ 

 The patient rambles in his ideas, is generally very talkative, and in a 

 state of great alarm and apprehension, expecting, for instance, to be 

 led to execution for some fancied crime. He is commonly pale and 

 cold, free from fever, and quite unconscious of pain. If not pre- 

 vented, he will rise from his bed and move about the room, using his 

 shattered limb with perfect unconcern. Traumatic delirium has some 

 points of resemblance with delirium tremens, and like it, occurs for 

 the most part in over-stimulated and exhausted constitutions. It is 

 sometimes fatal, but may generally be relieved by large quantities o: 

 wine and opium. 



Compound fracture. If the injury of which we are treating be con 

 fined to the bones and the parts immediately around them, the fracture 

 is said to be timple ; but if the bone be protruded through the skin 

 or an external wound otherwise inflicted communicate with the in 

 terval between the broken surfaces, the fracture is said to be compound 

 However small the wound in the skin may be, unless it can be 

 brought to heal by the first intention, which, though it rarely succeeds 

 should be always attempted, this in by far the most serious aggrava- 

 tion of the injury, whether we regard the suffering of the patient, the 

 progress of the case, or the prospect of recovery. A simple fracture 

 however extensive, if not into a joint, may generally be expected wit] 

 confidence to be well enough to permit the accustomed use of the limb 

 in a period ranging from two to eight weeks ; the pain and constitu 

 tional derangement seldom lasting beyond a few days. But a com 

 pound fracture threatens life, and, speaking generally, is at best an 

 affair of many months of suffering and sickness. This remarkabl 

 difference originates in the wide constitutional sympathies of the skin 

 as an organ of sensation and secretion ; in the importance of its func 

 Uon as a covering for the subjacent parts ; and in its great pi-oneness 

 to become inflamed when the subject of a punctured and lacerate 

 wound. It further results from the tendency of the inflammation tc 

 propagate itself from the edge of the skin along the track of th 

 wound to the periosteum ami other deep-seated parts ; it common! 

 spreads very extensively in cellular tissue between the muscles, under 

 the aponeurotic expansions which invest and separate them, and with! 

 the synovia! sheaths of their tendons. Some degree of inflammation 

 among these parts takes place In simple fractures, but it seldom ex 

 coeds manageable limits and the lower degrees of it may perhaps be 



considered as curative. But the inflammation which follows a conv 

 lound fracture puts a stop to all the natural processes of restoration, 

 md renders the artificial means, in other cases usefully employed to 

 tromote thorn, ineffectual nr inapplicable. It is attended with incessant 

 and exhausting fuver, at first ardent and afterwards irritative and 

 ectic [KereB], 'and occasions deep-seated sbsoassia, extensive de- 

 traction of the soft parts (tlvugkmg), and tedious separation of dead 

 Done (exfoliation). Such are some of the disastrous consequences of a 

 compound fracture, an accident which, in its severer forms, presents 

 uch a scene of suffering and a succession of such formidable drains 

 pon the strength, that, on the balance of evils, amputation is of tun,a 

 referable alternative. 



Itiaynutit <tf fracture. Much need not be said of the means by 

 which the existence of a supposed fracture may be ascertained. Tin- 

 nature of the accident is generally obvious enough, and the less 

 be parts are handled the better; but where there is any doubt, it 

 may be removed by attending to the grating sound, or the sensation 

 ominunicated to the touch occasioned by slightly moving the broken 

 ends of the bone against each other. This symptom is called rrcpi- 

 o/inn. 



Treatment. The principles of treatment are, in the first place, to 

 soothe by all possible and prudent means the muscular irritation and 

 spasm which are the immediate and most urgent consequences of 

 ecent fracture. The patient is to be placed in the easiest posture, 

 which, if the thigh or leg be broken, is generally on the same side or 

 in the back ; the limb is to be supported on soft pillows, the con- 

 iguoiw joints being half-bent in order to favour as much as possible 

 he relaxation of each class of muscles, especially the flexors ; gentle 

 riction, warm fomentations, or cold evaporating lotions are to be used 

 according to the circumstances of the case and the feelings of the 

 patient. 



When the relaxing rigidity of the muscle will permit, which may 

 not be for some hours or days, the bone is to be restored as nearly as 

 raesible to its proper situation by the gentle application of force in 

 any required direction. Violence would defeat its own object by 

 reproducing spasm. One hand or an asssistant should steady the 

 upper portion of the limb while the lower portion is drawn down and 

 turned till the proper length and bearings are restored. This process, 

 which is called the reduction or Kiting of the fracture, cannot always 

 completed on the first attempt ; and it is sometimes advisable, and 

 ndeed only possible, to effect it by degrees. The displacement may 

 also return ; and in oblique fracture this will certainly happen unless 

 the case admits of a very fortunate adjustment of the bandages. The 

 process we have described must then of course be repeated as often as 

 ircumstances may render it necessary. The setting of a broken limb 

 is not, as people generally imagine, a piece of legerdemain, to be 

 effected in a moment by some wonderful exertion of dexterity, and 

 then to be announced in oracular phrase by the surgeon as if it were 

 something too mysterious for a plain man to understand. It is a 

 perfectly simple and straightforward measure ; and little more than, 

 ;ommon sense and a gentle hand are necessary for its proper execution 

 if it be possible to effect it at all. 



When the limb is reduced, it is to be placed in tptinti, which arc 

 thin pieces of wood or other material of the requisite firmnc- 

 length, and suitably shaped and hollowed out to fit evenly without 

 making undue pressure upon prominent points, such as the ankle. 

 The skin is to be protected by folds of linen or thin soft pads a little 

 wider than the splints, which are also useful to prevent them from 

 slipping. When everything is properly arranged as to position, the 

 splints are to be bound upon the limb with a moderate degree of 

 pressure ; and it is right to remove and re-adjust them occasionally, in 

 order to detect and rectify any deviation from the correct line of the 

 bone that may arise or become apparent as the swelling subsides. 



Where there is no fear of the bone being displaced by the action of 

 the muscles that are attached to it, or by the restlessness of the 

 patient, it is not necessary to apply splints, which are only useful in 

 preventing motion, and otherwise rather retard the progress of the 

 case by their pressure, and for other reasons. 



In fracture of the ribs, it is sufficient to apply n broad belt or bandage 

 to prevent them from alternate depression and elevation in the act of 

 breathing, which can be carried on sufficiently well by the diaphragm 

 alone [RESPIRATION, in NAT. HIST. Div.] ; and all such means are 

 inapplicable in many cases, such as fracture of the vertebras, I 

 the neck of the thigh-bone, where all that can be done of a mechanical 

 kind is to place and keep the patient in a proper position. This can 

 be done most effectually by the help of a bedstead invented by Mr. 

 Earle, the frame of which is jointed, so that the back may be raised to 

 any required inclination, the knees being also raised, and the i 

 necessary, bound to a cross-board. The mattrass is provided with 

 moveable pieces, which preclude the necessity of change of position iW 

 any purpose. The paramount importance of constitutional trc : 

 and *>atrict regulation of the diet need scarcely be adverted to in this 

 as in all cases of injury, in which a primary object is to repress or 

 prevent inflammation. 



Union of fractured Bone. The process by which fractured bones are 

 united i generally uninterrupted in simple cases, if the constitution 

 be good and the accompanying contusion not very considerable. The cx- 

 travasated blood is soon absorbed, and the swelling and inflammation sub- 



