"FRACTURES, in surgery (see 4.201). - Further improvements in the treatment of fractured bone have been made, especially as the result of experience during the World War.
Before treatment of any fracture is undertaken, it is essential that an accurate knowledge of its detail be obtained. A diagnosis is made by X-ray photographs taken in two places at right angles to each other. The result, too, of treatment is noted by this means, and the progress of union ascertained by testing at intervals the degree of mobility between the fragments under the X-ray screen.
A fracture in which there is displacement of the fragments is always a serious injury, and the treatment is often difficult. The first aim of treatment is to restore the bone to its original anatomical alignment (reduction). The second is to keep this alignment, and at the same time to maintain the function of the muscles and joints of the limb. The two are interdependent, as the return of function depends to a very great extent on the accuracy of the reduction.
Two main methods of treatment are available in order to restore the alignment of the bone: non-operative and operative. Non-Operative Treatment. - One of two methods may be chosen, depending on the site and nature of the fracture: - (a) Immediate reduction by forcible traction and manipulation, and maintaining the restored position by appropriate splinting. (b) Gradual reduction. In this method continuous extension (traction by means of weights) is applied to the limb in order to cause relaxation of the muscles. The fragments will then tend to resume their normal position, or can be more easily manipulated into such position.
The object of operative treatment is to expose the fractured ends of bone, to replace them accurately in their original alignment, and in most cases to secure them in this position.
The best means by which to fix the fragments is still sub judice, but many materials have been used, notably bone grafts, metal plates and screws, bone pegs, metal wire, etc.
The bone graft has been widely used during the past few years. Its widest application is probably in cases where there is actual loss of bone substance, and the graft is used as a medium round which new bone may grow (old compound fractures). In the simple fracture its function is that of an internal splint to secure the fragments after reduction, and its value here is limited at present to the less severe cases. In the severe fractures the best method so far of securing a firm fixation is by means of a metal plate and screws (Arbuthnot Lane). Metal wire and bone pegs are valuable only in cases of injury to the smaller bones. When the fracture is in the neighbourhood of or involving a joint, as a rule the fragments are replaced in position only.
After-Treatment.--By whatever method the alignment of the bone is restored, the limb is splinted so that it is possible to commence at an early date general massage of the limb, and active movements of the joints in the neighbourhood of the fracture.
The splinted limb is suspended from an overhead frame-work. By a system of weights and pulleys a very wide range of movement is permitted to the patient, while the injured limb is maintained immobilized. This arrangement facilitates also the nursing of these often difficult cases. For fractures of the lower limb various forms of ambulatory s p lints have been devised to permit of walking at an early stage in the treatment.
In the case of compound fractures, some by reason of their situation are necessarily either directly or indirectly compound, e.g. a fracture of the mandible (lower jaw), or certain fractures of the base of the skull. The majority of compound fractures, however, occur in the limb bones. These may be caused by some violent force striking the limb, lacerating the skin and soft structures surrounding the bone, and at the same time fracturing the bone. Dirt, clothing, etc., are thus carried into the wound. Many thousand such cases occurred in the war from the effects of gunshot. On the other hand, a bone may be broken, and afterwards, from the continuation of the violence or from the crumpling of the limb, the sharp end of one of the fragments may be forced through the muscles and skin.
In either case the important point is that the injured tissues have been exposed to infection by micro-organisms and provide in their damaged condition very favourable soil for their growth. If infection (sepsis) gains a foothold, the condition is a serious one always, and at the worst may involve loss of the limb or even life, at the best a long and tedious treatment.
The first object in the treatment of a compound fracture is to convert it into a simple one. This is accomplished by an excision of all lacerated tissue, and closure of the wound (primary suture). The treatment is then continued as for a simple fracture. In a large number of cases during the World War, the wound had become infected before continuous treatment was possible. The primary consideration, therefore, was to deal with the sepsis, and the results of septic absorption.
As the result of experience certain principles were evolved, which advanced the treatment of these serious cases to a marked degree. The main principles may be briefly summarized as follows: (1) To obtain an accurate reduction of the bone fragments and coincidently of the soft structures, thus enabling them to combat at a greater advantage the effects of sepsis.
(2) By efficient splinting to ensure a complete immobilization of the whole limb; the chance is then given for a natural barrier against the spread of infection to be formed in the limb.
(3) To use a simple, cleansing, and as far as possible painless treatment for the wound itself. Of the many treatments tried, it is probable that the Carrel-Dakin method of intermittent irrigation is in these respects the best.
(4) To close the wound when it has become bacteriologically clean (secondary suture). (F. D. S.)
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