Part 11

3. Fractures of both bones of the fore-arm, may occur either at the ends, or in the middle of the limb. Frequent in the middle, and somewhat common below, they seldom occur in its upper part, where the fleshy portions of numerous muscles, combined with a considerable thickness of the ulna, resist the motions which tend to produce them. The two bones, though most commonly broken on the same line, are, however, sometimes broken on different ones. The fracture is almost always single: at times, however, it is double, and Desault, in particular, was once called to a patient, over whose fore-arm the wheels of a carriage had passed, and had broken it both in the middle and at the lower end, so that it evidently exhibited six fragments distinct from each other. The two middle ones, though completely insulated, united again to the others with but very little deformity. Like all other similar affections, these may be rendered compound by wounds, splinters, &c. circumstances which, as they fall within the general class of such injuries, will not be treated of at present.

14. They occur, in general, in two ways, being the result, sometimes of the action of external bodies, immediately applied, and at other times of the same action, operating by way of a counter-stroke. The occasional percussion of a body on the fore-arm, furnishes an example of the first mode of fracture. This is much more frequent, in general, than the other, which usually arises from a fall on the wrist; but, in such a case, as it is the large lower end of the radius that forms the principal point of articulation with the hand, that bone alone sustains almost all the force of the stroke, and is very generally the exclusive seat of the fracture.

§ III.

OF THE SIGNS OR APPEARANCES.

It is in general difficult to be mistaken with respect to the signs which characterize fractures of the fore-arm. A mobility of the limb where it was before inflexible; a crepitation almost always easily perceived; a depression, sometimes evident, at the place of division; a protuberance sometimes formed under the skin by the fragments; pain produced by the motion of the part; a crack sometimes heard by the patient, at the moment of the accident; an inability to perform the motions of pronation and supination; the almost constant semi-flexion of the fore-arm; such, together with the phenomena common to all fractures, are those which essentially characterize this, and which must generally remove all doubts which the swelling of the limb may temporarily create respecting its existence.

6. There is a circumstance, however, where a fracture near to the joint of the wrist, may give rise to appearances similar to a luxation of that part. In both cases, indeed, a convexity behind, and a depression before, or the reverse, are perceived, and are the effect of a displacement of the fragments. But the styloid apophysis being carefully examined, will always determine, according as it is found above or below the deformity, from which of the two causes the deformity arises. Besides, a greater mobility in one than in the other affection, and a crepitation, will guard the practitioner from an error, into which I saw a surgeon fall in the presence of Desault, whom he called on to consult, in the case of a child six years old, which laboured under a supposed luxation.

§ IV.

OF DISPLACEMENT.

7. Most of the phenomena which accompany fractures of the fore-arm (5), are evidently the result of a displacement of the fragments; a displacement, not, in general, very perceptible in the longitudinal direction of the bones, because the muscular action, tending to produce it in that direction, is not very powerful. When it does occur in this way, it is most frequently the immediate effect of the stroke that produced the fracture.

8. But it is different with respect to a displacement in the cross direction of the bone. Here the cause of the separation of the broken ends, may be the same with the cause of their fracture, as happens in the passage of a carriage wheel over the limb, or in the falling of some body against it; and then, 1st, the fragments are separated from before backward, or contrarywise, and hence, a protuberance on the one side of the limb, and a depression on the other; 2dly, or else they are pressed against each other laterally from without inwards. From this latter cause arises that inequality which the limb exhibits at the place of the fracture; the slight depression which it manifests on its sides; and the protrusion or bulging out of its anterior and posterior surfaces, by means of the mass of muscles which are pushed in these directions, by the approximation of the fragments to each other.

9. A proper reduction removes the first kind of displacement, namely, that which occurs in the cross direction of the bone backward or forward (8); and unless an external force be applied anew, it does not again return. On the contrary, how exact soever the reduction may be, in the second kind, namely, that which takes place laterally from without inwards, the fragments are soon found to have approached each other again. Above, the pronator teres presses the superior fragment of the radius against that of the ulna; below, the two fractured extremities are pressed against each other, by the contractions of the pronator quadratus. From this double cause arises, unless something prevent it, the contact of the four fractured ends, which have been sometimes found united together by a common callus, as is proven by several cases sent to Desault, and by the cases of different patients admitted into the Hotel-Dieu, after having undergone an improper treatment. In such cases, the movements of pronation and supination being entirely destroyed, are but imperfectly supplied, as Duverney remarks, by those of a rotation of the arm.

But if the four broken ends should not even be joined together by a common callus, still the space between the bones being evidently diminished, impedes muscular action and the motions of the limb depending thereon.

§ V.

OF THE REDUCTION.

10. It follows from what has been said on the displacement of the fragments (8), and on the causes which have a constant tendency to re-produce this displacement (9), that the extending forces, intended to remove it, should be, in general, less powerful than in most other fractures, because their principal object is, to restore to the limb its natural length, which is here but very little affected.

11. Previously to the application of these, it is necessary, according to the precept of Hippocrates, to place the fore-arm in a middle state between pronation and supination, flexion and extension. This position is highly favourable to the relaxation of the muscles, and is that, above all others, as the father of medicine observes, which those who have sustained a fracture naturally assume, and which alone they can, for a long time, retain, without experiencing any inconvenience.

12. The fore-arm being thus placed, an assistant makes extension, by taking hold of the four fingers; a mode to be adopted in preference to that of Petit, who directs us to make extension at the wrist; for the real momentum or force of a power is in the inverse ratio of its distance from the place of resistance. At the same time, another assistant makes counter-extension on the humerus, which he grasps with both his hands, in such a manner, that his thumbs correspond to the back part of it, while his fingers cross each other anteriorly.

13. It further follows, from what was said (8 and 9), that the process of conformation, so often useless and even injurious, in other fractures of bones, is necessary here, to restore to the fragments that exact contact which they have lost, in a transverse direction. If the displacement be forward, the surgeon pushes both fragments backward, while the assistants maintain the extension. If the bones project backwards, they must be pushed in the contrary direction. As to a lateral displacement (8) in which the broken ends approach each other, it is not altogether useless, as Petit observes, to endeavour to remove it, by forcing the muscles into the space between the bones. This is done by making a moderate pressure on the anterior and posterior surfaces of the fore-arm, in order that the bones, being thus removed from each other, may come in contact with their broken ends. If this be done, when the apparatus is first applied, the reduction is attended with but little difficulty, and the ends of the fragments are easily retained in apposition.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

14. Our forms of apparatus are nothing but means of continuing, for a long time, that state of things, which extension and the process of conformation temporarily produce at the time of reduction. This principle, though generally acknowledged, was particularly neglected in such fractures, as that now under consideration, till the time of Petit, who made it the basis of his practice. Before him, there was a common inconvenience attached to every kind of bandage. The two bones being pressed against each other, by circular rollers applied externally, were thus drawn in that very direction, in which the action of the pronator muscles already tended to displace them; because, the form of the fore-arm being irregular, made these rollers act more powerfully on its lateral parts, where it is very convex, than either behind or before, where it is very flat. It is well known that bandages will make the greatest pressure on the most projecting parts of the limbs round which they are applied; so that, if the fore-arm be bound or pressed on behind and before with a force equal to one, it will sustain laterally, that is, on its sides or edges, a pressure equal to two. Hence results, not only a tendency in the radius to approach the ulna, but also, a want of resistance in the muscles situated on the posterior and anterior sides of the fore-arm. For these muscles being, from their flatness, less compressed than the bones, give way, and do not, by forcing themselves between them, oppose the approach of the bones to each other.

15. Such was the disadvantage of the apparatus of Hippocrates, consisting of one roller applied immediately on the skin, of a many-tailed bandage intended to retain this, and of four splints, applied on the seventh day, and secured by another roller. Such was also the inconvenience of several bandages, proposed after the time of Hippocrates, by different authors, who modified his without improving it, and who, in attempting to alter it, even added to its imperfections. Thus, the compresses with which the limb was first covered, previously to the application of the rollers, served only, by becoming wrinkled, to render the compression unequal, fatiguing, and even painful to the patient. In like manner the pasteboard, which many authors, particularly Duverney, have substituted for splints, and which a majority of practitioners employ, even at the present day, soon becoming softened by moisture, bends without resistance, becomes incapable of preventing a displacement, and has at least the inconvenience of being useless.[18]

[18] On this point Desault is certainly mistaken. Paste-board, when of a proper thickness and well applied, makes an excellent splint for fractures of the fore-arm. It moulds itself to the form of the arm, sits easy, and retains the fracture extremely well. TRANS.

16. Is it to be wondered at then that a perfect cure of fractures of the fore-arm has been regarded as a thing of so much difficulty, and that most authors should have advised practitioners, as a thing of prudence, to warn the patient of its being impracticable to cure him, without the loss of the motions of pronation and supination? Thus, in like manner, it was formerly declared, that a constant deformity was the necessary consequence of fractures of the clavicle.

17. Petit first conceived, that he discovered, in the very means destined to prevent the displacement, the cause of its being continued, and that, in order to be effective, the bandage ought to do constantly what the hands of the surgeon do at the time of reduction (13); that is, it ought to oppose to the unremitting action of the pronators, a resistance equally unremitting, by pressing the muscles into the interstice between the bones. But, after having discovered the end to be attained, he accomplished it only in an imperfect manner. For by first applying a roller immediately round the fore-arm, he reproduced, in part, the very inconveniences and disadvantages he wished to prevent, by placing anteriorly and posteriorly two long and thick graduated compresses, intended to keep the bones asunder, by forcing the muscles between them.

18. Duverney, more judicious, proposed to place the graduated compresses of Petit on two circular compresses, previously applied round the fore-arm. But what availed these circular compresses? If they be drawn tight, will they not produce that approximation of the bones which the surgeon wishes to avoid? And if they be not tight, they will, in consequence of their loose and pliable state, form troublesome and inconvenient wrinkles, without being productive of any good to counterbalance this inconvenience.

19. It was from these different considerations, that Desault modified, as I am about to mention, the apparatus for fractures of the fore-arm. To a great degree of simplicity, this apparatus unites, when thus improved, great ease to the patient, and its advantages are proven by the freedom in the different movements of the arm always experienced by the numerous patients, whom he was called to attend. The pieces of the apparatus are, 1st, Two graduated compresses, one of them of such a length as to extend from the elbow to the wrist, and the other from the wrist to the fold of the arm on the inside. They are to be formed each of a single piece of linen, folded seven or eight times on itself, in such a manner, that the lower fold may be an inch wide, while the others, laid on top of each other, gradually diminish in width to the last. The thickness of these compresses ought to be less in very fat persons, where the anterior and posterior surfaces of the arm are more convex. 2dly, A roller about four yards and a half long, and four inches wide. 3dly, Four thin but stiff wooden splints, long enough to reach, one, from the fold of the arm to the wrist, the second, from the interval or hollow space between the olecranon and the condyl to the same part, the third from the internal condyl of the humerus to the styloid process of the ulna, and the fourth from the eternal condyl to the styloid apophysis of the radius. The breadth of the two first ought to be double that of the other two, as the latter occupy a space of but half the width of that occupied by the former.

20. Every thing being arranged, the reduction is to be executed as already directed (11–13); and while the extensions are still continued, the surgeon wets with vegeto-mineral water, or some other discutient liquid, the graduated compresses, and places them on the anterior and posterior part of the fore-arm, (which must be firmly supported in a state between that of pronation and supination, 11), in such a manner, that their broadest part or base may be in immediate contact with the limb. He then secures them with a roller wet with the same liquid, the casts of which, being first fixed at the place of the fracture, descend obliquely to the wrist, and are secured at the hand by being passed between the thumb and the fore-finger. Running across the back of the hand, the roller then reascends, either by oblique or reverse turns, according to the inequalities of the fore-arm, till it reaches the elbow. Here the surgeon relinquishes the roller, giving it into the hand of an assistant, and places the four splints on the parts already mentioned (19), while the hands of a second assistant secures them, by grasping them all at their lower end, next to the wrist. The surgeon then resumes the roller, and, in order to fix the splints immoveably, descends with it along the fore-arm by circular casts, till he reaches the hand, where he finishes.

There is, in the application of this bandage, an essential precaution to be observed; which is, that as each turn of the roller passes over the graduated compresses, the surgeon ought to press on these compresses with the thumb and fore-finger of his left hand, in order that the muscles, by being forced into the interstice between the radius and ulna may prevent their approximation, which would produce an inequality in the compression made by the apparatus.

21. After the application of the apparatus, if the patient be obliged to keep his bed, the fore-arm is to be extended on a pillow, taking care to keep it always half-bent, and guarded by hoops from the weight of the bed-clothes. But if the fracture be not a compound one, and if the fall has done no injury to the system in general, it is unnecessary to confine the patient to a position wearisome, and oftentimes insupportable to many persons. Then the limb is to be suspended in a sling, which is always sufficient to support it, without having recourse to the kind of hollow case recommended by Bell, which is seldom at hand, and the use of which must be extremely inconvenient.

22. The subsequent treatment to be adopted in such fractures is simple and easy: to wet the apparatus daily, for a few days, with vegeto-mineral water, to obviate, by proper means, the accidents that may occur; to renew the application of the roller at the end of eight days, or perhaps later, according to the degree of its relaxation; to repeat this application two or three times during the course of the treatment; to allow, at first, but light diet, which may be afterwards more solid, and given in larger quantity, and to admit finally of a return to the patient’s usual mode of living: such was, in cases of fracture, the practice of Desault, which was always attended with happy effects.

23. Sometimes a considerable swelling occurs, after the application of the bandage, on the back and face of the hand; small blisters appear between the fingers; the patient experiences sharp pains along the fore-arm; and other small blisters rise on its surface. It is then necessary to remove the apparatus, to open the blisters by pricking the cuticle, and dress the part with cerate spread on linen rags; replace the apparatus, making it less tight than before, taking care to renew it every day, till the excoriation be entirely gone. This accident, of no great consequence in itself, has frequently occurred to Desault, although the rollers were applied at first with but a moderate degree of tightness.

24. The consolidation being completed generally in twenty-four or twenty-five days, leaves, at this time, a little stiffness in the joints, in consequence of their having remained so long without motion: the movements of pronation and supination are performed but imperfectly. Their return is facilitated and hastened by frequent exercise of the limb, as well at its junction with the os humeri, as in its own proper joints; and, in general, by the fifteenth or twentieth day from the removal of the apparatus, things are in the same state in which they stood before the fracture.

FRACTURE OF THE RADIUS.

§ VII.

OF THE CAUSES AND THE DISPLACEMENT.

25. The radius, which is the moveable and almost the only support or abutment of the hand, receives, in falls on that part, a much greater share of the shock than the ulna, which is joined to the hand by only a small surface. Hence, without doubt, arises the greater frequency of the fractures of the radius; fractures which, when produced by falls on the hand, are evidently the result of a counter-stroke. Oftentimes also this bone is broken by the immediate action of external bodies, because it is defended below with but a thin covering of muscles.

In whatever way the fracture may be produced, it occurs in the middle or at the extremities of the bone; very rare near its articulation with the os humeri, it is more common in its middle; but more frequent still at its lower end. The difference arises probably from this circumstance, that, in falls on the wrist or hand, the shock is weakened and lost in proportion as it is propagated upwards.

26. In such fractures, displacement is almost constantly observable in the thickness or cross direction of the bone and fore-arm, and is produced by the action of the pronator muscles, which, by forcing the fragments of the radius towards the ulna, tend to diminish the interval between the bones. The ulna remaining unbroken, always prevents any displacement in a longitudinal direction. The first kind of displacement is the more perceptible, in proportion as the fracture is nearer to the middle part of the radius, where the bones are at the greatest distance from each other. This displacement is seldom outwards, because the interosseous ligament prevents that: yet experience furnishes some exceptions to this rule.

CASE I. Desault was called, in the month of July, 1781, to visit a mason, who, sleeping at the foot of a wall, with his fore-arm stretched out, received on the anterior part of it, a round stone, of the size of a bowl, which, falling from a scaffold, fractured the radius in its middle, and produced a large contusion, accompanied by an enormous swelling, to which the usual discutient remedies were applied. On the fifth day the swelling had in part disappeared; but then there was discovered a very evident protuberance of the inferior fragment, which, by pointing outwards, separated itself from the superior one, which remained nearly in its place. The interval between the bones was evidently increased below.

The fracture was reduced by pressing the lower fragment inwards, and, instead of employing graduated compresses the whole length of the limb, they reached only to its middle, along the part corresponding to the superior fragment. The roller was drawn a little tighter below than above, in order to keep the inferior part of the radius near to the ulna.

By being treated afterwards in the usual mode, the fracture was cured. But, in consequence of being over-stretched by the separation of the bones, the ligaments of the wrist became the seat of a tedious lymphatic swelling, which left behind it some degree of stiffness.

27. Examples of this kind occur too rarely to affect the general law relative to the direction of the displacement of a fractured radius, a displacement which, if not properly treated, makes the fragments unite in such a manner as to form an angle pointing inwardly towards the ulna, as is evinced by a perceptible depression under the cuticle. In such a case, from this contraction or narrowing of the interval between the bones, arise the inconveniencies already mentioned (9).

§ VIII.

OF THE SIGNS.

28. The diagnosis of fractures of the radius is in general easy, when they occur at the lower end, or in the middle (25). In these two cases, a depression more or less perceptible, on the external side of the fore-arm; an inability to perform pronation or supination, by the action of the muscles alone; and a severe pain, necessarily resulting from moving the bone in this two-fold direction. Such are the particular signs or appearances which first disclose the existence and the place of the fracture. The reality of the accident is afterwards more fully confirmed by the signs common to all fractures, namely, the flexibility of the bone, the crepitation perceived by moving it in different directions, &c.