Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.Thomson, Alexis
Science
Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.
Thomson, Alexis
Surgery
_Unnatural mobility_--that is, movement between two segments of a limb
at a place where movement does not normally occur--may be evident when
the patient makes attempts to use his limb, or may only be elicited
when the fragments are seized and moved in opposite directions.
_Deformity_, or the part being "out of drawing" in comparison with the
normal side, varies with the site and direction of the break, and
depends upon the degree of displacement of the fragments. _Crepitus_
is the name applied to the peculiar grating or clicking which may be
heard or felt when the fractured surfaces are brought into contact
with one another.
The presence of these three signs in association is sufficient to
prove the existence of a fracture, but the absence of one or more of
them does not negative this diagnosis. There are certain fallacies to
be guarded against. For example, a fracture may exist and yet
unnatural mobility may not be present, because the bones are impacted
into one another, or because the fracture is an incomplete one. Again,
the extreme tension of the swollen tissues overlying the fracture may
prevent the recognition of movement between the fragments. Deformity
also may be absent--as, for instance, when there is no displacement of
the fragments, or when only one of two parallel bones is broken, as in
the leg or forearm. Similarly, crepitus may be absent when impaction
exists, when the fragments completely override one another, or are
separated by an interval, or when soft tissues, such as torn
periosteum or muscle, are interposed between them. A sensation
simulating crepitus may be felt on palpating a part into which blood
has been extravasated, or which is the seat of subcutaneous emphysema.
The creaking which accompanies movements in certain forms of
teno-synovitis and chronic joint disease, and the rubbing of the
dislocated end of a bone against the tissues amongst which it lies,
may also be mistaken for the crepitus of fracture.
It is not advisable to be too diligent in eliciting these signs,
because of the pain caused by the manipulations, and also because
vigorous handling may do harm by undoing impaction, causing damage to
soft parts or producing displacement which does not already exist, or
by converting a simple into a compound fracture.
It is often necessary for purposes of diagnosis to administer a
general anæsthetic, particularly in injuries of deeply placed bones
and in the vicinity of joints. Before doing so, the appliances
necessary for the treatment of the injury should be made ready, in
order that the fracture may be reduced and set before the patient
regains consciousness.
_Radiography in the Diagnosis of Fractures._--While radiography is of
inestimable value in the diagnosis of many fractures and other
injuries, particularly in the vicinity of joints, the student is
warned against relying too implicitly on the evidence it seems to
afford.
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