BUFFALO MEDICAL JOURNAL VOL. LXVIII. AUGUST, 1912. Compound Fractures' By THEW WRIGHT, M.D. Attending Surgeon Emergency Hospital Assistant Surgeon Buffalo General, Erie County, and Children's Hospitals No. 1 Instead of taking up your time in the consideration of the popular surgical topics of the day, I am going to ask your attention for a few moments upon a subject as old as the art of surgery, as interesting as you choose to make it, and as important as any with which we are called upon to deal. I know of no branch of surgery in the practice of which versatility, ingenuity, conservatism, quick decision and good judgment are more essential to the securing of good results than in the treatment of compound fractures. To be sure these injuries have lost much of the dread with which they were viewed before the introduction of Lister's methods, when the sugeon's choice. lay between primary amputation and death from infection, and when primary amputation often failing to save life the mortality from compound fractures was between 40 and 50%. With the introduction of antiseptic methods the mortality decreased to less than 10%. But these injuries still remain, perhaps, the most important division of traumatic surgery. Compound fractures are defined in many ways. A satisfactory definition is that a compound fracture is one in which there is a more or less direct communication between the seat of fracture and the external air through a wound in the skin and soft parts. This communication may be brought about by the force which causes the fracture lacerating the soft parts on its way to reach the bone, or one of the fragments of the bone may produce the laceration. A fracture may be simple at first and become compound secondly, either by faulty handling allowing jagged bone ends to pierce the skin or by anything which will cause a dissolution of the continuity of the soft parts overlying the fracture, as for example the infection of a blister. Every step in the treatment of these injuries is of importance and in order that our discussion may follow in logical sequence 1. Read before the Central New York Medical Association, November 18, 1911, and he Erie County Medical Society, April 22, 1912. 277063 let us consider for a moment the question of "first aid." That is, what shall we do and what shall we not do if called to such a patient on the street in the factory or on the road. The clothing should be cut open with a knife or shears so that it may be readily removed without being rubbed and dragged across the site of injury, thereby adding to the probability of infection. A compound fracture may be considered as an infected wound in practically every instance. It was this fact of the presence of infection of course which made these injuries so formidable in the preantiseptic era. But care must be taken not to add to the infection already present. After the wound is exposed it should be covered with sterile gauze, if such is at hand, or if that is lacking, with the cleanest available cloth, which should be snugly bandaged in place. Should severe hemorrhage persist in spite of this, it may be necessary to apply a tourniquet. The extremity, if it be one, should now be immobilized in a pillow, blanket or board splint, usually without attempt to correct the deformity which may be present and always without such attempt if a fragment of bone is protruding from the wound. The reduction of such a fragment before it is thoroughly cleaned may readily cause the introduction of infectious material into an otherwise comparatively clean wound. There should be no handling of the wound at this time and the immobilization should be so complete that there is the least possible disturbance to the injured part during transportation to the patient's house, the doctor's office or, what is always the best place for such injuries, the hospital. If the fracture be of an extremity, the first question that arises is, can the limb be saved or will it require amputation? This is a question that often cannot be answered at this time. I have seen limbs apparently hopelessly crushed which were saved and ultimately restored to usefulness. Unless the force which caused the fracture has cut off all the principal arteries supplying the part, I believe a primary amputation is never justifiable and that in the vast majority of cases, with proper treatment, the part will be saved. I have never primarily amputated an extremity in which there was any demonstrable arterial circulation and altho a subsequent amputation has been required in some cases, there have been enough instances in which this was not the case, that I feel that we cannot easily be too conservative in the matter. If the points upon which I shall touch are carefully carried out we have very little to lose by conservatism and usually much to gain. To be sure there are cases of compound comminuted fractures, especially of the foot and ankle, where we can be sure that even though the part be saved the best possible outcome, even after months of treatment, would leave a member so distorted and deformed as to be no better than an artificial limb. In such a case primary amputation should be done. This will be more often justifiable in the leg than in the forearm, for the loss of the hand is a far more serious matter than that of a foot in these days of excellent, prosthetic work and it is justifiable to run great risks in the effort to save it. Having decided against amputation the next step is to render the injured part as nearly sterile as possible. This to my mind always means the administration of a general anesthetic, unless we are dealing with a fracture of a phalanx, in which case local anesthesia either by immersing the part in warm carbolic solution or by injecting cocaine will often. suffice. The thorough cleansing and primary dressing of a compound fracture of a large bone can only be properly carried out with the patient asleep. Ether, always the safest anaesthetic, is especially indicated in this class of cases where preliminary preparation is impossible. As to our method of attempting to sterilize the injured parts I feel we can not be too dogmatic in our statements. I feel that here, as in other fields of surgery, we must suit our methods to the individual case at hand. The man who says he always does this or always does that will ofttimes err, not in judgment for the very fact that he always follows a routine precludes the use of judgment. Right here in the choice of methods of sterilizing the wound we are called upon to exercise most careful judgment. There are men who say, always scrub the skin thoroughly with soap and water, then scrub the wound in the same manner. Others say, never scrub either one or the other, but rely upon our best antiseptic iodine to sterilize. In deciding the method to be used we must take into consideration the way in which the compound element of the fracture was produced as well as the extent of the laceration of soft parts. If the lesion to the soft parts was produced from without inward we have certain infection of the wound, the extent of which varies with the amount of foreign matter carried into it. If the wound was made by the protrusion of the bone end we have probably no infection in the wound and if we can thoroughly disinfect the surrounding skin, and the bone end before replacing it we will have none at any time. In this latter class of cases the best results will be obtained by cleansing the surrounding skin with gasoline and then applying iodine, treating the protruding bone end in the same manner. If we find dirt ground into the bone end, and this cannot be easily removed, it will be wise to clip or rongeur away the soiled surface and |