Part 45

Symptoms.—Some of these fractures are easily recognized, while others are difficult to identify. The ordinary deformity which characterizes a fracture of the external angle of the ilium, its dropping and the diminution of that side of the hip in width, unite in indicating the existence of the condition expressed by the term "hipped." An incomplete fracture, however, or one that is complete without displacement, or even one with displacement, often demands the closest scrutiny for its discovery. The lameness may be well marked, and an animal may show it but little while walking, though upon being urged into a trot will manifest it more and more, until presently it will cease to use the crippled limb altogether, and travel entirely on three legs. The acute character of the lameness will vary in degree as the seat of the lesion approximates the acetabulum. In walking, the motion at the hip is very limited, and the leg is dragged; while at rest it is relieved from bearing its share in sustaining the body. An intelligent opinion and correct conclusion will depend largely upon a knowledge of the history of the case, and while in some instances that will be but a report of the common etiology of fractures, such as blows, hurts, and other external violence, the simple fact of a fall may furnish in a single word a satisfactory solution of the whole matter.

With the exception of the deformity of the ilium in a fracture of its external angle, and unless there has been a serious laceration of tissues and infiltration of blood, or excessive displacement, there are no very definite external symptoms in a case of a fracture of the hip bone. There is one, however, which, in a majority of cases, will not fail—it is crepitation. This evidence is attainable by both external and internal examination—by manipulation of the gluteal surface and by rectal taxis. Very often a lateral motion, or balancing of the hinder parts by pressing the body from one side to the other, will be sufficient to render the crepitation more distinct—a slight sensation of grating, which may be perceived even through the thick coating of muscle which covers the bone—and the sensation may not only be felt, but to the expert may even become audible. This external manifestation is, however, not always sufficient in itself, and should invariably be associated with the rectal taxis for corroboration. It is true that this may fail to add to the evidence of fracture, but till then the simple testimony afforded by the detection of crepitation from the surface, though a strong confirmatory point, is scarcely sufficiently absolute to establish more than a reasonable probability or strong suspicion in the case.

In addition to the fact that the rectal examination brings the exploring hand of the surgeon into near proximity to the desired point of search, and to an accurate knowledge of the situation of parts, both pro and con as respects his own views, there is another advantage attendant upon it which is well entitled to appreciation. This is the facility with which he can avail himself of the help of an assistant, who can aid him by manipulating the implicated limb and placing it in various positions, so far as the patient will permit, while the surgeon himself is making explorations and studying the effect from within. By this method he can hardly fail to ascertain the character of the fracture and the condition of the bony ends. By the rectal taxis, as if with eyes in the finger ends, he will "see" what is the extent of the fracture of the ilium or of the neck of that bone; to what part of the central portion of the bone (the acetabulum) it reaches; whether this is free from disease or not, and in what location on the floor of the pelvis the lesion is situated. By this method we have frequently been able to detect a fracture at the symphysis, which, from its history and symptoms and an external examination, could only have been guessed at. Yet, with all its advantages, the rectal examination is not always necessary, as, for example, when the fracture is at the posterior and external angle of the ischium, when by friction of the bony ends the surgeon may discern the crepitation without it.

Every variety of complication, including muscular lacerations with the formation of deep abscesses and injuries to the organs of the pelvic cavity, the bladder, the rectum, and the uterus, may be associated with fractures of the hip bone.

Prognosis.—The prognosis of these lesions will necessarily vary considerably. A fracture of the most superficial part of the bone of the ilium or of the ischium, especially if there is little displacement, will unite rapidly, leaving a comparatively sound animal often quite free from subsequent lameness. If there is much displacement, however, only a ligamentous union will take place, with much deformity and more or less irregularity in the gait. Other fractures may be followed by complete disability of the patient, as, for example, when the cotyloid cavity is involved, or when the reparatory process has left bony deposits in the pelvic cavity at the seat of the union, which may, in the case of the female, interfere with the steps of parturition, or induce some local paralysis by pressure upon the nerves which govern the muscles of the hind legs. This is a condition not infrequently observed when the callus has been formed on the floor of the pelvis near the obturator foramen, pressing upon the course or involving the obturator nerve.

Treatment.—In our estimation, the treatment of all fractures of the hip bone should be of the simplest kind. Rendered comparatively immovable by the thickness of the muscles by which the region is enveloped, one essential indication suggests itself, and that is to place the animal in a position which, so far as possible, will be fixed and permanent. For the accomplishment of this purpose the best measure, as we consider it, is to place the horse in a stall of just sufficient width to admit him, and to apply a set of slings, snugly, but comfortably. (See Plate XXXI.) This will fulfill the essential conditions of recovery—rest and immobility. Blistering applications would be injurious, though the adhesive mixture might prove in some degree beneficial.

The minimum period allowable for solid union in a fractured hip is, in our judgment, two months, and we have known cases in which that was too short a time.

As we have said before, there may be cases in which the treatment for fracture at the floor of the pelvis has been followed by symptoms of partial paralysis, the animal, when lying down, being unable to regain his feet, but moving freely when placed in an upright position. This condition is owing to the interference of the callus with the functions of the obturator nerve, which it presses upon or surrounds. By my experience in similar cases I feel warranted in cautioning owners of horses in this condition to exercise due patience, and to avoid a premature sentence of condemnation against their invalid servants; they are not all irrecoverably paralytic. With alternations of moderate exercise, rest in the slings, and the effect of time while the natural process of absorption is taking effect upon the callus, with other elements of change that may be so operating, the horse in due time may become able once more to earn his subsistence and serve his master.

FRACTURE OF THE SCAPULA.

This bone is seldom fractured, its comparative exemption being due to its free mobility and the protection it receives from the superimposed soft tissues. Only direct and powerful causes are sufficient to effect the injury, and when it occurs the large rather than the smaller animals are the subjects.

Cause.—The causes are heavy blows or kicks and violent collisions with unyielding objects. Those which are occasioned by falls are generally at the neck of the bone, and of the transverse and comminuted varieties.

Symptoms.—The diagnosis is not always easy. The symptoms are inability to rest the leg on the ground and to carry weights, and they are present in various degrees from slight to severe. The leg rests upon the toe, seems shortened, and locomotion is performed by jumps. Moving the leg while examining it and raising the foot for inspection seem to produce much pain and cause the animal to rear. Crepitation is readily felt with the hand upon the shoulder when the leg is moved. If the fracture occurs in the upper part of the bone, overlapping of the fragments and displacement will be considerable.

The fracture of this bone is usually classed among the more serious accidents, though cases may occur which are followed by recovery without very serious ultimate results, especially when the seat of the injury is at some of the upper angles of the bone or about the acromion crest. But if the neck and the joint are the parts involved, complications which are likely to disable the animal for life are liable to be present.

Treatment.—If there is no displacement, a simple adhesive dressing to strengthen and immobilize the parts will be sufficient. A coat of black pitch dissolved with wax and Venice turpentine, and kept in place over the region with oakum or linen bands, will be all the treatment required, especially if the animal is kept quiet in the slings.

Displacement can not be remedied, and reduction is next to impossible. Sometimes an iron plate is applied over the parts and retained by bandages, as in the dressing of Bourgelat (Plate XXX); this may be advantageously replaced by a pad of thick leather. In smaller animals the parts are retained by figure-8 bandages, embracing both the normal and the diseased shoulders, crossing each other in the axilla and covered with a coating of adhesive mixture.

FRACTURES OF THE HUMERUS.

These are more common in small than in large animals, and are always the result of external traumatism, such as falls, kicks, and collisions. They are generally very oblique, are often comminuted, and though more usually involving the shaft of the bone will in some cases extend to the upper end and into the articular head.

Symptoms.—There is ordinarily considerable displacement in consequence of the overlapping of the broken ends of the bone, and this of course causes more or less shortening of the limb. There will also be swelling, with difficulty of locomotion, and crepitation will be easy of detection. This fracture is always a serious damage to the patient, leaving him with a permanently shortened limb and an incurable, lifelong lameness.

Treatment.—If treatment is determined on, it will consist in the reduction of the fracture by means of extension and counter extension, to accomplish which the animal must be thrown. If successful in the reduction, then follows the application and adjustment of the apparatus of retention, which must be of the most perfect and efficient kind. Finally, this, however skillfully contrived and carefully adapted, will often fail to effect any good purpose whatever.

FRACTURES OF THE FOREARM.

A fracture in this region may also involve the radius or the ulna, the latter being broken at times in its upper portion above the radio-ulnar arch at the olecranon. If the fracture occurs at any part of the forearm from the radio-ulnar arch down to the knee, it may involve either the radius alone or the radius and the cubitus, which are there intimately united.

Cause.—Besides having the same etiology with most of the fractures, those of the forearm are, nevertheless, more commonly due to kicks from other animals, especially when crowded together in large numbers in insufficient space. It is a matter of observation that under these circumstances fractures of the incomplete kind are those which occur on the inside of the leg, the bone being in that region almost entirely subcutaneous, while those of the complete class are either oblique or transverse. The least common are the longitudinal, in the long axis of the bone.

Symptoms.—This variety of fracture is easily recognized by the appearance of the leg and the different changes it undergoes. There is inability to use the limb; impossibility of locomotion; mobility below the injury; the ready detection of crepitation—in a word, the assemblage of all the signs and symptoms which have been already considered as associated with the history of broken bones.

The fracture of the ulna alone, principally above the radio-ulnar arch, may be ascertained by the aggravated lameness, the excessive soreness on pressure, and perhaps a certain increase of motion, with a very slight crepitation if tested in the usual way. Displacement is not likely to take place except when it is well up toward the olecranon or its tuberosity, the upper segment of the bone being in that case likely to be drawn upward. For a simple fracture of this region there is a fair chance of recovery, but in a case of the compound and comminuted class there is less ground for a favorable prognosis, especially if the elbow joint has suffered injury. A fracture of the ulna alone is not of serious importance, except when the same conditions prevail. A fracture of the olecranon is less amenable to treatment, and promises little better than a ligamentous union.

Treatment.—Considering all the various conditions involving the nature and extent of these lesions, the position and direction of the bones of the forearm are such as to render the chances for recovery from fracture as among the best. The reduction, by extension and counterextension; the maintenance of the coaptation of the segments; the adaptation of the dressing by splints, oakum, and agglutinative mixtures; in fact, all the details of treatment may be here fulfilled with a degree of facility and precision not attainable in any other part of the organism. An important, if not an essential, point, however, must be emphasized in regard to the splints. Whether they are of metal, wood, or other material, they should reach from the elbow joint to the ground, and should be placed on the posterior face and on both sides of the leg. This is then to be so confined in a properly constructed box as to preclude all possibility of motion, while yet it must sustain a certain portion of the weight of the body. The iron splint (represented in Plate XXX) recommended by Bourgelat is designed for fractures of the forearm, of the knee, and of the cannon bone, and will prove to be an appliance of great value. For small animals the preference is for an external covering of gutta-percha, embracing the entire leg. A sheet of this substance of suitable thickness, according to the size of the animal, softened in lukewarm water, is, when sufficiently pliable, molded on the outside of the leg, and when suddenly hardened by the application of cold water forms a complete casing sufficiently rigid to resist all motion. Patients treated in this manner have been able to use the limb freely, without pain, immediately after the application of the dressing. The removal of the splint is easily effected by cutting it away, either wholly or in sections, after softening it by immersing the leg in a warm bath.

FRACTURE OF THE KNEE.

This accident, happily, is of rare occurrence, but when it takes place is of a severe character, and always accompanied with synovitis, with disease of the joint.

Cause.—It may be caused by falling upon a hard surface, and is usually compound and comminuted. Healing seldom occurs, and when it does there is usually a stiffness of the joint from arthritis.

Symptoms.—As a result of this fracture there is inability to bear weight on the foot. The leg is flexed as in complete radial paralysis, or fracture of the ulna. There is abnormal mobility of the bones of the knee, but crepitation is usually absent.

Prognosis.—Healing is hard to effect, as one part of the knee is drawn upward by the two flexor muscles which separate it from the lower part. The callus which forms is largely fibrous, and if the animal is put to work too quickly this callus is liable to rupture. In favorable cases healing takes place in two or three months. Many horses during the treatment develop founder, with consequent drop sole in the sound leg, as a result of pressure due to continuous standing.

Treatment.—Place the animal in the slings, bring the pieces of bone together if possible, and try to keep them in place by a tight plaster-of-Paris dressing about the leg, extending down to the fetlock. Place the animal in a roomy box stall well provided with bedding so that he can lie down, to prevent founder.

FRACTURE OF THE FEMUR.

The protection which this bone receives from the large mass of muscles in which it is enveloped does not suffice to invest it with immunity in regard to fractures.

Cause.—It contributes its share to the list of accidents of this description, sometimes in consequence of external violence and sometimes as the result of muscular contraction; sometimes it takes place at the upper extremity of the bone; sometimes at the lower; sometimes at the head, when the condyles become implicated; but it is principally found in the body or diaphysis. The fracture may be of any of the ordinary forms, simple or compound, complete or incomplete, transverse or oblique, etc. A case of the comminuted variety is recorded in which 85 fragments of bone were counted and removed.

The thickness of the muscular covering sometimes renders the diagnosis difficult by interfering with the manipulation, but the crepitation test is readily available, even when the swelling is considerable, and which is liable to be the case as the result of the interstitial hemorrhage which naturally follows the laceration of the blood vessels of the region involved.

Symptoms.—If the fracture is at the neck of the bone the muscles of that region (the gluteal) are firmly contracted, and the leg seems to be shortened in consequence. Locomotion is impossible. There is intense pain and violent sweating at first. Crepitation may in some cases be discerned by rectal examination, with one hand resting over the coxo-femoral (hip) articulation. Fractures of the tuberosities of the upper end of the bone, the great trochanter, may be identified by the deformity, the swelling, the impossibility of rotation, and the dragging of the leg in walking. Fracture of the body is always accompanied with displacement, and as a consequence a shortening of the leg, which is carried forward. The lameness is excessive, the foot being moved, both when raising it from the ground and when setting it down, very timidly and cautiously. The manipulations for the discovery of crepitation always cause much pain. Lesions of the lower end of the bone are more difficult to diagnosticate with certainty, though the manifestation of pain while making heavy pressure upon the condyles will be so marked that only crepitation will be needed to turn a suspicion into a certainty.

Treatment.—The question as to treatment in fractures of this description resolves itself into the query whether any treatment can be suggested that will avail anything practically as a curative measure; whether, upon the hypothesis of reduction as an accomplished fact, any permanent or efficient device as a means of retention is within the scope of human ingenuity. If the reduction were successfully performed, would it be possible to keep the parts in place by any known means at our disposal? At the best the most favorable result that could be anticipated would be a reunion of the fragments with a considerable shortening of the bone and a helpless, limping, crippled animal to remind us that for human achievement there is a "thus far and no farther."

In small animals, such as dogs and cats, however, attempts at treatment are justifiable, and we are convinced that in many cases of difficulty in the application of splints and bandages a patient may be placed in a condition of undisturbed quiet and left to the processes of nature for "treatment" as safely and with as good an assurance of a favorable result as if he had been subjected to the most heroic secundum artem doctoring known to science. As a case in point, mention may be made of the case of a pregnant bitch which suffered a fracture of the upper end of the femur by being run over by a light wagon. Her "treatment" consisted in being tied up in a large box and let alone. In due time she was delivered of a family of puppies, and in three weeks she was running in the streets, limping very slightly, and nothing the worse for her accident.

FRACTURE OF THE PATELLA.

This, fortunately, is a rare accident, and can result only from direct violence, as a kick or other blow. The lameness which follows it is accompanied with enormous tumefaction of the joint, pain, inability to bear weight upon the foot, and finally disease of the articulation. Crepitation is absent, because the hip muscles draw away the upper part of the bone. The prognosis is unavoidably adverse, destruction being the only termination of this incurable and very painful injury. Most of the reported cases of cures are based upon a wrong diagnosis.