(From frango, to break). Catagma; classis; clasma; agme. A fracture. Dr. Cullen places this genus of disease in the class locales, and order dialyses; and defines it part of a bone having its cohesion destroyed by violence, and separated into large fragments.
Fractures are differently denominated, according to their direction; as a transverse, oblique, or longitudinal fracture. When one bone is broken in one place only, and no remarkable injury is perceived in the adjacent parts, it is called a simple fracture: when a bone is broken in more parts than one, or when two bones that are joined together, as the radius and ulna, are both broken, it was formerly called a compound fracture; but the term is now confined to those fractures in which the external integuments are penetrated by the end of the fractured bone. If with a fracture there is a dislocation, or a wound, it is then a complicated fracture. In fractures, the reunion of the separate parts of the bone is by a renewal of the organical bony substance, and not by a glutinous matter, which hardens into what is called callus.
Fractures are discovered by the eye, the ear, and touch. The period in which the reunion may take place is influenced by the constitution, and many different circumstances. In pregnant women, a cure is sometimes not effected until after delivery; see London Medical Observations and Inquiries, vol. iv. and Hildanus mentions three cases of this kind: but the reunion sometimes takes place even in these circumstances. A scorbutic or a venereal taint may prevent the bone from healing, or a caries may retard the union; if a wasting of the limb, or a palsy, comes on, the cure will be slow, if ever effected. If a fracture happens in a bone over which an ulcer hath long continued, it is very difficultly united. A fracture in the cranium, vertebrae, ribs, sternum, os ilium, or os pubis, is dangerous, on account of the vicinity of the brain, spinal marrow, or other viscera.
If called after the tumour or a violent inflammation be come on, the extension must be deferred until these are removed; but if these symptoms are slight, reducing the limb may prevent their increase. If there is a wound, all extraneous matters should be removed at the first dressing, and all strictures lessened; if the wound is too small, it should be dilated; and, if possible, this should be done before inflammation comes on, as the parts are then more sensible; and if it can be effected without altering the relaxed state of the limb, a circumstance of such importance that hardly any thing should interfere with it, the dilatation should be made so that the discharge may be depending. Indeed, every means of preventing the matter accumulating in a depending part should be avoided. If a bone protrudes, a portion should be sawed off, unless it can be easily reduced; an operation but little troublesome. If a luxation accompanies a fracture, it should first be reduced, and afterwards the fractured bones replaced, though, if the fracture be very near the head of the luxated bone, the luxation may be left till the fracture is healed. When a simple fracture happens, the bones should be replaced, and the limb laid in an easy slate, slightly bent: the reduction was called by the Greeks ca-thidrusis. A cataplasm of oatmeal, oil, and vinegar, or, as a substitute, a plaster of ceratum album, should be next applied. The bandage with eighteen tails is the best, both in simple and compound fractures; it is more commodious than the roller, as it allows of viewing the limb without disturbing it. At the conclusion, if the leg is oedematous, cold pumping, the lace stockings and daily rubbing with a flannel, will restore the natural state of the limb.
Compound fractures are often attended with mortification; but this should not always hasten amputation. When any tendency to this symptom appears, a fomentation of a strong decoction of camomile flowers and wormwood, in which sal ammoniac has been dissolved, sprinkling the flannels with a strong camphorated spirit at the time of applying it, should be used. The wound should be dressed twice a day, the part wrapped up with a warm cataplasm, and bladders about one half full of warm water applied, to keep up a proper warmth. The bark joined with rhubarb, in some cases with nitre, and in others with opium, camphor, volatile alkali, and snake-root, should be given.
When amputation seems necessary, we should consider whether life will not be endangered if it is omitted. It is impossible in some instances to know immediately whether a limb can be saved. However, when a bone or bones are broken into many pieces, and to a considerable extent, as is frequently the case when the accident happens from cannon shot, broad wheels of carriages, etc. when the soft parts are so torn and bruised as to render a mortification of the part a probable and immediate consequence, amputation will be necessary without delay. If the ends of a bone, or two bones, by which a joint is formed, be crushed, and its ligaments considerably injured, amputation cannot with propriety be deferred. Some instances of compound fractures also require speedy amputation; for an inflammation seizing the limb tends quickly to gangrene, and the progress is usually rapid. Instead, therefore, of waiting for a separation of the mortified from the sound part, or to try what art can effect, the operation is immediately necessary. A very short time makes all the difference between probable safety and death. If in a compound fracture this inflammation hath taken place, and hath continued some hours, amputation would destroy; and the only chance is to use such regimen as appears to be indicated; and when this has no further use, then to support the patients with cordials, wine, and bark. Again, inflammation may not run high; yet frequently there are collections of matter, which after several openings recur: the patient, instead of being recruited, wastes by the discharge, hath night-sweats, loses his appetite and strength. In these cases the bones continue disunited, and amputation at last is necessary. Mr. Pott observes, that in compound fractures there are three points of time in which amputation may be requisite. 1st, Immediately, or as soon as possible after receiving the injury; 2d, when the bones continue long without any disposition to unite, and the patient's strength failing from the discharge, death apparently impends; 3d, when a mortification shall have taken such complete possession of the inferior part of the limb, down to the bone, that, upon separation of their parts, the bone or bones would be left bare in the intermediate space. The necessity of early amputation in these cases arises from the ill effects of a greatly obstructed circulation, from the destruction of numerous vessels. The pain, irritation, and the admission of air, also produce consi-derable fever and inflammation, which quickly terminate in gangrene and death. If a joint is injured, the danger is increased; as the pain and irritation, with the subsequent inflammation, from the admission of air into the cavity, are greater. If possible, then, the operation should be determined' on before inflammation approaches; for, if this has taken place, it will be too late. In the second instance, the particular time for amputation must be determined by the patient or his friends; for, with the surgeon, it is not choice, but necessity. In the third instance, the time requires no consideration; for if the soft parts are destroyed, either the surgeon must saw the bones, or they must be left to separate. In either case the patient loses his limb. These are some of the principal instances which determine in favour of amputation; experience, and the several authors who have written on this subject, will suggest others, and amongst these may be consulted Pott's Works, with his pamphlet entitled Remarks on the Necessity, & c. of Amputation in certain Cases; Gooch's Works; Observations on Mr. Pott's General Remarks on Fractures, by Thomas Kirkland, Surgeon; and the Systems of Surgery, by Bell, Dease, Kirkland, etc.