Fracture, in surgery, a disruption or separation between the parts of a bone or cartilage, produced by external violence or the sudden and forcible contraction of muscles. The fracture is said to be simple when there is no external wound; compound when complicated with lesion of the surrounding soft parts; and comminuted when the bone is broken into many fragments. Fractures may occur at any time from the end of intra-uterine life to extreme old age; in youth, fractures are comparatively rare on account of the elasticity of the bones, and in advanced life common from their brittleness. Ruptures of vessels and nerves are the most dangerous complications of fractures of the extremities; gangrene is often the consequence of the former, and paralysis, convulsions, or intense pain and inflammation, of the latter; comminuted fracture is very apt to be followed by tedious suppuration, necrosis, false joint, or much shortened limb; dislocation also is not unfre-quently added to fracture. Fractures may be transverse or oblique; the former are most common in children, and are accompanied by little displacement; the latter are the most frequent, and often require all the surgeon's skill and sufferer's patience to effect permament reduction and prevent deformity of the limb.
The causes of displacement in the ends are muscular contractions and the weight of the fractured part; the lower fragment rides over the upper, sometimes to the extent of several inches. The bones most liable to fracture are the superficial ones, like the clavicle, tibia, and skull; or such as, like the radius in the forearm, are likely to receive the weight of the body during a fall; old age, caries, and cancerous, scorbutic, and venereal diseases, predispose to fracture. Violence applied to a part does not always produce a direct fracture; for instance, a fall upon the shoulder may indirectly break the clavicle; the kneepan and the olecranon are the bones most commonly broken by muscular action. The physiological symptoms of fracture are pain and inability to move the limb; the physical characters are unnatural mobility of the parts, change in the length, direction, or form of the limb, and crepitation when the broken fragments are moved upon each other. When there is great swelling, it is often difficult to ascertain the nature or even the existence of a fracture.
The course of a simple fracture is a painful and inflamed swelling a few days after the accident, with more or less febrile reaction; these gradually subside, and with proper treatment the bone unites in from one to two months, with or without deformity according to circumstances not always under the control of the surgeon; when the constitution is diseased, or the reparative process injudiciously interfered with, union may not take place and a false joint be formed. Complicated fractures often terminate in the death of portions of bone and of the soft parts, in unhealthy abscesses and tetanus, leading perhaps to fatal consequences unless the limb be removed. The prognosis of fracture of course depends on its situation, extent, complication with wounds, and a variety of circumstances which will occur to every physician. The process of reparation has been described in the article Bone (vol. iii., p. 6l), and it will only be necessary to say here that lymph is effused between the broken surfaces, which is gradually converted into cartilage, and in a few weeks into a spongy ossific mass called the provisional callus; this holds the ends together for a few months until the permanent callus is deposited between them; the former is gradually absorbed, and the latter has all the characters of true bone.
In the interior of the skull, however, and in the cavities of the synovial membranes of the joints, no provisional callus is formed; if the parts be kept in close apposition, bony union will slowly take place; if not, the union will be ligamentary. The indications of treatment are to reduce or set the fragments, and keep them at rest and in close contact, so as to prevent deformity; all disturbing muscles must be relaxed, the ends of the bones extended, and the parts properly supported and kept in place; the limb is bandaged, and some kind of splint or apparatus is applied to keep it immovable and of its natural length. Splints are made of wood, pasteboard, tin, and more recently and best of gutta perch a, all properly padded and secured against displacement; the starched bandage, consisting of layers of cloth imbued with starch or dextrine, is light, firm, and capable of very exact application; a plaster of Paris apparatus has been much used in Germany, especially for intractable persons and on the field of battle. When swelling and inflammation run high, antiphlogistic and refrigerant applications should precede the use of bandages and splints; and the latter when applied should be loosened when swelling comes on, and afterward readjusted so as to keep the parts uniformly in ' place.
The variety of bandages, splints, and apparatus for the different kinds of fractures is very great; and in nothing does American surgery stand more preeminent than in its ingenious and effectual instruments for the treatment of broken bones. The accompanying symptoms of depression, inflammation, delirium, painful twitchings of muscles, and other complications, must be treated on principles familiar to every surgeon. When a false joint is produced, attempts at union are made by exciting inflammation in the separated pieces by rubbing, the seton, sawing off the ends, and other operations now in vogue; care being taken at the same time to strengthen the patient, and to correct any evident constitutional vice. In compound fractures, especially the severe ones from railroad accidents, the question of amputation is frequently a most difficult one to resolve; much depends on the strength, habits, and age of the patient, the degree of laceration, the proximity to joints, and the injury to vessels and nerves; if the operation be decided on, it is generally performed at once, before the accession of inflammatory fever.
If it be determined to retain the limb, the bone should be reduced to its natural position, loose pieces removed, and the necessary applications be made to induce the wounds to heal; in proper time bandages and splints should be applied; cooling lotions, opium to quiet pain and restlessness, prevention of lodgment of matter, tonics and stimulants to support the strength under profuse discharges, are the additional general indications of treatment.