FRACTURES E. H. HAMBLY

I.-Dislocation of shoulder-joint with fracture ofgreater tuberosity of Humerus.

...... -,...

2 and 3.-Fracturcs of the seca-phoid, undiagnosed at time ofinj ury. Bilateral and un-united.

::: ...-....,,,. ..,

4 and 5.-Trans-scapho-perilunar dislocation. This case wasfirst treated merely as a fracture of the scaphoid. Thelateral view shows the Os Magnum displaced behind thesemilunar bone.

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FRACTURES E. H. HAMBLY

6.-Fissure fracture of head of radius.

........

7.-Fracture of mid-shafts of radius and ulna.This type should be plastered from knucklesto axilla.

*. :.:...... ......::..:

....

8.-Fracture of lower third of shaft of humerus. 9.-Fracture of mid-shaft of tibia. This typeshould be plastered from toes to upper thigh.

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FRACTURES E. H. HAMBLY

t...

io.-Monteggia fracture-dislocation of shaft of ulna plus head of radius (withmyositis ossificans).

.;

iI -Inter-trochanteric fracture of the femur with secondarycoxa vara.

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128 POST-GRADUATE MEDICAL JOURNAL April, I945Case IV (J.T., aged 47).

Admitted to Stoke' Mandeville Hospital 24th July1942. In January I942, during an epileptic fit, he fellinto the kitchen fire and sustained full-thickness burns ofthe right cheek, lower eyelid, and deep partial-thicknessburns of the upper eyelid and right side of the forehead.He was treated by local dressings (details unknown),and allowed to heal by scar tissue formation with resultantsevere ectropion of the right lower eyelid and a markedectropion of the lower lip. There was a marked rightcorneal opacity.The ectropion was corrected by freeing the lower eyelid

into an over-corrected position, followed by the applica-tion of a Thiersch graft. Further work on the lips andcheeks was postponed for domestic reasons but could notbe carried out because death followed a fall into his bathduring another fit.Comment: Corneal opacity resulting from neglected

ectropion-a condition which should be prevented bygrafting at the earliest possible opportunity.

Case V (T.B., aged 6).Admitted to Stoke Mandeville Hospital igth January,

I 943. On 7th August, 1942, whilst playing with matches,his clothing caught fire as a result of which he receivedextensive burns of both upper limbs, right side of faceand neck, and the right chest wall. All areas were treatedat his local hospital with gentian violet and he was dis-charged five months later with the severe scar contracturesseen in the illustrations.

Of these the neck scar received primary attentionbecause if left it would interfere with the development ofthe mandible. These scars were divided, all deep scartissue removed, and the wound opened out to the fullestextent. Free grafts were applied, and the patient placedin a previously prepared posterior plaster shell.

Later the flexure contracture of the elbow and adductioncontracture of the axilla were corrected in the same manner,the limb being placed vertically above the head by meansof plaster splints.

All these grafts took well, resulting in a full recoveryof function in all joints, except for a few degrees limitationof extension of the neck.Comment: An example of the correction of scar con-

tracture by free grafts. These burns known to be deepat the time of injury should have been treated by graftingwithin two or three weeks during the original treatment;the contractures could have been foreseen and prevented.

I am deeply indebted to all the members of my team atthe County Hospital, Whiston, and particularly to Pro-fessor T. Pomfret Kilner for his constant encouragementand helpful criticism.

REFERENCESACKMAN, D. et al (I944), Annals of Surgery, 119, i6i.ALDRICH, R. H. (I933), New Eng. Journ. Med., 208, 299.ALDRICH, R. H. (I937), New Eng. Journ. Med., 217, 9II.ALLEN, H. S. and KOCH, S. L. (I942), Surg. Gynae and Obstet.,74, 924.BATTLE, R. J. V. (I944), Personal Communication.BARNES AND TRUETA (I941), Lancet, 1, 623.BERKOW, S. E. (1924), Arch. Surg., 8, 138.BLACK, D. A. K. (I940), Brit. Med. Journ., 2, 693.BODENHAM, D. C. (1943), Lancet, 2, 725.BROWN, J. B. and McDOWELL, F. (I943), Skin Grafting of Burns

(J. B. Lippincott).BUNYAN, J. (I940), Proc. Roy. Soc. Med., 34, 23.BUNYAN, J. (I94I), Brit. Med. Journ., 2, I.CLOWES, G. H. A. et al (I943), Annals of Surgery, 118, 76I.COLEBROOK, L. (1944), Brit. Med. Journ. 1, 342.CONNOR, G. J. and HARVEY, S. C. (I944), Annals of Surgery, 120, 361.DAVIDSON, E. C. (I925), Surg. Gynae and Obstet., 41, 202.DINGWALL, J. A. (I943), Annals of Surgery, 118, 427.DOUGLAS, B. (I936), Journ. Tennessee M.A., 29, i6o.DOUGLAS, B. (I939), Amer. Journ. Surg., 43, 2.DOUGLAS, B. (I939), South Med. Journ., 32, I2.DOUGLAS, B. (I944), Surgery, 15, 96.

ELKINTON, J. R., WOLF, W. A., and LEE, W. E. (I940), Annals ofSurgery, 112, 150.

ERB, I. H. et al (I943), Annals of Surgery, 117, 234.GABARRO, P. (1943), Brit, Med. Journ., 1, 723.GOLDBERG, H. M. (I944), Lancet, 1, 37I.GORDON, R. A. (I943), Canad. M.Ass.J., 49,478.FLEET, G. A. and ACKMAN, F. D. (I944), Canad.M.Ass.J., 2, Iog.-HARKINS, H. N. et al (1940), Surg., Gynae and Obstet., 4, 4IO.HANNAY, J. W. (I94I), Brit. Med. Journ., 2, 4.HUDSON, R. V. (I94I), Brit. Med. Journ., 2, 7.LEE, W. E., WOLFF, W. A. et al (I942), Annals of Surgery, 115, II3I.LEVENSON, S. M., and LUND, C. C. (I943), Journ. Amer. Med. Assoc.,

5, 272.LEVITT, W. M., and GILLIES (I942), Lancet, 1, 440.McINDOE, A. H. (I940), Proc. Roy. Soc. Med., 34, 56.MITCHENER, P. H. (1933), Brit. Med. Journ., 1, 447.MOWLEM, R. (194I), Proc. Roy. Soc. Med., 34, 22I.MULHOLLAND, J. H. et al (I943), Annals of Surgery, 118, IOI5.OLSON, W. H., and NECHELES (1943), Amer. Joutrn. Physiol., 139, 574.OSBORNE, R. P. (I944) Brit. Journ. Surg., 125, 24.PADGETT, E. C. (I942), Skin Grafting (BailliUre, Tindall and Cox).PEARSON, B. P. et al (I94I), Brit. Med. Journ., 2, 4I.RAVDIN, I. S. (I940), Annals of Surgery, 112, 576.SILER, V. E., and REID, M. R. (I942), Annals of Surgery, 115, IIo6.TAYLOR, F. H. L. et al (1943), Annals of Surgery, 118, 2I5.WELLS, D. B., et al (I942), New Eng. Journ. Med., 26, 629.WILSON, W. C. (I929), Med. Research Counc., No. I4I (H.M. Stationery

Office.)WHIPPLE, A. 0. (943), Annals of Surgery, 118, I87.WOLFF, W. A., and LEE, W. E. (I942), Annals of Surgery, 115, II25.

FRACTURES-PART -I

PRINCIPLES OF DIAGNOSISAND TREATMENT

by E. H. HAMBLY, F.R.C.S.(Surgeon E.M.S., Royal National Orthopaedic

Hospital, W.I)The knowledge and treatment of fractures has

progressed within the last decade almost beyondrecognition in certain branches of the subject.Side by side with this development on the medicalside there is growing in the minds of laymen andpatients alike a greater knowledge of the treatmentand attainable results. On the other hand, theclinician is greatly helped by the ever-growingvariety of radiological and therapeutic methodsavailable.

PRINCIPLES OF CLINICAL DIAGNOSISThe patient complains of pain, swelling, and

tenderness in the neighbourhood of a particularbone or joint.He frequently gives a clear history of an injury,

which he usually describes as a sprain. Thehistory may be misleading, inasmuch that, in anold fracture, the injury may have been forgotten.It is only too easy to accept the patient's history ofa sprain at its face value. Every sprain should beassumed to be a fracture until proved to the contraryby X-rays.On examination of the patient the following

points should be particularly noted. A generalexamination should always be made to exclude

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A 5ril. Io94 PRACTICALITIES 129

any predisposing causes of fracture, e.g.: primarycarcinoma of the breast with secondaries in thebone; Fragillitas Ossium, etc. The generalexaplination will furthermore take note of thecondition of the heart, lungs and kidneys. Suchfactors will have to be considered in the choiceof anaesthesia, and in the treatment generally.The local examination should be made with the

greatest care, both in regard to the examinationof physical signs and in preventing further injuryto the affected& part. .For example, the much-quoted elicitation of crepitus at the site of thefracture site causes both great pain to the patient,and may damage the fracture further as well as thesoft tissues. In any case it is unnecessary toelicit this physical sign.The affected region will be swollen, and warm to

the touch. The skin may be blistered and bruised.Blistering is most common in severe injuries of theelbow and ankle joint. Tenderness is most markedover the site of the fracture.

In the limbs deformity may or may not beobvious. Swelling often masks such a deformity.For example, in fractures of the nasal bones, theserious deformity is never apparent until a weekafter the injury owing to swelling. Inability touse the affected part is a most important clinicalsign, e.g. fracture of the neck of the femur causesinability to elevate the limb.Once the diagnosis of fracture is suspected,

examination is made for complications, e.g. incases of fracture-dislocation of the spine, evidenceof paralysis or loss of sensation in the lower limbsis looked for; in fractures of the shaft of the tibia,it should be noted whether the blood supply of thefoot is endangered.

PRINCIPLES OF RADIOLOGICAL DIAGNOSISEvery sprain should be assumed to be a fracture

until proved to the contrary by X-rays.Every fracture and dislocation, although the

diagnosis be obvious, should be X-rayed beforereduction. This is as essential on medical groundsas it is on legal grounds. See X-ray No. i.Every fracture and dislocation should be X-rayed

immediately after reduction, in the operating theatreif possible.

All fractures should be re-X-rayed at suitableintervals after reduction, e.g. usually after twoweeks, and again at suitable intervals until unionis obtained:

Certain common fractures present difficulties indiagnosis, even in the presence of good X-rays.Three such fractures are those of the carpal sca-phoid; first degree Pott's fracture-dislocation ofthe ankle; and fractures of the head of the radius.

In fractures of the carpal scaphoid there is ahistory of a sprained wrist. Actually, a simple

sprain of the wrist is very rare without an asso-ciated fracture of the lower end of the radius orof the scaphoid. See X-ray No. 2, 3, 4 and 5.The ordinary straight antero-posterior and

lateral X-rays of the scaphoid frequently fail toshow any evidence of fracture of the waist of thescaphoid. An oblique view should always be taken.Incidentally, the treatment of fracture of thescaphoid is immobilisation in plaster, with thethumb in abduction until union is secured. Thistakes from twelve weeks to two vears. The plastershould be taken to the metacarpo-phalangeal jointof the thumb, which should be at right-angles tothe plane of the palm.

First degree Pott's fracture-dislocations of theankle are worse in many ways than third degreeones. This is because the latter are obvious, bothclinically and radiologically, and are always treatedquite correctly as most serious injuries. A firstdegree Pott's fracture-dislocation, with a fractureof the external malleolus, is also very serious. Itis frequently not diagnosed, and, even when it is,treatment is frequently incorrect. Osteo-arthritiswith a painful ankle is only too common as alate result.

In a first degree Pott's fracture-dislocation ofthe ankle a true antero-posterior and lateralX-ray does not show the full displacement of thefractured fibular fragments. If careful observa-tion is made in the antero-posterior X-ray it willbe seen that the articular surfaces of the astragalusand of the tibia are not parallel. An oblique viewshould always be taken. This demonstrates awide gap in the fracture of the external malleolus,which represents the degree of the dislocation ofthe ankle. The treatment of first degree fracture-dislocations of the ankle is immobilisation inplaster, in inversion in the case of abductionfracture-dislocations, and in eversion in the caseof adduction injuries. The patient should not bearweight until the fracture is united, which takesabout ten weeks. Quite clearly the ankle jointconsists of the astragalus acting as a wedge, whichwidens the socket formed by the two malleoliwhen weight-beari-ng occurs.

In fractures of the head of the radius the injuryboth to the bone and to the articular cartilage ofthe head of the radius and of the capitellumrgreatly exceeds the X-ray findings. Antero-posterior and lateral X-rays often fail to show afissure fracture of the head of the radius. Anoblique view should be taken. See X-ray No. 6.The treatment for fracture of the head of the radiusis only too frequently the worse possible treatmentfor such an injury. Physiotherapy of all kinds is.the worse treatment. Manipulation of the elbowjoint for stiffness resulting from a fractured radialhead is even worse. It always produces myositis

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130 POST-GRADUATE MEDICAL JOURNAL AIril, I945ossificans. The correct treatment for all injuriesof the elbow joint is active movements only. Thus,the patient should wear a sling for three to fourweeks, and move his arm freely within it. Thecarrying of heavy weights or forcing of the elbowshould be completely avoided. See X-ray No. IO,showing myositis ossificans resulting from massage-and manipulation of an elbow which was stiff,secondary to a fracture of the radial head.

PRINCIPLES OF TREATMENTSimple Fractures.The treatment of all fractures may be sub-

divided into immediate, or first-aid; manipulativewith immobilisation- and thirdly, after-treatment,which includes continued immobilisation andphysiotherapy.

First-aid TreatmentFirst-aid treatment consists in splinting the

affected limb with anything available, e.g. awooden splint, or a broom-handle in the. case ofthe leg. Morphia should be administered for therelief of pain, which is severe. The patient, whois always shocked, should be kept warm andrested. A hot beverage is of great value, unlessit is contemplated to give an anaesthetic very soon.The patient should not be fussed over, but shouldbe allowed to rest until the ambulance arrives tocouvey him to hospital.

Manipulation and -reduction of fractures shouldalways be undertaken in an up-to-date fractureclinic only. It is impossible to get satisfactoryresults over a considerable series under any othercondition.A twenty-four hour X-ray service must be

available both for diagnosis and for confirmation,of reduction of the fracture.

Fractures should be treated only by those who-are well qualified by experience and training. Thetreatment of fractures is indeed fraught withdifficulties, more so than any other branch ofsurgery. All fracture clinics should offer a con-tinuous day and night service under the direction.of a full-time resident surgical officer with specialqualifications.

Fracture clinics should be held daily, includingSaturdays, so that complications and unsatisfactoryreductions can *be rectified. An expert ortho-paedic and fracture surgeon should be availableat all times for his advice and treatment as re-quired. If, possible, he should take all thefracture clinics himself. However, as this is notalways practical, all new cases should be referredto him at his next regular out-patient clinic. Acontinuous fracture service of this nature isimperative to get satisfactory results.

This does not mean that there is no place for thegeneral practitioner in the treatment of fractures.The contrary is the case. He should, if convenientto himself, assist in or see the treatment of thefracture throughout -all its stages. This appliesequally to fractures treated in an out-patientdepartment and to those who are in-patients andwho will eventually be discharged home under thecare of the general practitioner.Many poor results of fractures treated in special

fracture clinics to-day are due to the fact that thegeneral practitioner is not co-opted into the workof treating the patient from the beginning. Frac-ture work is essentially team work. The generalpractitioner, to whom the case belongs, shouldfrom the beginning fully appreciate what is in themind of the surgeon in difficult cases.

In the reduction of a fracture or a dislocationdeep anaesthesia is essential. Nitrous oxide gas,as usually administered in a casualty department,is not satisfactory. Complete relaxation is essen-tial to enable full reduction Qf the fracture and toprevent damage to soft tissues. Either pentothalor gas, oxygen and ether should be employed.

All fractures should be immobilised until they areunited. Failure of union is due more to failure toimmobilise the fracture until union has occurredthan to any'other factor. Some fractures take avery long while to unite. Special cases'are thelower shaft of the humerus; see X-ray No. 8the carpal scaphoid; the shaft of the ulna; theneck of the femur; the lower one-third of the shaftof the tibia; and all ilffected fractures. All of thesemust be fully and absolutely immobilised untilstrong bony union has occurred.In a long bone both joints on either side of the

fracture must be completely immobilised. Forexample, in fractures of the mid-shaft of the tibia,the plaster should extend from the base of thetoes to the upper thigh, with the knee flexed toforty degrees. See X-ray No. 9. Fractures of themid-shafts of the radius and ulna should beplastered from the knuckles to the axilla. SeeX-ray No. 7. An exception to this rule is afracture of the mid-shaft of the humerus, whichunites with the arm in a collar-and-cuff sling witha plaster back-slab.

Compound Fractures.Compound fractures may be classified from the

point of view of treatment into two main groups.The first group are clean compound fractures, withminimal injury to skin and to soft tissues. Thetreatment for this type is excision of the skinedges, reduction of the fracture, securing of haemo-stasis, and the application of a p'added plaster.The operation must be carried out in a main

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April; I945 PRACTICALITIES 131

operating theatre with full and IOO per cent "notouch" technique. Nothing less will suffice. Thistechnique is discussed later. The patient shouldbe most carefully watched in bed in hospital forundue swelling and for infection. Prophylacticpenicillin 50,000 units should be administered, withthe addition of sulphanilamide, and anti-gasgangrene serum.The second group of compound fractures, which

include dirty fractures; compound fractures withserious bruising or de-vitilisation of soft tissues;and "Clean'" compound fractures which cannot beguaranteed to be clean, or where infection isdoubtful. Every hour of delay in the treatmentof these fractures greatly increases the chance oflosing the limb or even the life of the patient.At best, infection of the bone greatly lengthens thetime of union of the fracture.A compound fracture can be one of the worst

injuries it is possible to suffer. The after-resultsare worse than those of an abdominal emergency.It may be mentioned in this connection that acompound fracture of a finger in a working man willbe more serious afterwards than a fracture of thefemur.The patient should primarily be treated for

shock, i.e. warmth, morphia, and rest in bed inquiet surroundings.As soon as the patient can be prepared for an

anaesthetic, and as soon as the limb can be cleaned,operation should be undertaken. If pain is severeit may be necessary to leave the clea.ning up of thelimb until the patient is under an anaesthetic.The skin edges are excised; all de-vitalised

muscle and other tissue is excised; fragments ofloose bone are removed; and haemostasis is se-cured. All fascial planes are opened up andforeign bodies removed. Penicillin with sulphanil-amide powder should be introduced by insufflation.The fracture is reduced by gentle manipulation andleverage with blunt hooks.The wound is lightly packed with vaseline

gauze, and the surrounding skin is covered withtulle gras or vaseline gauze to prevent excoriationof the skin by pus. No catgut is buried except tosecure haemostasis. No skin stitches are insertedif infection is at all likely.The limb is then encased in a complete plaster,

which is padded in the case of the first plaster toallow for swelling. Some surgeons prefer to leavea window over the wound. It this is done, thewindow should be large, and the patient should bekept at rest in bed until the skin wound has healed,even if the fracture unites beforehand.The plaster is changed after six weeks, or before

if pus is excessive. Successive plasters do notrequire cotton wool padding. The plaster can beapplied direct to the skin, except for the skin sur-

rounding the wound, which is covered withvaseline gauze. The plaster is continued until thefracture has united and the skin wound hashealed. This may take up to a year or more. Ifskin loss is severe grafting is indicated as soon aspossible.

This "closed plaster" technique for the treat-mnent of compound fractures should only be carriedout in a hospital under the continuous supervisionof the surgeon. It is no alternative for poorsurgery. The plaster is only a protective splint.Abscesses must always be drained, and all infectedfascial planes must be opened up. The skin shouldnever be sutured over potentially infected tissues.

Prophylactic Penicillin, 50,000 units, eitherintravenously or intramuscularly, with sulphanil-amide should be administered with the additionof anti-gas-gangrene serum in an initial maximumdose.The first sign of gas gangrene is ushered in with

increased pain, pallor, and signs of toxaemia,undue brightness of the eyes, and an increase ofpulse-rate. The presence or absence of actual gasshould never be waited for.

AFTER-TREATMENT OF ALL FRACTURESAlthough complete immobilisation of the frac-

tured bone is essential, it is equally important toencourage active movements of the limb from thecommencement of treatment. For exampl,e, incases of Colles's fracture, the hand and fingers mustbe used from the day of the injury. The slingmust be completely abandoned after the firsttwenty-four hours. It is equally important toexercise neighbouring joints, e.g. in fractures of theforearm, it is essential to encourage the patient touse the fingers and the shoulder normally.The patient must not be permitted to become

fracture-minded. He must be re-assured that t ieplaster has fixed the fracture, and that it is theduty of the patient to prevent stiffness of the softtissues. In the case of Colles's fracture, the bonenever fails to unite. Failure, however, to movethe fingers and hand from the first day only toofrequently causes prolonged or even permanentstiffness of the fingers and wrist. In these casesswelling of the fingers is a sign that the hand isnot being used enough. The patient is inclined torest the hand. Provided the plaster is not tootight, swelling of the fingers is caused by failure touse the hand, and is only relieved by active move-ments.

Similarly, a patient with a fractured spine mustnot be given the opportunity to meditate upon his"broken back." After reduction of the fractureand immobilisation in a plaster jacket, exercisesto extend the spine must be commenced at once.He may be encouraged to play games and to

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132 POST-GRADUATE MEDICAL JOURNAL April, I945resume his work. This not only distracts hisattention from the fracture, but it ensures excellentfunction once the plaster has been removed. Thespinal muscles by this time have become so strongthat they are stronger than normal, and a spinaljacket is unnecessary.Re-X-ray at suitable intervals is essential in the

after-treatment. Over one-third of all Colles'sfractures tend to relapse within the plaster aboutten to twelve days following reduction. A re-plasteror re-reduction should be undertaken at thisperiod.

In a similar way inter-trochanteric fractures ofthe head of the femur, although perfectly correctedinitially, always tend to go into coxa vara deformityabout the eighth week after reduction. This isdue to the strong pull of the adductor magnusoccurring when union is commencing. Thus thelimb should be kept in full abduction until theeleventh or twelfth week. See X-ray No. II.

After the plaster is finally removed a reactionaryswelling of the limb occurs. In the case of thelower limb, an elastoplast or viscopaste bandageshould be worn from the base 'of the toes to theknee for three to six weeks, with the knee in a crepebandage if the latter is swollen. In the case of aColles's fracture, the plaster should be kept on forfive weeks, and after its removal a bandage shouldbe worn for three days to one' week.

After removal of the plaster physiotherapy andre-habilitation are continued until the function isnormal. Re-education can greatly be helped byoccupational therapy in a re-habilitation centre, or,alternatively, by early return to work in a factorywhere the work can be graded upwards.

CAUSES OF FAILURE OF TREATMENTFailure to diagnose the fracture early enough

ranks quite high in the list of causes of failure oftreatment.The most important cause of failure of union,

however, is failure to immobilise the reducedfracture long enough, in fact, until strong bony unionis secured.

Inadequate immobilisation is included in thiscategory. Both joints on either side of the fracturein a long bone must be immobilised completely;

Failure to reduce the fracture adequately ismore the cause of mal-union rather than non-union. Nevertheless, mal-union in many sites isalmost as bad as non-union. A perfect anatomicalreduction must be the one aim of the fracturesurgeon. If this cannot be obtained by manipula-tion, open reduction, with or without internalfixation with bone-grafts, vitallium plates, orpreferably onlay grafts with vitallium screws mustbe undertaken. Such procedures should never beundertaken except in a major operating theatre

with a full ioo per cent "no touch" technique.Incidentally, stainless steel plates and screws shouldnever be used, as vitalliumn does not ionise in thebloodstream. Stainless steel rusts, breaks, andlater abscesses tend to form around the screwsand plates.

The "No Touch" Technique.Sepsis is the greatest menace in bone and joint

surgery. No surgeon should undertake an openoperation upon bones or joints unless he is insistentupon a IOO per cent "no touch" technique.The limb should be cleaned and prepared for

three days if possible before the operation. Natur-ally this does not apply to compound fractureswhere immediate operation is indicated. Thetheatre sister should lay out all the instrumentswith an instrument holder. No suture material,such as catgut, should ever be touched with thefingers. The surgeon should tie all knots withinstruments. Catgut and other suture materialshould be buried as little as possible in the neigh-bourbood of bones and. joints. In the case oftendon suture it was found that silk gives lessreaction in the tissues later than catgut, and istherefore preferable.The operating instruments should be laid out

in one row only, not in' the usual two rows. Thisis to prevent the points of the nearer row of instru-ments from touching the already used handles ofthe further row. A green towel on the nearerhalf of the instrument trolley, as advised by Mr.Watson-Jones, is a good reminder to the surgeonto place all the handles of his instruments afteruse in one line, with the instruments parallel, andwith the points not touching each other. Thisprevents a pile of instruments accumulatingthroughout a long.operation in which the handles ofused instruments may contaminate the points ofclean instruments about to .be used.

Furthermore, a complete "no touch" techniquegives a great lead to the nursing staff, who arequick to be dispirited by any bad habits thesurgeon may have. Furthermore, the writer hasknown of three deaths resulting from sepsis,secondary to bone-grafting operations in just overtwelve months.

In the reduction of simple fractures with the useof local anaesthesia, it is equally important to employthe full "no touch" technique. Otherwise theprocedure results in a compound grossly infectedfracture.Another cause of sepsis is rough handling of the

soft tissues.Once sepsis has occurred, not only is the chance

of union seriously delayed, but the life of the limband even of the patient is in jeopardy. If, however,

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April, I945 PRACTICALITIES 133

the technique of the surgeon and of the theatrestaff is perfect, and nothing less must suffice, itwill be found that bones are not filled with "blackingratitude" as was formerly thought, but willfulfil the surgeon's highest expectations.

Failure to treat the soft tissues gives as bad anafter-result as failure to treat the fracture ade-quately. Thus active exercises, physiotherapy,occupational therapy and general rehabilitationmust be started from the first day of injury asdescribed previously.

Finally, the financial and economic side of thepatient's happiness should be attended to. Thewriter is reminded of one of his patients, who wasoff work for seven months with no compensation.This was due to the fact that he fell and fracturedhis femur on his way to work and not while atwork. Both he and his family, including twochildren, were on relief throughout treatment.The patient's treatment should not be marred bysuch financial worry. Such cases are questionsfor legislation, but it is the duty of the medicalprofession to make its voice heard in such matters.The patient should always be treated as a whole

and not, for example, merely as a case of a fracturedfemur.

SCLEROTIC THERAPYIN PRACTICE IV.

The Injection Treatment of Hydroceleand Some Other Conditions

By R. R. FOOTE, M.R.C.S., L.R.C.P.,D.R.C.O.G.

Varicose veins and haemorrhoids have beendiscussed in previous articles,, and it now butremains to say a few words about some commonconditions occurring in general practice, which maybe frequently benefited by injection treatment.The mention of rare conditions and of conditionsin which opinion is divided as to the value ofsclerotic treatment are especially avoided. Cystichygroma, branchial cysts, ranula, certain mam-mary cysts, varicocele, enlarged prostrates andherniae have all been the subject of writingsregarding the advantages of injection treatment.

If some of the statements in this short articleappear too elementary and trivial to warrantmention, it must be remembered that attentionto detail is of paramount importance in thesesimple treatments. Dickson Wright, that greatteacher of our times, will spend much time teachingstudents how to sharpen a needle before injectinga varix (5 c.c. of lithocaine in the wrong place-makes a nasty mess!). He frequently states that

it is harder to apply a bandage correctly than it isto remove manv a gall-bladder.For some reason. difficult to fathom, the injec-

tion treatment of idiopathic hydrocele appearsto be a much neglected therapy. Patients areconstantly being advised surgical treatment whena simple injection will produce a permanent andperfect result. Campbell (1937) wrote regarding76 cases of infection in 502 cases treated by surgery.Furthermore, he showed that there was a 6 percent recurrence rate, and that there was some post-operative haemorrhage in i8 per cent. Add tothis hospitalisation, expense, and anaesthetic risks,and it is difficult to understand why cases are sotreated, since the only contra-indications to thisform of treatment are in those cases in which apreliminary aspiration of fluid has demonstratedthe presence of an abnormal testicle. It is agreedthat the hydroceles of the new-born and those ofearly infancy should be left alone for some time,since spontaneous resolution is probable. Shouldthis condition persist into later life, surgery is thebest treatment having regard to the possibility ofthe persistence of a congenital opening into theperitoneal cavity. The presence of a haematoceleor of a spermatocele is a further indication toavoid injection. There is some difference ofopinion among surgeons regarding the injectionof the spermatocele. Some advocate it, butowing to the frequently associated disease of theepididymis it is wiser to attack the matter from thesurgical angle so that the organ may be removedat the same time if it be considered necessary.Injection of a spermatocele may anyway be apainful matter owing to the active communicationwith the testicle or epididymis. Beyond theseprovisos it is safe to say that there are but fewcases of hydrocele which cannot be cured easilyby injection. Bilateral hydrocele occurs in about4 per cent of cases, and the two sacs may be treatedat the same time, although a time interval is pre-ferable. The patient must be warned that fromone to four injections may be required in order toeffect a cure. He should not lose any time fromhis work however, and with normal care runs. verylittle risks of a complication. This care consistsin putting the right amount of solution into theright place and the strict avoidance of sepsis.The following are the rules for successful injec-

tion treatment.

i. The patient should lie on a couch with thelegs well separated. The scrotum is sup-ported by means of a sling of elastoplaststretching between the thighs.

2. The site of injection must essentially be highup towards the neck of the scrotum. This isof importance, since neglect of this precaution

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