11. The displacement here is, in general, inconsiderable, because,
being drawn in contrary directions, by the muscles of the arm and
fore-arm, the condyls separated from the bone remain stationary between
these two forces. A fall, a percussion, or some other external cause,
can alone produce a displacement, by communicating some degree of
motion to the fragments. Now, from what was formerly said (5 & 6), the
condyls may, under such an impulse, move either forward or backward, or
else may separate from each other, leaving between them an intermediate
void. Hence the apparatus ought to oppose to them a resistance in these
four directions, namely, inward, outward, forward, and backward; a
resistance which it will be easy to make, by means of four splints,
placed in these directions, and properly retained by a roller. The two
lateral splints, are particularly necessary, when the condyls are both
separated from the body of the bone, and divided from each other (3).
If one of them be still attached to the humerus (4), a splint on that
side becomes less useful.
12. It is needless for the apparatus to extend as high up as in a
fracture of the arm. What effect, in sustaining the fragments, would
casts of a roller have, when applied to the body of the bone, above the
place of division? Their only advantage would consist in compressing
the brachial and triceps muscles, and in that way preventing their
action.
On the other hand, the roller must be continued along the fore-arm, in
order that the elbow joint may correspond, according to the judicious
precept of Paul of Egina, to the middle of the bandage, which is in
general more compact and solid, in the middle than in any other part,
and also, that a slight compression may be thus made on the muscles
attached to the condyls.
13. The pieces which compose the apparatus, are 1st, A roller five or
six yards long, and three inches broad, made of soft linen or muslin,
and rolled up in a ball. 2dly, Four splints (11), two of them flexible
in the middle, in order that they may bend to fit the fold of the arm,
and the elbow, and the other two very strong and inflexible, intended
to be applied at the two sides.
14. Every thing being arranged, the reduction is effected in the
following manner. One assistant is directed to make extension at the
upper part of the arm, which he grasps with both his hands; another
makes extension on the fore-arm half-bent, which he uses as a lever
of the second kind,[12] where one of his hands, being placed under the
wrist, forms a fulcrum, while the other applied towards the fold of
the arm, represents the power. The surgeon, in the mean time brings
the condyls together, adjusts their level and apposition, both between
themselves, and with the body of the bone, and then proceeds to the
application of the apparatus, the limb being still kept in a half-bent
position, as was long since recommended in such cases by Paul of
Egina. “_Si in vicinia cubiti brachium fractum est, etiam ipse cubitus
deligandus, angulari figura servata._”
[12] In this form of lever, the power is applied between the
fulcrum and the weight to be moved, or the resistance to be
overcome. TRANS.
15. The roller (13), wet with vegeto-mineral water, which facilitates
its application, and prevents the swelling of the part, is fastened
by one of its ends, about two-thirds down the fore-arm, and continued
upwards by oblique and reverse casts, to the joint. The surgeon then
passes a cast of the roller from the anterior and superior part of the
fore-arm, to the posterior and inferior part of the arm (humerus),
redescends by an oblique cast from the other side, over the fore-arm,
and returning along the first track, makes a number of casts in the
form of the figure of 8, round the joint, which he next covers by
circular casts, applied so close to each other, as to leave no opening
between them; he then proceeds upwards by oblique casts, as at the
first, to the middle part of the arm (humerus), when the roller is
given into the hand of an assistant.
The first of the splints (13) is now placed anteriorly on the fore-arm
and arm, and, if it does not bend, in such a manner, as to accommodate
itself to the fold of the arm, the vacant space beneath it is filled
up with compresses, laid on top of each other, so as to make its
compression uniform throughout. The second, being applied on the
posterior side part of the arm, moulds itself to the projection of the
elbow, while the other two occupy the sides. These are secured below by
an assistant, while the surgeon resuming the roller, which he had just
given out of his hand, fixes them firmly by circular casts descending
along the arm and fore-arm.
The limb is then laid on a pillow, so disposed that the hand may be
raised higher than the elbow, in order to prevent the subsequent
swelling, which is oftentimes produced by the fracture, as has been
already mentioned (7).
16. The effect of this bandage is simple, and has a particular relation
to those directions and causes, in and by which, displacements might
occur. The two lateral splints prevent the separation of the condyls
from each other; the anterior and posterior ones prevent them from
moving backward or forward; the muscles are compressed; the motion of
the joint is prevented; and, in common, no great length of time is
necessary for the reunion of the bone.
As soon as this is accomplished, it is of importance to move the limb
in every direction, to prevent that stiffness, which is so commonly
the consequence of fractures situated in the neighbourhood of joints.
The following case, drawn up by Le-geulle, will furnish the reader
with a detailed account of the treatment pursued, in such accidents, by
Desault.
CASE I. Joseph Kisler, an ostler, aged forty-one, fell from a height of
thirty feet, on the left side, his arm being undermost, and fractured
the lower end of the humerus. A surgeon gave him immediate assistance,
and, at the expiration of two days, he was carried to the Hotel-Dieu.
From the signs formerly mentioned (5 and 7), Desault discovered a
fracture, consisting in a separation of the condyls from each other, by
a longitudinal division, and from the body of the bone, by a transverse
one. The usual apparatus (16) was applied, and, from a state of extreme
anguish, which he had till now suffered, the patient experienced
immediate relief.
In the mean time, a considerable swelling around the joint, pointed out
the necessity of blood-letting, a low diet, and other antiphlogistic
remedies. These were immediately had recourse to, and the limb was
placed in the proper position (16).
Notwithstanding these precautions, the tumefaction and redness were
increased on the following day. The bandage was applied anew, and wet
from time to time with vegeto-mineral water.
On the following days, pain less severe, the bandage kept constantly
wet with the same fluid.
Eighth day, the swelling almost gone; the apparatus, being loosened,
was again reapplied.
Fifteenth day, the fragments, being examined, were found in regular
contact, and already united by a substance of considerable firmness;
the strictness of regimen gradually relaxed; solid food taken in small
quantity.
Nothing new till the twenty-second day, when the splints were laid
aside, having become useless, in consequence of the rapid progress of
reunion: from this time till the completion of the cure, nothing was
used but the simple roller.
On the twenty-fourth day, gentle flexion and extension of the arm and
fore-arm were for a short time performed; these movements were attended
with acute pain, notwithstanding which, the fortitude of the patient
enabled him to persevere in them.
Thirtieth day, no pain accompanies the movements of the arm: the range
of these movements visibly increased; the roller laid aside; from this
time the range of motion increases rapidly.
On the thirty-seventh day, the patient was discharged perfectly
cured, and free from every vestige of his disease, except a trifling
stiffness, which was doubtless soon removed by the motions of the joint.
17. When wounds, splinters, or severe contusions, render these kinds
of fractures more complicated, an inflammation occurring on the
articular surfaces, may cause them to unite together, and by that
means give rise to an anchylosis. But this accident, inevitable in
such a case, according to writers, does not always occur, provided
nature be assisted, by a judicious mode of treatment, in her attempt
to reunite the broken bone. Desault has established this truth, in
many instances. Here, as in other joints, he has oftentimes obtained
a complete cure, without the loss of motion, although the part had
sustained the greatest violence. Incisions, easily made, the extraction
of splinters, a frequent renewal of dressings, a most vigilant care to
prevent all jarring of the limb, and consequently all derangement of
the contact of the fragments, an assemblage or combination of those
minute attentions, which art cannot teach, which genius suggests, and
which characterize the true surgeon; a precaution (not to be dispensed
with) to make the limb perform motions, gentle at first, but gradually
increased afterwards, when the adhesion of the parts has acquired
sufficient solidity to admit of it; such are, in general, the steps and
circumstances constituting the bases of that treatment, requisite in
these complicated fractures, which, like all others, appear, in each
case, to assume a new aspect, and to present different indications.
CASE II. A person, carrying a heavy burden, fell with his elbow on
a sharp corner of a bar of iron. The external condyl was broken,
being separated from the body of the bone, by an oblique division
running into the joint. Anteriorly, a large contusion; posteriorly,
a transverse wound; on the outside, the end of the condyl projecting
through the soft parts, which it had lacerated: such were the
complications of a fracture, for which the patient was admitted into
the Hotel-Dieu, on the seventh day of January, 1794.
On examining the state of the parts, Desault discovered, in the
transverse wound, two splinters which when extracted, gave vent to an
effusion of blood. He reduced, instead of cutting it off, as authors
have advised, the end of the separated condyl, applied a bandage of
strips,[13] and, to prevent accidents, ordered a strict diet, copious
blood-letting, and diluting drinks.
[13] (_Bandage a bandalettes._) This is a most convenient form
of bandage, in fractures of the upper or lower extremities. It
is composed of strips of soft linen or muslin, from two to three
inches wide, and of a length accommodated to the size of the
limb, on which they are to be applied. These strips are not sewed
together, but merely laid along side of each other, or rather
spread in such a way that their adjoining edges may overlap a
little. Being thus arranged, on the bed or mattress, where the
patient is to lie, the broken limb is placed on them, when the
surgeon, taking them, one by one, folds them round it, so as to
form a very perfect and neat covering. The number of these strips
must be regulated by the extent of the limb, or, at least, of that
portion of the limb, which they are intended to cover. TRANS.
Compresses wet with vegeto-mineral water, kept the apparatus constantly
moist.
On the day following, the dressing was renewed superficially; severe
pains in the part; abated towards evening; almost gone next day; low
diet continued.
Fourth day, pains returned; an incipient swelling around the joint;
more blood drawn.
Sixth day, considerably better; all the apparatus renewed; suppuration
beginning to appear.
Tenth day, a small abscess on the external condyl opened, and a
splinter extracted posteriorly.
Fifteenth day, the parts assume a flattering aspect; suppuration
favourable; fragments in contact; from this time the dressings are less
frequent.
Twentieth day, a bilious diathesis; edges of the wounds livid; loss of
appetite; nausea; vomiting; an emetic is administered.
Thirtieth day, unfavourable appearances gone; reunion commencing;
wounds visibly healing. Fortieth day, all external injuries healed,
except the one situated anteriorly; callus already very firm; gentle
motions performed with the limb, which is still surrounded by the
apparatus.
Forty-seventh day, the apparatus become useless; motions gradually
increased; articulation already tolerably free. Fifty-seventh day,
bilious diathesis returned; low diet and evacuants. Sixty-fifth day,
the patient discharged from the hospital; consolidation perfect; wounds
entirely healed; motions of extension still difficult to be performed
in their full extent, but are recovered in a great measure, and will
doubtless, in a short time, be completely re-established, provided the
same mode of treatment be continued.