49. There are no fractures, the treatment of which demands more
attention, or is surrounded with more difficulties, than that of the
olecranon. Here art cannot, as in the thigh, and the clavicle, oppose
to the ever active power of the natural muscles, a constant resistance
produced by the action of a kind of artificial muscle, consisting in
permanent extension. The superior fragment, being too small to give
any purchase to extending forces, can be only pushed downwards, and
kept in that position with a greater or less degree of stability and
firmness, while the ulna, so to speak, is drawn to meet it. Whence it
follows, that extension here is of little use, and that it is chiefly
by position or attitude, aided by a judicious conformation, that the
reduction is effected.
50. The position has varied in the hands of different practitioners.
Some have proposed that, in which the fore-arm is half-bent, so as
to form a right angle with the os humeri. The example mentioned by
David, is not the only one where recourse has been had to this. But,
by rejecting the general principle respecting the reunion of parts,
which requires them to be kept in perfect contact, this mode is exposed
to a double inconvenience. The reunion is extremely slow in being
accomplished, and, when ultimately obtained, is accompanied by the
loss of one part of the movements of the limb, in consequence of the
length of the callus. This callus must necessarily fill up the whole
space that intervened between the fragments during the treatment, and
being thus added to the natural extent of the olecranon, lengthens this
appendix to such a degree, that, in extending the fore-arm, its summit
or upper end comes too soon into contact with the cavity in the os
humeri destined to receive it.
51. This practice appears to have been chiefly owing to an opinion then
in existence, that an anchylosis being the necessary consequence of the
fracture, it was proper to place the arm in that position in which it
would be most likely to be still of some service.
52. We must not, however, by throwing the fore-arm into the greatest
possible degree of extension, allow it to be drawn into the opposite
extreme. From this error the same inconveniencies would result. In
such a case, should the fragments touch each other, and press too hard
at their posterior edges, they must inevitably leave an intervening
vacuity or space between their anterior edges. Hence a greater
thickness of callus on the one side than on the other, and consequently
an impediment more or less troublesome in the motions of the joint. If
the inferior fragment do not touch the superior one, it sinks into the
olecranon cavity, leaves the other behind it, and hence another source
of irregularity in the consolidation.
53. Between these two extremes (50 and 51), it remains to choose a
middle course, and that position will be best, in which the fore-arm
shall be, so to speak, in a state between semi-flexion and extension.
By this the fragments, being brought into perfect contact, will
experience no obstacle to a reunion, which will be therefore both
speedy and uniform.
54. But it would be useless to place the limb in a proper position,
if no means were made use of to retain it there. Being immediately
submitted to the action and influence of a multitude of causes, it
will lose its position, and the work of nature being interrupted, the
consolidation will be retarded.
Hence appears, both the necessity of placing a solid body, as Desault
did, before the whole of the limb, to prevent its flexion, and the
insufficiency of the apparatus proposed by Duverney and others, who
directed to lay a thick compress on the fracture, to surround the elbow
then by a circular one, to secure the whole by a kind of figure of 8
bandage, similar to that used in blood-letting, and, finally, to place
the limb on a pillow, without further precaution.
55. Position alone evidently acts only on the lower fragment, which
it directs towards the upper one. But it is also necessary to draw
the upper fragment towards the lower one, and fix it there, and this
is certainly the most difficult point; because, the triceps muscle
having a constant tendency to contract, opposes its action to the
approximation of the fragments, and indeed prevents it, if, as in the
means usually proposed and adopted, the pieces of the bandage glide
easily over each other.
56. These considerations determined Desault to search for some means
which, being more efficacious than those already in use, might better
fulfil the indications of the fracture. He accordingly invented the
apparatus which we are about to describe; some ideas of this apparatus
are indeed borrowed from other bandages. The success which attended
the use of it at the Hotel-Dieu, will, without doubt, introduce it
generally into rational practice, where the insufficiency of the old
forms of apparatus is acknowledged.
1st, The fore-arm being placed in the position already directed (53),
two assistants retain it in that situation, while the surgeon applies
on its lower part the end of a roller five or six yards long, and about
four inches wide, wet with some discutient liquid, making with it, at
first, one or two circular turns to fasten it. Then ascending from
below upwards, he covers the whole of the fore-arm with oblique and
reverse turns moderately tight.
2dly, Having arrived at the joint, he stops, and makes an assistant
draw the skin of the elbow upwards, lest, being loosened and wrinkled
by means of the extension, it might get between the fragments, and
create an impediment to their reunion. Then, taking hold of the
olecranon, he draws it down towards the ulna, and passes behind it, as
a substitute for his fingers which have hitherto kept it firmly fixed,
a cast of the roller, which he brings from the anterior part of the
fore-arm above the elbow. Descending again with the roller along the
external side of the arm, and returning across the anterior part, he
pursues again the same course, so as to make the casts of the roller
lie on each other, and surround the elbow like a kind of figure of 8.
3dly, The surgeon proceeds now by oblique turns, to the upper part
of the arm, where he fixes the roller, by a circular turn, and gives
it into the hand of an assistant. He next applies along the arm and
fore-arm, a splint very strong, but a little bent at the place which
corresponds to the joint, in order to prevent too great an extension
of the limb: then, resuming the roller, he employs it, in a descending
direction, to secure the splint.
4thly, The apparatus being applied, the limb is placed on a pillow, so
as to be equally supported throughout its length, and is protected by
hoops from the weight of the bed-clothes.
57. To the bandage which we have just described, Desault added formerly
a strip of linen, to be placed all along the posterior part of the arm,
secured first at its upper end by circular casts, which began above;
this strip was secured afterwards by oblique casts, as far as to the
place where it met the olecranon, separated from the ulna. Here, the
surgeon quitting the roller, took hold of the bit of linen, and drew
it downwards, and along with it the circular casts of the roller,
together with the muscles on which these casts were applied, and also
the fragment which the muscles drew upwards. An assistant then secured
it here, while the surgeon, after having made some casts in form of the
figure of 8, descended to the inferior part of the fore-arm, where the
end of the strip was made fast by tight circular turns. (See fracture
of the rotula.)
58. The intention of this additional piece of apparatus, was to draw
down the superior fragment, to prevent the circular casts of the roller
from separating by their relaxation, and, by that means, to retain the
fragments in apposition. But, on the one hand, may not the superior
fragment be drawn by the hand, as well as by a roller employed for
the purpose? And, on the other, if the circular casts of the roller
be liable to become relaxed, why not the strip of linen also? These
considerations induced Desault to lay it aside, and use the bandage in
the form just described.
59. The advantages it offers are far from being equivocal. 1st, The
limb is kept in a state of invariable extension by the anterior splint,
and, on this account, there can be no displacement on the part of the
inferior fragment. 2dly, The bandage, which accurately envelopes the
whole limb, restrains the action of the muscles by compressing them,
and prevents in part the contractions of the triceps; while the casts
in the form of the figure of 8, applied with skill and precision,
hold down the superior fragment, and render it difficult for it to be
displaced. 3dly, Without the application of a roller over the whole
limb, a swelling, more or less considerable, would probably be the
effect of the constriction at the elbow, which must necessarily be
somewhat tight, because, as the turns of the roller, in form of the
figure of 8, act on the olecranon obliquely, if they be too loose, they
will slip and not perform the office of retention.
60. Like all kinds of apparatus composed of rollers, this ought to be
frequently examined, lest, by becoming relaxed, it should not make
sufficient resistance to the triceps, which is always disposed to draw
itself upwards. There can be no period fixed on for the reapplication
of the apparatus; the moment it begins to become slack, it ought to be
renewed: three or four times during the course of the treatment are
generally sufficient. Should a considerable swelling give reason to
suspect that the constriction is too great, it will be necessary to
remove the bandage in order to apply it anew.
61. The period necessary for the reunion of fractures of the olecranon
varies, according as the bandage is more or less exactly kept in its
place. Among ten cases of this kind, collected in the Hotel-Dieu,
four united in twenty-four days, three in twenty-eight, and three in
thirty-two. Hence, taking the mean term, all other circumstances being
alike, the process of cure requires about twenty-six days.
62. When this is completed, it is necessary to impress on the limb
motions of flexion and extension, gradually increased every day. This
is, as David properly observes, the most certain method of avoiding a
stiffness, and even an anchylosis, too often the consequence of this
fracture.
63. But that illustrious practitioner, in recommending this salutary
remedy, has erred with regard to the mode in which it operates. To
consume, by degrees, a superabundant callus in the interior of the
articulation, and thus reduce it to a level with the articulating
surfaces, is not, as he conceives, the effect which these motions
produce. This opinion, founded on the ancient doctrine of an osseous
juice, is refuted by the dissection of many bodies of patients that
died during the treatment, and in which Desault discovered no trace,
either of an effusion of osseous juice, during the reunion, or of its
superabundance after this reunion had been completed.
The exercise communicated to the limb, appears to act principally by
removing the congestion of the tendons and membranes surrounding the
joint, which, being at first irritated by the fracture, are thrown into
a state of _engorgement_; and further by dissipating a kind of numbness
which affects the muscles after they have remained too long in a state
of rest.
64. But whatever may be its mode of action, it ought to be gradually
increased, according to the state of the parts, and continued for at
least twenty days, a period sufficiently long to restore to the limb,
in general, its natural motions.
65. It is seldom that after this methodical treatment, the patient is
exposed to an anchylosis, a thing inevitable in such cases, according
to most authors, A celebrated surgeon, believing the long continued
extension of the fore-arm to be the cause of this accident, has advised
here to abandon every kind of bandage, and to commit the cure entirely
to nature. But this doctrine, contrary to the general principles of
the reunion of divided parts, has not in its favour the result of
experience, which proves that, under such neglect, the stiffness in
the parts near to the joint is always as great as in other cases, that
the reunion is more tedious and more deformed, and that sometimes it
cannot be accomplished at all. The analogy of the inconveniences and
disadvantages attributed to the method of Foubert, in fractures of
the neck of the os femoris, constitutes another argument against this
method, which is now almost entirely abandoned.
66. To the cases already published, proving the success of that which
we have proposed, let us add one more, reported by Maublanc.
CASE IV. Silvan de la Noue, aged thirty, fell on his elbow, having
his fore-arm bent, while the shoulder of the same side supported a
heavy load. Acute pains at the instant of the fall; a sudden inability
to extend the fore-arm; a considerable swelling appears almost
immediately, around the joint; and a superficial echymosis at the hind
part.
During the night the pains were augmented, the swelling increased, and,
on the day following, February 9th, 1791, the patient was received into
the Hotel-Dieu.
From the presence of the signs formerly mentioned (43), Desault
recognized the fracture, and applied the apparatus (56),
notwithstanding the swelling and echymosis, persuaded that the
compression made by this apparatus on the tumefied parts, was the most
effectual mode to remove the enlargement.
Next day, pains almost gone; swelling diminished; on the fifth day,
the bandage become loose, by the almost entire disappearance of the
swelling; a new application of it; the joint wet frequently with
vegeto-mineral water.
Seventh day, usual regimen allowed; ninth day, a slightly bilious
disposition; evacuants somewhat active administered, to remove it.
Thirteenth day, a third application of the apparatus; echymosis
entirely gone.
Thirtieth day, the consolidation complete; the apparatus laid aside;
from this time motions gradually impressed on the limb.
Fifty-eighth day, the patient discharged, free in all his motions,
except a little stiffness, which exercise will soon remove. Since that
time, it has been understood that the limb had completely recovered its
natural functions.