22. Two great indications enter into the treatment of fractures in
general, and of that of the os femoris in particular; namely, to bring
the fragments into proper contact, and to maintain them so. Let us
examine each of these in all their details.
Hippocrates, and every practitioner since his time, have replaced
the fragments by what they call extension, counter-extension, and
coaptation.[23] This threefold method, though sanctioned by long usage,
and rendered almost venerable by age, is by no means necessary at all
times in practice, as will presently be observed. Previously to having
recourse to it, it is necessary to place the patient in a suitable
position. But this position varies: most of the moderns adopt, after
the example of the ancients, a horizontal position: so that the thigh
may be extended on the body, and the leg on the thigh. This is the
common practice at present in France.
[23] A term of nearly the same import with “conformation.”
TRANS.
23. Pott imagined, on the contrary, that if the lower extremity were
kept in a half-bent position, the muscles, being more relaxed, would
offer less resistance to the efforts of the extension: he, therefore,
proposed to bend the leg on the thigh, and the thigh on the pelvis, and
to lay the patient on his side, a position, which, when first employed
in reduction, was to be continued throughout the treatment, during
which it would render the causes of displacement less active (10 ...
15). Bell adopted this method, which indeed appears to be generally in
use in England.
24. But the difficulty of making extension and counter-extension,
with the limb thus situated, the necessity of making them on the
fractured bone itself, and not on a part distant from the fracture,
such as the lower part of the leg; the impossibility of comparing
the diseased thigh with the sound one, to judge of the regularity
of the conformation; the uneasiness occasioned by this position, if
long continued, though it may at first appear the most natural; the
troublesome and painful pressure of the body on the great trochanter of
the affected side; the derangements to which the fragments are exposed
when the patient goes to stool; the difficulty of fixing the leg with
sufficient steadiness, to prevent it from affecting the os femoris by
its motions; the evident impracticability of this method, when both
thighs are broken; and, finally, experience, which, in France, has
been by no means favourable to the position recommended by Pott: such
were the considerations, which determined Desault to have recourse to
it no more, after having tried it on two patients, in one of whom the
limb was considerably shortened, notwithstanding the most scrupulous
attentions.
25. Besides, all that is gained by the relaxation of some muscles, is
lost, by the tension of several others. The knee cannot be bent without
the triceps flexor being brought into action; an inconvenience the more
serious, as this muscle acts immediately on both fragments. The rectus
anterior, though relaxed by the flexion of the thigh, will be thrown
into a state of tension by the flexion of the leg. The muscles attached
posteriorly to the upper fragment, and even to the superior part of the
lower one, will also in certain positions of the limb be rendered tense.
26. Hence it follows, that there can be no just comparison instituted
as to the position proper for the limb, between fractures of the upper
and those of the lower extremities; that, in the latter, the method
pursued by the English surgeons presents an aggregate or general amount
of inconveniences so great as to overbalance that of its advantages;
and, that the position directed by Hippocrates and the other Greek
physicians (22) ought to be adopted.
27. Having determined on the position, the operator proceeds to
extension and counter-extension, which are to be made first in the
direction of the limb as deformed or altered by the fracture, but must
be changed afterwards according to the natural direction of the thigh.
I need not here repeat the directions for this double operation: common
to all fractures, they contain nothing particular, in relation to
that of the thigh. But, on what part should extension be made? Petit,
Heister, Duverney, and all their predecessors, recommend to apply the
means or powers for making extension above the knee; a precept which
is still to be found in the surgical department of the Encyclopedia. A
strap surrounding the lower part of the thigh, aided by another placed
at the ancle, serves, in this respect, to draw the inferior fragment
downward.
28. Dupouy was the first to remark, that this practice rendered it
necessary to employ great force, and that it would be better to make
extension only on the foot. To this consideration Fabre added that
of the inconvenience of the pressure made on the muscles, a pressure
which, by irritating them and making them contract, multiplies the
obstacles to the reduction.
Desault adopted their doctrine, from nearly the same views of the
subject, introduced it into the Hotel-Dieu, and the success which
attended it, in his practice, contributed not a little to bring it into
general use.
29. For the purpose of making extension, he used the foot as a lever
of the first kind. The two hands of an assistant, grasping it in such
a manner, as to make the fingers cross on the back of it, while the
thumbs, also crossing each other, corresponded to the sole, represented
the power; the articulation represented the centre of motion, or
fulcrum, and the leg together with the lower fragment, the resistance.
The requisite motion was then communicated to the foot, and in that way
was the extension effected. This mode is more advantageous than that
usually employed, where the hands are applied to the lower extremity
of the leg; for the force of the extending power is generally in the
inverse ratio of its distance from the resistance intended to be
overcome.
30. What I have said of extension (28), applies also to
counter-extension. The strap, which was formerly placed for this
purpose in the groin of the affected side, by compressing the
adductores, and the rectus internus, produced in them a contraction,
which, by drawing the lower fragment towards the pelvis, opposed
obstacles to the reduction, which are seldom experienced, when, like
Desault, the surgeon contents himself with having the trunk held by
assistants, either exclusively at the hips, or both at the hips and
under the arm-pits. The resistance being always easily overcome in this
affection, renders it unnecessary to have recourse to more powerful
means.
31. Hippocrates advises, in fractures of the os femoris, to aid
extension by coaptation, performed with the hand. All practitioners,
since his time, have added this third manœuvre or process to the two
first, namely, extension and counter-extension. But, what effect
can the hands produce, in most cases, on the bone through the thick
covering of the soft parts? Are we able to communicate to it through
such a mass whatever lateral movement we please? Being quite lost in
the intervening soft parts, will our efforts reach the bone, in the
direction which we give them? The muscles bring the fragments into
contact, much better than we can, as soon as extension has removed
their overlapping. Indeed, if well executed extension makes the lower
fragment return along the same track which it pursued in becoming
displaced, it will then be inevitably brought into contact with the
upper one by the contraction of the muscles. Besides, in most oblique
fractures, is it not evident, that the lower fragment must be made
to slide from above downward, on the inclined plain presented by the
upper one, and on which it has slided from below upward, in becoming
displaced? Is it while extension is making that coaptation ought
to be performed? Certainly not: because, if the extension be well
directed, an attempt at coaptation will derange it; and if it be not
well directed, its course ought to be changed. Is it after extension
is finished that recourse ought to be had to coaptation? By no means:
because if there be then any remains of deformity, it must be owing to
extension having been improperly directed. The remedy, therefore, is,
to renew the extension, and direct it properly.
32. Hence, it follows, in general, that coaptation is here a feeble
assistant towards reduction; that if it renders any service, it is
only in cases of displacement laterally, or in the direction of the
cross-diameter of the bone; and that it is by giving the proper
direction to extension, by managing it according to the disposition of
the muscles, and by knowing when to augment and when to slacken it,
that the fragments are brought into regular contact.
33. If the inferior fragment has experienced a rotatory motion on its
own axis outwards or inwards (18), the assistant ought, in making
extension, to turn the limb very gradually in the opposite direction.
34. Extension was formerly attended with difficulties, which are
rarely met with at the present day. Oftentimes, if we give credit to
authors, it was altogether useless to endeavour, in the first instance,
to reduce the fracture, and restore the limb to its natural length,
as the contraction of the muscles rendered the operation absolutely
impracticable. Hence, applications of a soothing and sedative nature
were employed, previously to an attempt at reduction. The following
circumstances have been assigned as the cause of these difficulties.
The upper strap, irritating and drawing upwards the adductores and
the rectus internus, drew the lower fragment in the same direction,
while the semi-tendinosus, semi-membranosus, biceps, &c. being drawn
downwards by the lower strap applied over them, drew the pelvis also
downwards, and, consequently, the superior fragment connected with it.
From this double action arose a double motion directly opposed to that
which ought to be produced by extension.
35. There are still cases, where the muscles, in consequence of
being irritated by projections or points of bone, by the efforts of
the assistants, and by a morbid state of the nerves, increase their
contraction to such a pitch that no practicable force can bring the
fragments into apposition. What means are then to be employed? All
those, in general, that diminish irritability, varied according to
circumstances, such as diet, venesection, &c. In such cases, Desault
obtained the most happy effects, by placing the limb in a state of
continued extension; fatigued by the permanent tension in which they
are thus kept, the muscles relax by degrees; their force diminishes; at
length they yield, and the reduction is accomplished.
§ VI.