127. Since the same causes, as in the preceding cases, tend here to
destroy this contact, when the superior fracture is oblique (122), the
apparatus ought, therefore, to be so constructed as to counteract these
causes, that is, it ought, 1st, to draw the two condyls down; 2dly, to
retain the pelvis up, and with it the superior fragment. This twofold
indication relates only to the upper division of the bone, without any
reference to that which separates the condyls; 3dly, it is necessary
to counteract the tendency which the condyls may have to separate from
each other.
128. Permanent extension, made in the manner already mentioned (60 ...
63), fulfils the two first indications; while two lateral splints, and
the bandage of strips fulfils the third. Desault, therefore, applied to
this particular case his apparatus for permanent extension, modified
only in such a way, that, instead of terminating at the knee, the
bandage of strips was continued to a distance down the leg, in order
that its action might be the more efficacious. For, it is well known,
that it is at its middle part that the firmness and retentive power of
a bandage are greatest, because the casts of the roller at the upper
and lower ends, serve to secure those in the middle. The upper splint
being altogether useless, was not employed.
129. If the superior fracture be transverse, the condyls, as I have
already said, meet with resistance against the body of the bone, while
they, on the other hand, support it in such a manner, as to prevent
it from descending, though pushed by the weight of the body along the
inclined plain made by the pressure of the nates. Here, then, permanent
extension is generally useless, and all that is necessary is, to retain
the condyls and prevent their separation by means of lateral pressure.
The same apparatus may still be employed, provided the two rollers for
extension be laid aside.
130. If a wound in the soft parts accompany the fracture, whether it
be produced by the same cause, or by the subsequent passage of the
fragments through the integuments, and whether it communicate with
the articulation or not, it is necessary, as soon as suppuration has
taken place, to renew the dressings every day or every other day,
taking care, in the mean time, to supply, by the hands of an assistant,
the want of extension by means of the apparatus. The following case,
extracted from the Journal, exhibits a specimen of the treatment that
ought to be adopted in similar cases.
CASE XI. Claudius Legrange, aged thirty-one, and of a sound
constitution, was wounded by the kick of a horse, on the internal
condyl of the left os femoris. The violence of the pain obliged him to
throw himself on a heap of straw, that lay at a little distance, and
which he reached by hopping on his right foot. The pains were augmented
by this, for at each step, the thigh being alternately bent or extended
at the injured part, was moved sometimes backward and sometimes
forward. The patient was brought to the Hotel-Dieu, a few hours after
the accident.
The signs already specified (121 and 122) announced to Desault, a
longitudinal fracture separating the two condyls, and terminated above
by another fracture of the body of the bone, which descended obliquely
from about five inches above the external condyl, to within two inches
of the internal one.
The muscles of the thigh, by means of violent contraction, had drawn
that portion of the os femoris attached to the external condyl upwards,
and the superior fragment downwards. The sharp point of the latter had
passed through the skin, and produced a wound of an inch and a half in
extent, on the inside of the thigh, and a little above the condyl.
The patient being undressed, was placed on a bed nearly horizontal, on
which had been previously spread the necessary pieces of apparatus,
disposed in proper order. Desault then examined the wound, extracted a
splinter of the bone, covered the wound with lint, and then proceeded
to the application of the apparatus which he usually employed in such
cases (128).
The extension was accompanied by no pain: on the other hand, it gave
immediate relief: diluting drinks were prescribed. Next day, no pain;
pulse a little raised; no dryness, nor any alteration of the skin; diet
the same as on the preceding day; the apparatus wet with vegeto-mineral
water. Fourth day, a new application of the apparatus, which had become
relaxed; appearances of suppuration.
From this time the dressing was renewed every other day, till the
sixteenth, when the wound was cicatrized. After this the apparatus
was not touched except when deranged; it was only wet from time to
time with vegeto-mineral water, and great pains were taken to keep up
the extension. The apparatus was not laid aside till the sixty-fourth
day, although the callus appeared to have acquired a state of solidity
somewhat sooner.
The patient was soon in a situation to take exercise. The stiffness
then disappeared rapidly, and, in about three weeks, he left the
hospital, able to bend the leg to a right angle with the thigh, and
under a full confidence that he would in a short time regain all the
motions of the limb.
§ XXII.