This plate gives a full view of an apparatus for making permanent
extension, in oblique fractures of the leg, when both bones are broken.
This apparatus was first devised and constructed several years ago, by
Dr. James Hutchinson, then a pupil in the Pennsylvania hospital, and is
now in general use among the practitioners of Philadelphia.
Fig. 1. Represents the leg and foot, with the apparatus applied.
A. A common roller, passed several times round the leg a little below
the knee, on which counter-extension is made.
B. A silk handkerchief folded, or a strong roller made of soft muslin,
passed once round the leg, just above the ancle, from behind forward.
C. The place where its two ends cross each other to pass down along
each side of the foot, as seen at _b_, to D, where they are secured by
a knot drawn but moderately tight. _a a._ The same ends continued to
E where they are again secured by a firm knot over the cross piece F,
which passes between the two strong splints G G, that run on each side
of the leg from a little above the knee, to the distance of four or
five inches beyond the sole of the foot. This is the bandage by which
extension is made, as will be mentioned hereafter.
H. Two bits of strong tape, each about two feet long, placed in the
longitudinal direction of the leg, and firmly secured by the roller A,
which passes over their middle. Two such bits of tape, are thus applied
on each side of the leg, and their four ends, passing through four
holes in the upper end of each of the splints G G, are secured on their
outsides by firm knots as represented at H.
Fig. 2. A view of one of the splints G G, separated from the leg.
_a._ The four holes in the upper end, through which the bits of tape H
pass.
_b._ The mortise in the lower end, which receives the cross-piece F.
Fig. 3. A view of the cross-piece F, which must be firmly fixed in one
of the splints G G, but moveable in the mortise of the other, so that
the splints may be taken asunder at pleasure.
The following is the method of applying this apparatus.
While extension and counter-extension are made by two assistants, the
surgeon placing the bits of tape H on each side of the leg, secures
them firmly by the roller A applied round the limb, with a proper
degree of tightness. He then applies the middle of the handkerchief
or roller B on the tendo Achillis, brings its ends across each
other, before the leg at C, and carrying them down along each side
of the foot, secures them by a knot at D. Letting go the ends of the
handkerchief B, he next places on each side of the leg the splints G
G, connects them at the lower end by the cross-piece F and secures
them at the upper end by the tapes H. He then resumes the ends of the
handkerchief B, carries them downward as seen at _a a_ and secures them
by a firm knot at E round the cross-piece F.
From this view and explanation of the apparatus Fig. 1, I presume its
construction, application, and mode of operation will be very easily
understood. It is unnecessary therefore to add, that the extension and
counter-extension made on the limb, will be directly proportioned to
the degree of force with which the ends _a a_ of the handkerchief B are
drawn over the cross-piece F. As action and reaction, in this case,
must, as in all others, be equal, the splints G G will be pushed upward
by the ends of the handkerchief B with precisely the same force that
is applied on these ends to draw the foot and lower fragments downward.
Hence the counter-extension made above on the roller A will be exactly
equal to the extension made below by the handkerchief B.
I ought to have observed, that it is necessary to defend the soft
parts, both above and below, from the pressure of the extending and
counter-extending straps, by means of soft compresses applied next to
the skin. This is particularly necessary on the instep C where the ends
of the handkerchief B cross each other. It requires some attention on
the part of the surgeon to prevent this spot from being excoriated,
especially if it be found necessary to make a forcible extension.
If the fracture be simple, a bandage of strips previously applied round
the limb from the ancle to the knee is highly useful. It secures the
fragments more effectually from lateral displacement, and prevents the
swelling of the leg. A simple roller applied with a moderate degree of
tightness round the foot, is also of service in preventing a swelling
in that part, as well as in removing it if it has already occurred.
This apparatus is still more strikingly useful in compound fractures,
on account of the facility with which it enables the surgeon to
apply the necessary dressings. These can be renewed as often as may
be requisite, without giving the patient the least pain, without
discontinuing extension, or in any measure whatever deranging the
fragments. The surgeon can also, in all cases, discover by a single
glance of his eye, whether or not the fragments are in proper
apposition. It is right to secure the whole apparatus by three bits
of tape passed round it, similar to those tied round the leg in the
apparatus for fractures of the thigh, as represented in plate 2.
I shall only add, that the surgeon must employ such bolsters and
compresses as he may find necessary to support the limb, and protect
it from undue pressure, and that he must be vigilant to prevent, by
frequent examinations, the extending and counter-extending straps from
becoming relaxed.
For a few further remarks on the subject of this apparatus, the reader
is referred to a paper published by Dr. Hutchinson, in the second
number of the Philadelphia Medical Museum.