FRACTURES.
HEAD AND TRUNK.
=Fracture of the lower Jaw.—The External Splint and Bandage.=—A
method requiring the lower jaw to be firmly fixed against the upper
one while the broken bone knits.
_Apparatus_.—1. One and a half yards of bandage four inches wide.
2. A piece of gutta-percha, sole leather, or binder’s millboard.
3. Dentists’ silk or wire.
4. Boiling hot, and cold water.
Step 1. The fracture is first reduced. While the apparatus is being
fitted, the recurrence of the displacement is prevented by the hands
of an assistant, or by lacing the teeth together with stout silk or
wire. It is well also to wet the patient’s chin with a sponge and
cold water, to prevent the gutta-percha from sticking to his beard
while it is soft.
Step 2. A piece of gutta-percha is prepared 2½ inches wide and long
enough to reach from one angle of the jaw to the other when passing
in front of the chin. This is softened thoroughly by immersion in
boiling water, and when quite pliable should be quickly removed
from the hot and plunged for a moment into cold water: if a towel be
previously laid in the hot basin, the gutta-percha can be lifted on
it without stretching. It should be laid on a table, and its surface
sponged with cold water to prevent it sticking to the skin, it is
then slit from each end into tails 1 inch and 1½ inch wide, leaving
2 inches uncut at the centre. So prepared, the splint is applied to
the jaw with the middle pressing against the chin, the narrower ends
being carried horizontally backwards to the angles of the jaw; the
broader part is next bent up beneath the chin, its ends overlapping
the horizontal ones. While the splint is still soft, the surgeon
presses it firmly upwards that the gutta-percha may mould itself
accurately to the chin. When set, the splint is removed, trimmed,
and punched with holes here and there for evaporation. A covering of
wash-leather may be added, if desired. When the splint is finished,
it is replaced on the chin. If sole leather or pasteboard be used
instead of gutta-percha, they must be prepared in the same way, but
allowed to remain on the chin twenty-four hours that they may set
before the final trimming and adjustment.
Step 3. A bandage, 4 inches wide and 1½ yard long, and slit from each
end to about 2 inches from the centre, is then applied to the splint,
and a small pad of folded flannel should be placed at the nape of
the neck to protect the skin from the crossed bandage. When all is
ready, the two upper ends are carried behind the neck, crossed,
drawn tight, and tied or pinned on the forehead; the lower ends are
carried upwards, taking a turn round the first pair at the temples,
and fastened at the vertex (see fig. 23).
[Illustration: Fig. 23.—Outside splint for fracture of the lower jaw.]
The ligatures that may have been used on the teeth can now be
removed, or if they cause no pain, they may be left for a week or two.
It is a useful precaution to place a piece of soap plaster spread on
soft leather, under the chin and along the throat, to protect the
skin from the chafing of the splint while it is worn.
Sometimes the jaws close too nearly to allow food to be taken
between them. It is then necessary to place a thin wedge of softened
gutta-percha, 1½ inch long, ½ inch wide, and about ⅓ inch thick,
between the molars on each side. The gutta-percha must not be
softened much, or when the bite is taken the teeth will pass through
it. These plugs should be omitted unless absolutely required, as the
fragments keep a better position without them.
On emergency, when gutta-percha, leather, or pasteboard are not at
hand, the jaw may be set, and then kept in position by a four-tail
bandage, made from a pocket-handkerchief, until more complicated
apparatus can be prepared.
The apparatus must be worn five weeks before it is laid aside and
mastication permitted.
=Interdental Splints.=—In cases of unusual difficulty, interdental
splints may be employed. To fashion some of these, the mechanical
skill of a dentist is requisite, unless _Morel Lavallée’s plan_ is
resorted to. He applied a mould or socket to the line of the teeth,
and kept it in place by pressure underneath the jaw. He first brought
the fragments into apposition by means of threads and wire. Then he
took a piece of gutta-percha, about ⅓ inch thick and ½ inch broad,
and long enough to extend, when bent along the lower jaw, from one
wisdom molar to the other. This was softened in water, and pressed on
the teeth; next a well-padded horse-shoe plate was placed under the
chin, reaching from one angle of the jaw to the other, and two wires
were passed through the side of this plate opposite the angle of the
mouth; these were drawn through the plate by a screw nut; their upper
ends being curved into hooks with sharpened points. The points catch
into the gutta-percha; by screwing up the nuts, the chinplate was
raised, and the teeth driven up and bedded into the splint.
This method, however, has its disadvantages. If the fracture take
place behind the first molar, the bearing on the upper fragment is
too slight to keep it down in its place.
In the _New York Medical Journal_ for September and October, 1866,
Mr. Gunning, of that city, has published a mode of applying caps
fitted to the teeth for fracture of the jaw-bone. External support is
abandoned wherever it is possible. In simple fractures, the caps or
interdental splints, being accurately fitted, require no fastening to
the teeth.
The jaw should be adjusted in its splint as quickly as possible
after the accident. The fragments are first brought into their true
position. Gaps through loss of teeth at the line of fracture, are
filled by plugs of hard wood, and the fragments kept in place by
wiring the teeth together tightly. Continued strain on the teeth
causes much pain; hence all means for keeping the fragments in place
while the splint is being fitted should be removed when that is
accomplished, though ligatures used solely to support loosened teeth
may be left, as there is no traction upon them. Stumps, and teeth
loose before the accident are best taken out, if they interfere with
the arrangement of the splint.
[Illustration:
Fig. 24.—Vulcanite Interdental Splint to fit the arch of the teeth
of the lower jaw, seen upside down. The holes marked a pass through
to the upper surface, to allow water to be injected between the
splint and the teeth, while it is worn, for cleaning.
]
The next thing is to take a mould of the lower jaw in wax softened by
heat, holding the wax in an ordinary dentist’s tray. From this mould
a plaster cast of the jaw is made. If the line of teeth be uneven in
the cast, it is to be sawn through, the pieces raised to the right
level, and cast again. In this cast a vulcanite plate is made exactly
fitting the teeth (see fig. 24). The margins of the mould or splint
should be carried down below the line of the gums, to grasp the jaw
beyond the alveolar border; and when the fracture takes place behind
the teeth, its outer side should be prolonged backwards as far as
the muscles will allow, to prevent the displacement of the anterior
fragment outwards which muscular action produces in these fractures.
Holes should be made in the top of the splint, to permit a stream
of water to be sent between the splint and the teeth daily, for
cleanliness. Also, in difficult cases, a hole should be cut opposite
a tooth in each fragment, for ascertaining from time to time that
each part continues in its proper position while the splint is worn.
Metal is used for the plate by English dentists, instead of
vulcanite. It can be made thinner, and is less brittle than the
latter.
The perfect fit thus secured suffices, in simple fracture, to keep
the parts in close apposition; while the movements of eating and
speaking are very little interfered with.
[Illustration:
Fig. 25.—Showing the method for supporting externally the jaws in
the splint, when the teeth are not fastened to it by screws, E.
Upper wing; G. Lower wing; H. Mental band to keep the jaw up in the
splint; I. Neck-strap to keep the band back; K. Balance-strap to
hold skull-cap in place. The upper wings are of course dispensed
with, when a single splint only is used.
]
When the displacement is considerable the fragments are held in place
by riveting one or more teeth to the cap, or, when circumstances
prevent support being obtained in this way, external support is
supplied to the splint by steel wings, fixed into the splint at the
angles of the mouth (see fig. 25), and carried outside the cheek
to the angles of the jaw. A piece of stout jean or canvas, cut to
fit under the chin, is then connected with these wings, and also
fastened by a tape behind the neck.
If the case require that a bearing be made on the upper jaw as well
as the lower one, as in fracture of both jaws in edentulous persons,
the two splints are articulated behind, so that they may open and
shut with the lower jaw. Each piece then carries a wing, the lower
one supporting a chin-piece, and the upper one being connected by
strings attached at the temples to a close-fitting skull-cap. The
skull-cap is prevented from slipping forward by connexion with a
strap fastened to both shoulders.
=A fractured Rib= is very well treated by strapping the injured side
alone, without enrolling the chest in a tight bandage, which harasses
the patient by impeding respiration.
_Apparatus._—1. Diachylon plaster.
2. Can of boiling water.
[Illustration: Fig. 26.—Strapping a broken Rib.]
Strips of plaster long enough to reach from the spinal column to the
sternum, and 2 inches wide, are to be firmly drawn round the injured
side. The first strip should be carried as high as can be managed
under the arm-pit. The next strip overlaps it about an inch (fig.
26), each succeeding strip overlapping and fixing the preceding one
until the lower ribs are covered in. The arm should then be bandaged
to the side, and supported in a sling.
A _second mode_ of treating fractured ribs, is to take a flannel
roller 6 inches wide, and 8 yards long, and carry it firmly round the
chest in successive spirals, beginning at the armpits, and passing
down till the waist is reached. The turns of the roller may be kept
from slipping down by throwing across the shoulders two strips of
bandage like a pair of braces, and stitching each turn to the brace
in front and behind. The arm should be confined to the side as in the
other method. This plan has the inconvenience before mentioned of
interfering with respiration.
=In Fracture of the Pelvis=, the fragments are kept in position by a
broad roller carried several times round the pelvis and fastened.
THE UPPER EXTREMITY.
=Fracture of the Metacarpal Bones.=
_Apparatus._—1. A piece of gutta-percha.
2. A roller 2 inches wide.
In treating this fracture it is important to keep the broken bone in
place without confining the wrist or fingers.
A pattern of the palm and dorsum of the hand is cut out of paper,
which is doubled round the radial side, letting the thumb out through
a hole of convenient size to clear it (see fig. 27). The piece of
paper is then laid on a sheet of gutta-percha ¼ inch thick, and the
requisite quantity cut off; a hole as big as a pea is next punched
in the gutta-percha in the middle, about 1 inch from the lower
border, or at a point corresponding to the hole in the paper for
the thumb. The fragments are then pushed into place and held so by
an assistant, while the surgeon softens the gutta-percha in boiling
water; when thoroughly soft, he draws the thumb through the little
hole punched in the gutta-percha, and moulds the splint to the palm
and back of the hand, bringing the ends of the gutta-percha together
at the ulnar side of the hand; the fragments are held carefully in
position till the splint is set. The splint is afterwards removed
and trimmed. A few holes should be punched in it after it is moulded
to allow perspiration to escape. The splint may then be covered
with wash-leather, and a pair of straps with buckles stitched on to
keep it in place. It is worn for three or four weeks, or until the
fragments are united.
[Illustration: Fig. 27.—Gutta-percha Glove for fractured Metacarpal
Bone.]
Should gutta-percha not be at hand, another plan is effectual.
_Apparatus._—1. A firm ball of tow large enough to fill the palm,
stitched in old linen.
2. A roller 2 inches wide.
The broken bone is first replaced; then the hand and fingers bound
on to the ball by carrying the roller around them until they are all
immoveably confined.
This plan has the disadvantage of confining the whole hand for the
fracture of one metacarpal bone; the gutta-percha allows free use of
all but the metacarpal bones.
=Broken phalanges= are treated by bandaging them on to a slip of
wood long enough to reach into the palm; the slip must be well
padded, that the somewhat concave anterior surface of the digit may
accommodate itself on the flat splint. If more than one finger be
injured, and the fracture be compound, the splint should then reach
up the palmar aspect of the forearm and hand. Fingers should be cut
in it to correspond with the fingers to be fastened to the splint.
=Fracture of the lower end of the Radius.=—_Colles’ Fracture._—The
displacement in this fracture is mainly due to the lower end of
the radius and the carpus being carried backwards while the shaft
projects in front.
_Apparatus._—1. A straight splint of wood. A second splint, curved at
its lower end.
2. Pads and cotton wool.
3. A roller 2 inches wide.
4. A sling.
5. A strip of plaster.
The objects to be attained in treating this fracture are to press
the lower fragment forwards and to draw (adduct) the hand towards
the ulnar side of the limb. For this purpose a straight and a curved
splint are used.
No bandage should be placed under the splints in treating any
fracture of the shaft of the radius or ulna, lest the broken ends be
pressed into the interosseous space.
Step 1. Prepare the splints. The straight splint should reach, when
the arm is bent, to a right angle with the thumb upwards, from a
little below the inner condyle to the lower end of the upper fragment
or shaft; the curved or pistol splint extends from the outer condyle
to the joint of the first and second phalanges. The width of both
splints should slightly exceed that of the forearm. The bend of the
lower end of the pistol splint should be abrupt, and directed towards
the ulnar border opposite the wrist, where the margin of the splint
should make an obtuse angle of about 1½ right angles (see fig. 28).
[Illustration: Fig. 28.—Pistol Splint for fracture of the Radius near
the lower end.]
Pads used with these and other wooden splints are made of layers of
cotton wool, carded sheep’s wool, tow, or folds of old blanket. These
materials should be stitched in old linen or calico, and covered
outside with oiled silk where likely to be stained with the discharge
from wounds.
The pads must be thicker below than above, to keep the splints
parallel along the forearm; and that of the pistol splint is thickest
opposite the carpus, to push the lower fragment forwards.
Fixed deformity opposite the wrist is usually present from impaction
of the fragments; moderate extension may be employed to remove this,
but forcible or continued efforts give great pain and do harm,
by further straining the already wrenched ligaments. After these
preparations the splints are applied.
Step 2. Put a very little cotton wool in the palm and across the
root of the thumb, before the roller is begun, lest it chafe the
carpus in front. The curved splint, with the barrel or longer part
inclined downwards below the forearm, is next attached to the back of
the hand by a roller carried in figures of 8 round the hand and root
of the thumb, but not above the wrist (see fig. 29). This is made
fast by a pin.
[Illustration: Fig. 29.—Fracture of the Radius.]
Step 3. Raise the straight part of the outside splint till parallel
to the forearm, thus adducting the hand to the ulnar side; and fix
the splint by a strap of plaster an inch wide carried round it and
the forearm below the elbow.
Step 4. Apply the inside straight splint next, keeping the front of
the carpus and of the lower fragment exposed. Draw the two splints
together by simple spiral turns of a roller, begun just below the
elbow and carried down to the lower end of the inside splint, there
fasten it off.
Step 5. Put a narrow sling under the forearm between the elbow and
the wrist to support the limb comfortably.
When the apparatus is finished the position of the broken fragments
should be visible (see fig. 29) and not concealed by bandage. The
hand should also be quite free of the sling, lest it be drawn from
its proper adducted position. The fragments are in good position
when the hollow on the anterior aspect of the wrist and the
prominence on the corresponding posterior surface are removed.
=The Gutta-percha Gauntlet= is another plan of treating fracture
of the lower end of the radius that may often be adopted from the
first, and may always replace the wooden splints and bandage when
the swelling has subsided. It was contrived by Mr. Heather Bigg, and
permits the patient to use his hand to some extent while the bone is
uniting.
_Apparatus._—1. A piece of gutta-percha ¼ inch thick, wide enough
to enwrap the metacarpus and wrist, and long enough to reach up the
lower half of the forearm. Two thirds across the width, and about 1
inch from the lower end, a small round hole is punched. The sheet is
then softened in hot water, and applied to the hand, the thumb being
thrust through the hole punched to receive it, which rapidly enlarges
when soft. The gutta-percha is then adjusted to the hand and forearm,
its borders meeting at the ulnar side of the limb, rather nearer the
inner border of the arm than is depicted in fig. 30.
[Illustration: Fig. 30.—Gutta-percha Gauntlet for Colles’ Fracture.]
If the fracture is recent, it must be reduced while the splint is
soft by extending the hand and holding the parts in the required
position until the gutta-percha is set. Before removing the splints
superfluous edges should be marked, and, when the splint is off,
trimmed away with a knife. Holes must also be punched at frequent
intervals that the perspiration may escape. The splint is next lined
with wash-leather, and fitted with a pair of straps and buckles to
keep it in place.
By this plan the fingers are left free, and some motion allowed also
to the thumb. The only joints kept immoveable are those of the carpus
and wrist.
Apparatus of some kind must be worn three weeks continuously; then
for a fortnight longer, while it is removed every day to allow
passive motion of the fingers and gradually of the wrist also to be
practised. Care should be taken to warn the patient that pain and
stiffness last long in these fractures, lest he blame the surgeon
because he does not quickly recover full use of his arm.
=Fracture of the Shaft of one or both Bones of the Forearm.=
_Apparatus._—1. Two straight wooden splints.
2. Pads and wool.
3. 2-inch wide roller.
4. Sling.
The treatment is the same whether one or both bones are broken.
Caution has been already given against bandaging the forearm
underneath the splints.
Step 1. Prepare two straight wooden splints; one to go in front of,
and one behind the forearm. The posterior or outside reaches from the
external condyle to the end of the metacarpus; the anterior or inside
splint from a little below the internal condyle only as far as the
wrist, keeping clear of the ball of the thumb. The splints should be
slightly broader than the forearm, and well padded; towards the lower
end the padding should be thicker than above. The forearm is bent to
a right angle and the thumb put upwards.
Step 2. Reduce the fracture by gentle slow extension at the wrist;
this being effected, apply the splints to the forearm, and let an
assistant hold them while the bandage is rolled on.
Step 3. When a little wool has been wrapped round the hand and wrist,
fasten the dorsal splint by figures of 8 carried round those parts;
then draw the two splints together by simple spirals continued to the
elbow (see fig. 31).
[Illustration: Fig. 31.—Fracture of both Bones of the Forearm.]
Step 4. Support the forearm in a sling, to complete the apparatus.
The splints are worn three weeks; after this, passive motion may be
practised daily, and the splints finally abandoned ten days later.
But a sling is still required some ten days after the splints are
laid aside.
When the ulna alone is broken, an anterior splint reaching from the
inner condyle to the tips of the fingers often suffices without a
second one.
_When the shaft of the radius is broken high up_ (a rare accident)
the displacement is sometimes very difficult of reduction unless
the wrist be well supinated. To preserve this position it may be
necessary to use a wooden angular splint, and to fix the vertical
part to the arm behind the elbow, while the horizontal part is
carried along the back of the forearm.
=Fracture of the Olecranon.=—This fracture, if seen early before
effusion takes place, may be put up at once, but if delay till the
joint is swollen has occurred, the limb must be kept quiet on a
pillow, or on a splint in an easy position with evaporating lotions,
until the effusion is absorbed, before any means can be taken to
restore the position of the olecranon. Though the straight position
of the elbow is usually employed, it is not essential for even very
close union of the fragments.
In treating this fracture the following plan is useful.
_Apparatus._—1. Straight hollow splint.
2. 2-inch rollers and finger rollers.
3. Pad, wool, and lint.
4. Strapping plaster.
5. Pins.
Step 1. Bandage the fingers; wrap the hand in cotton wool and bandage
it. When the wrist is passed, fasten the bandage for a time by a pin,
and straighten the arm.
Step 2. Push the olecranon down as close as possible to the rest of
the ulna, and put a dossil of lint over it. Place the middle of a
strap of plaster an inch wide and 16 inches long, on the lint, and
carry its ends round the forearm in a figure of 8; to some extent
this alone fixes the fragment.
Step 3. Continue the bandage up the forearm by reverses, keeping the
elbow straight; and pass the joint by figures of 8 carried over the
compress of lint and the forearm, to draw down the olecranon (see
fig. 32). When this is secured, prolong the bandage to the deltoid,
to confine the action of the triceps muscle.
Step 4. Pad lightly a hollow splint about 2 inches wide, reaching
from the axilla nearly to the wrist, and apply it along the anterior
aspect of the limb, then fix it by a second roller. This completes
the apparatus.
[Illustration: Fig. 32.—Bringing down the Olecranon with Figures of
8.]
The splints and rollers should be removed on the fourth or fifth day,
that the positions of the fragments may be examined and the roller
again applied to draw them closer together. After ten or twelve
days, passive motion of the wrist and fingers, with pronation and
supination of the radius, should be adopted, but great care is to be
taken that the patient does not inadvertently bend the elbow joint
while free of the splint. The splint must be worn, with the frequent
removals directed above, for five weeks, by which time gentle flexion
of the elbow may be practised.
Hamilton notches his splint at each border about its middle so that
the notches shall be 3 inches below the tip of the olecranon (see
fig. 33). He begins the bandaging by fastening his splint on to the
hand and forearm, as high as the notches; here the roller is carried
above the olecranon and again down to the notches; this is repeated
again and again, each turn below the last, until the notches are all
covered, he then continues the bandage upwards by circular turns
until the top of the splint is reached.
[Illustration: Fig. 33.—Hamilton’s Splint for fracture of Olecranon.]
=Fractures of the Humerus near the Elbow.=—These resemble
dislocations of the ulna and radius backwards, but are distinguished
from them by the ease with which the bones slip into place and again
slip back from it when left to themselves; by crepitus; and, when
the fracture is above the condyles, the common accident, by those
projections retaining their natural relation to the olecranon. In
children and youths the articulating surface of the humerus may
separate from the shaft without carrying the rest of the lower
epiphysis with them. In this rare accident the main distinctions from
the usual fracture are, the projection of the olecranon behind the
condyles; from dislocation, the absence of the hollow of the sigmoid
notch, and facility of reduction.
In ordinary cases, where the deformity is reduced without much
difficulty, and the injury to the joint is not severe, lateral
rectangular splints of leather, hollowed wood, or wire gauze, answer
very well. These are placed both inside and outside the limb, and
reach from the axilla and shoulder to the wrist. They are applied in
the following manner:—
_Apparatus._—1. Lateral hollowed angular splints.
2. Pads and wool.
3. Rollers 2 inches wide for the arm, and 1 inch wide for the fingers.
4. Sling.
Step 1. The splints must be prepared.
Wooden and wire gauze splints are double. One, inside the arm,
reaches from the axilla to the wrist, the forearm being bent to a
right angle. The other extends, on the outside, from the deltoid
to the wrist. They are better if provided with hinges opposite the
elbow, so that their angle can be altered, if desired, in the later
stage of the treatment. Splints of wood or wire gauze must be evenly
and lightly padded before application.
Step 2. Bend the arm to a right angle with the thumb upwards. An
assistant next reduces the fracture, and holds it in position. Then
apply the splints. When adjusting the inside splint, care must be
taken that the internal condyle is eased from pressure by sufficient
padding above and below it. Next fasten on the splints by a roller
begun at their lower end, leaving the hand free, and carried up to
the elbow. Before turning round that joint a soft pad must be placed
in the hollow of the elbow to push the lower end of the humerus back,
and the length of the arm should be measured against the unbroken one
to make sure that the shortening is reduced. Extension is kept up
the whole time the splint is being fixed to the arm, which is done
by carrying the roller round the elbow with figures of 8 and simple
spirals up to the axilla, where it is finished off.
Step 3. Lastly, the forearm is supported in a sling under the wrist,
leaving the elbow free (as in fig. 35, page 52).
After three weeks of complete immobility, passive motion should be
applied to the elbow daily, during a fortnight or three weeks more in
which the splint is still worn.
If the displacement returns very easily, it is better to use an
L-shaped splint passing behind the arm and below the forearm. This
may be made of wood, or of leather, or of gutta-percha, in the mode
about to be described.
The =L-shaped splint= of gutta-percha, or leather, is made as
follows:—
_Apparatus._—1. Sheet gutta-percha ¼ inch thick.
2. A tray or wide wash-hand basin.
3. A basin of cold water.
4. A kettle of boiling water.
5. A towel.
6. A knife.
7. A sheet of newspaper.
Cut a pattern of paper reaching, while the elbow is bent and the
thumb upwards, from the arm-pit down the back of the arm and under
the elbow and forearm to the wrist. The sides must be brought forward
to the biceps and front of the forearm as seen in fig. 34. Next cut
from the sheet of gutta-percha a piece to match the pattern. Prepare
the tray with the hot water, lay in it the towel, and then soften
the gutta-percha by laying it in the tray and covering it with almost
boiling water, adding more water as the first cools; this may be done
by an assistant, while the surgeon directs another assistant to grasp
the forearm and reduce the fracture. The assistant keep extension
while the surgeon lifts the softened gutta-percha with the towel from
the hot and plunges it a moment into cold water, then lays it on the
limb, which the assistant keeps at a right angle, and the bone in
place, while the splint is setting to the limb. This done, the splint
is removed to be trimmed, perforated, and covered with wash-leather.
It is then ready for use.
[Illustration: Fig. 34.—Gutta-percha Splint for fracture at the lower
end of Humerus.]
_Leather_ takes so much time to set that it should not be used in
recent fractures. When the bone is partly set, leather is a useful
substitute for wood. It is prepared from a pattern in the same manner
as the gutta-percha, but is trimmed before soaking, not after it is
moulded, like gutta-percha. If possible it should have twenty-four
hours soaking in _water_ before being fitted to the limb; but when
this cannot be done, immersion in hot water, into which a teacupful
of vinegar has been thrown, will make the leather quite supple in a
quarter of an hour. The leather splint must be worn twenty-four hours
while it sets, and then be removed for covering (see Leather Splints).
=Fractured Shaft of the Humerus.=
_Apparatus._—1. Four straight hollow splints.
2. Rollers 2 inches wide, and 1 inch for the fingers, or straps and
buckles.
3. Pads and wool.
4. Sling.
When broken below the attachment of the deltoid and coraco-brachialis
muscles the displacement of the bone is commonly prevented with
ease; neither shoulder nor elbow-joint need be fixed, and it is not
necessary to apply the splints so tightly as to risk interference
with the venous circulation. If the pectoral muscles or deltoid be
connected with the lower fragment, the displacement is sometimes
obstinate; in such cases it is necessary to buckle the splints
lightly. For this to be done, the fingers, hand, and forearm must be
previously bandaged to prevent œdema; with this addition, the method
of treatment is the same in both varieties of fracture.
Step 1. Select the splints; they should be hollowed, of wood,
perforated sheet zinc, or wire gauze, about 2 inches broad, lightly
padded, and provided with straps and buckles.
The external one reaches from the acromion to the outer condyle; the
inner one from the axilla to the inner condyle; a third shorter one
is placed behind the arm, and if there is much projection forwards of
the lower fragment, a fourth very short one is added in front. The
patient should sit on a chair while the apparatus is being put on.
Step 2. The fingers and thumb are bandaged; then, the hand and
forearm, first padded with a little wool in the palm and over the
wrist, are evenly bandaged to the elbow, round which the roller is
carried while the joint is well flexed; this being covered in, the
roller is made fast.
The first step of bandaging the hand and forearm before applying the
splints is better omitted if the compression requisite to procure the
natural position of the bone does not interfere with the circulation.
Step 3. An assistant grasping the elbow in one hand, pulls down the
lower fragment, while he steadies the shoulder with the other. The
displacement thus reduced, the surgeon applies the splints, taking
care that the inside splint does not reach too high into the axilla,
lest it compress the axillary vein.
In simple cases, the splints should be drawn close by straps and
buckles; where the muscles are powerful, a roller should be wound
round the splints instead of straps.
[Illustration: Fig. 35.—Fractured Shaft of the Humerus.]
Step 4. A 2 inch wide roller is fastened to the arm above the elbow,
and then carried round the trunk to the arm again, to steady the
limb against the body.
Step 5. The hand and wrist are supported by a sling over the
shoulders, the elbow being allowed to hang (see fig. 35).
This apparatus is worn three weeks, when the bandages are removed
from the forearm, and the splints replaced less tightly than before.
They may be substituted by a sheath of gutta-percha moulded to the
arm from the acromion to the elbow, and buckled on to the limb. The
arm must be supported by splints for five weeks, but passive motion
of the elbow and wrist should be adopted after the third week. The
wrist especially should be set at liberty as soon as possible. In
treating this fracture great care is necessary that the bone be kept
in accurate and close position, as the humerus is specially prone to
remain un-united for many months.
=Fracture of the Anatomical or Surgical Neck of the Humerus=, of the
Great Tuberosity, and of the Neck of the Scapula. These fractures are
similarly treated.
_Apparatus._—1. Paper for pattern.
2. Gutta-percha, leather, or millboard.
3. Pads. A soft thin pad, 10 inches long, 5 inches wide (a double
fold of thick flannel or blanket answers very well), is wanted to
line the axilla. If the cap is of leather or gutta-percha, a lining
of wash-leather should be added after the splint is made.
4. Rollers, 2 inches and 1 inch wide for the fingers.
5. Scissors.
6. A tray, and kettle of hot water.
7. A towel, and basin of cold water.
8. Sling.
9. Cotton wool.
Step 1. Cut out a paper pattern of the splint on the limb to be
fitted. The pattern should reach along the clavicle to the root
of the neck, and over the scapula to its posterior border, and be
continued down the arm to the elbow, tapering as it goes, but having
its anterior and posterior margins brought sufficiently to the
inner side of the arm to give the splint a good grasp of the limb
in descending. The end should be left long enough to turn a couple
of inches round the point of the elbow (see fig. 36). A notch must
be cut at the upper end of the paper pattern to make it fit on the
shoulder between the clavicle and the spine of the scapula; this
should not be repeated in the gutta-percha, as that can be moulded on
without; and for that reason the cap is much more serviceable when
made of gutta-percha than of leather, where a notch must be cut and
stitched together when the leather is set. The gutta-percha, when cut
to pattern, must be softened in the manner described in making the
splint for the elbow at page 50, fig. 34; then accurately adjusted
to the shoulder as high as the root of the neck, and turned under
the point of the elbow a couple of inches (see fig. 36), while the
forearm is well raised across the chest.
[Illustration: Fig. 36.—Cap for fracture near the Shoulder.]
When set, the splint must be removed that it may be trimmed and
lined with wash-leather. If of gutta-percha, it must be perforated
with small holes; if of leather, the notch at the shoulder must be
stitched together. Next prepare a soft thin pad, 5 or 6 inches broad,
and 8 or 10 inches long, to fill the axilla.
Step 2. Bandage the fingers and thumb separately, then, putting a
little wool in the palm and round the wrist, bandage the hand and
forearm to the elbow, where the bandage is fastened.
Step 3. Apply the splint. First get on the cap; then put the soft
pad in the axilla, filling it out if the arm-pit is very hollow with
cotton wool, and bend the elbow till the hand lies on the breast
of the opposite side. Then, while an assistant holds the limb and
apparatus in position, fasten them all in place by continuing the
roller of the forearm in figures of 8 round the elbow until the
splint is well fixed to it; and carry the roller up the arm by
reverses to the axilla.
Step 4. A little wool or piece of flannel having been placed in the
opposite arm-pit to prevent chafing, a spica for the shoulder is then
applied (see page 16), beginning at the root of the neck and working
downwards. Careful extension is continued by the assistant all the
time this bandage is being put on, until the head of the bone is well
drawn into the cap.
[Illustration: Fig. 37.—Fracture at the upper end of Humerus. The
apparatus completed.]
Step 5. The arm is drawn to the side, and the forearm fixed against
the chest by a roller carried round the arm and trunk and over the
shoulder (see fig. 37).
After three weeks the forearm may be released, but the cap and
axillary pad must be continued to be worn two or three weeks longer
while the arm is well drawn to the side, and the wrist carried in a
sling.
=Fracture of the Great Tuberosity= of the humerus is difficult to
treat, on account of the tuberosity being carried backwards by the
muscles and the humerus being rotated forwards. Hence the parts must
be braced together with a firm cap of gutta-percha moulded on to
the shoulder while soft, and while the fractured parts are held in
apposition, which may be done by the fingers, or by putting on a wet
roller firmly over the shoulder as a spica before the splint is set.
When the splint is hard the bandage may be taken off, and the splint
removed and finished ready for application. In doing this, the steps
are the same as for fracture of the surgical neck of the humerus,
and the necessity for fixing the arm well to the side of the body as
great as in that fracture.
=Fracture of the Acromion= is treated very much like fracture of the
clavicle, that is, the arm is well raised by a sling under the elbow,
and then fastened to the side. It is not necessary to fill the axilla
with a pad, as in fracture of the clavicle, for in this case the
shoulder is not drawn inwards.
=Fracture of the Clavicle.=
_Apparatus._—1. Axillary pad.
2. Roller, 3 inches wide.
3. Sling.
4. Wool.
Fractures of the clavicle nearly always leave some deformity after
union; this is best avoided by keeping the patient on his back on a
flat couch with the head alone supported by a cushion, and the arm
fixed to the side until union has taken place. As most persons will
not submit to a fortnight or three weeks’ confinement in bed for
this accident, the fragments must be kept in position as nearly as
possible by apparatus while the patient goes about.
The displacement of the outer fragment is _inwards_, _downwards_, and
_forwards_. Many varieties of apparatus are employed to prevent this
displacement during union; the following mode is perhaps as effectual
as any other in accomplishing this object.
Step 1. Fix in the arm-pit a firm wedge-shaped pad of bedtick filled
with chaff; 5 inches broad, 6 inches long, and 1½ or 2 inches thick
at the thick end, or just enough to fill the axilla and throw out the
humerus without compressing the axillary vein, hence the thickness
varies with the hollowness of the axilla (see fig. 38). A band and
buckle are stitched to the thick end, which is uppermost. When in
use, this band is passed over the opposite shoulder and keeps the
pad in place. A little wool should be put under the band, where it
crosses the root of the neck, to prevent chafing.
[Illustration: Fig. 38.—Wedge-shape pad for broken Collar-bone,
attached to the American ring-pad.]
Step 2. The elbow is elevated by an assistant, who keeps the arm
vertical and lays the fingers on the breast bone. A roller attached
to the arm by a couple of turns is carried behind the back round the
trunk, and over the arm above the elbow, drawing that close to the
side.
Step 3. To support the elbow, the longest border or base of a
three-cornered handkerchief is carried under it, one end passes in
front, the other behind the body; both are then drawn tightly and
crossed over the opposite shoulder, where one end is taken under the
axilla, and tied in front. In giving this direction the ring-pads
shown in the figures are supposed not to be at hand. Lastly, the
loose corner at the wrist is folded neatly and pinned up (see fig.
39).
[Illustration: Fig. 39.—Apparatus for broken Clavicle finished.]
This apparatus must be watched from time to time, and re-adjusted if
any part slips. The sling and pad are to be worn for four weeks.
Union sometimes takes place in three weeks or less, in which case the
pad may be removed so much the earlier; but a sling should be worn
for a fortnight after the bandage and pad are laid aside. In children
the pad must be very much thinner and shorter than that described;
the sling should be replaced by a bandage carried alternately round
the body, and over the opposite shoulder. After it is put on the
turns should be well stitched together, and smeared over with stiff
starch. In bandaging children, great care must be taken to protect
with wool the parts likely to be chafed.
_Figure-of-8 bandage._—Many surgeons still employ a figure-of-8
bandage carried under each axilla and crossed behind the back.
Under any circumstances this is exceedingly irksome to the patient,
but is least so if two silk handkerchiefs be substituted for the
bandage, one being passed round each shoulder and the ends of both
braced tightly together behind the back. The wedge-shaped pad may be
dispensed with if the shoulders are braced back, but the elbow must
still be raised and drawn to the side.
The American surgeons have a very good plan for attaching the sling
to the sound shoulder. Instead of carrying the ends of the sling
round the shoulder and under the axilla, they pass over the shoulder
a loose but well-stuffed collar or ring-pad (see fig. 38), to which
they fasten the ends of the sling in front and behind; this prevents
all cutting or chafing under the armpit, and distributes the strain
evenly.
LOWER EXTREMITY.
=Ruptured tendo Achillis= is treated by extending the foot and
flexing the knee; for this purpose the patient wears a high-heeled
slipper. A band is sewn to the heel, drawn tight, and fastened to a
buckle and strap round the thigh, just above the knee. The patient
should not walk for a month unless he will use a wooden leg on which
he can kneel, with the knee bent.
=Separation of the Epiphysis of the Calcaneum=, which sometimes
occurs instead of rupture of the tendo Achillis, is treated in the
same way.
=Fracture of the Fibula.=—_Dupuytren’s Splint._—When the fibula only
is broken, it may be treated in several ways; this, however, is the
common plan:—
_Apparatus._—1. Straight wooden splint.
2. Pad and wool.
3. A roller.
Step 1. The splint should be about 3 inches broad, and long enough
to reach from the head of the tibia to 4 inches beyond the sole of
the foot. A notch 1½ or 2 inches deep is generally cut at the lower
end of the splint to catch the bandage in. The splint is then padded,
care being taken that the padding is sufficiently thick to prevent
galling at the upper end against the inner condyle of the tibia, and
that it becomes thicker as it descends along the leg, for that to
rest easily against the splint; lastly, the pad should end in a thick
boss or projection opposite the internal malleolus, beyond which it
should not reach, lest it interfere with the rotation and adduction
of the foot inwards.
Step 2. The splint, when thus prepared, is applied along the inner
side of the leg, taking care in doing this that the internal
malleolus is against the middle of the splint, and not allowed by the
assistant to slip towards the anterior or posterior border.
Step 3. A roller is then carried round the limb and splint, beginning
below the knee and continuing in simple spirals for three or four
turns, when it is fastened and cut off.
Step 4. A light layer of wool is wrapped round the outside of the
ankle, heel, and dorsum of the foot. Then a roller, beginning at
the splint, passes outwards in front of the ankle over the external
malleolus, behind the heel and the splint; then over the dorsum to
the outer margin of the foot, next under the sole through the notch
of the splint to the front of the ankle joint again, where it repeats
the same course three or four times. Each turn must be tightly
applied and made to draw the foot well inwards to the splint, and in
doing so to tilt outwards the broken part of the fibula (see fig. 40).
This splint is cumbersome, hence after two or three weeks, should
be replaced by a light starch or gum casing for the foot and leg,
leaving the knee free.
[Illustration: Fig. 40.—Dupuytren’s Splint for fracture of the
Fibula.]
=Fractures of the Tibia= with or without the fibula, and fractures at
the ankle joint.
These fractures are often from their obliquity difficult to keep in
good position; in such cases _McIntyre’s Splint_ is very generally
used in the early part of the treatment. For this splint the
following _apparatus_ is required:—
1. McIntyre’s splint.
2. Pads for the double incline plane and foot-piece.
3. Sock of flannel for the foot.
4. Rollers, 3 inches wide.
5. Wool, pins, needle and thread, strapping plaster.
6_a_. A sling-cradle, or
6_b_. Board, block, gimlet, screws and screw-driver.
The McIntyre’s Splint may be used either bent or straight, whichever
position of the knee most relaxes the tension of the muscles on the
fragments. As a general rule the straight position is best if the
fracture is high up, and the bent one, when near the ankle joint.
Step 1. A splint of suitable length is selected, by measuring the
sound leg. The joint of the splint should be put opposite the
patella, and space be left below the foot for the foot-piece to slide
along the slot when extension is made.
The splint is next padded, the hollow where the lower part of the
calf and small of the leg will come being well filled, that the leg
may be thoroughly supported; but the space behind the heel and tendo
Achillis must be left quite clear. A small pad is then fastened by a
strip of strapping or by needle and thread to the foot-piece.
Step 2. The limb having been first cleaned and dried, the dorsum of
the foot and ankle are wrapped in an even layer of cotton wool. A
sock or boot made of flannel is next put on the foot. This may be
readily extemporised by cutting off the foot of an angola stocking,
slitting it up along the back to the toes, and sewing on to the
sole, one inch in front of the heel, the middle of a piece of tape ¼
inch wide and 18 inches long. The foot is then wrapped in the sock,
the edges drawn together by a needle and thread, care being taken
that the sock fits closely round the ankle and dorsum of the foot.
A little wool having been wrapped round the knee, the limb is next
raised, while the splint is placed under it; the screw is turned
until the inclined planes are at an angle suited for the maintenance
of the fragments in position, and the foot-piece is pushed up to
the foot with its screw-pin loose, that it may be adjusted to the
amount of flexion or extension necessary for the foot; this being
ascertained, the screw is tightened to keep it so while the foot is
fastened to the foot-piece. For this the strings of the sock are
brought over the top of the foot-piece, and drawn tight before tying
them.
[Illustration: Fig. 41.—McIntyre’s Splint. The thigh fixed ready for
extension of the leg.]
The position of the heel is very important. It should not sink below
the splint, or it will rest on the bandage; neither should it be
drawn up too high, or the weight of the leg will hang on the sock,
instead of resting on the pad; both frequent causes of pain at the
heel. When the proper position is obtained, the strings are made fast
to the pin behind the foot-piece, and the foot is steadied by two or
three turns of a roller carried round it and the foot-piece (fig. 41).
Step 3. The thigh is next fastened to the thigh-piece by a roller
carried from the top of the splint downwards along the thigh to the
knee, or below that joint if the fracture is near the ankle.
In doing this the roller is passed inside the screw, should that be
placed underneath the splint, as in fig. 43 page 65, and not at the
side as in fig. 41, for the screw will be wanted free for further
adjustment.
[Illustration: Fig. 42.—McIntyre’s Splint slung in Salter’s Cradle.]
Step 4. An assistant grasps with both hands the foot and foot-piece,
and pulls them downwards until the shortening is removed. While doing
this, he tilts the foot up or down as the surgeon finds necessary
for adjusting the fragments, who also bends the knee and raises or
lowers the foot until a good position is attained. The general rule
is to keep the great toe in a line with the patella. This done, the
surgeon tightens up the screw-pin of the foot-piece, and completes
the attachment of the foot by continuing his roller with figures of 8
round the foot and ankle; these turns should not however pass above
the fracture, and be no more than sufficient to secure the position
of the foot and of the lower fragments (see fig. 42).
Step 5. The bandaging usually ceases with what has been already done;
but if the limb swell, a separate roller may be carried along the leg
to support the muscles and restrain œdema, otherwise the leg is best
left bare, that the position of the fragments may be watched, and
evaporating lotions applied.
[Illustration: Fig. 43.—McIntyre’s Splint raised on a Block.]
Step 6_a_. This consists in slinging the limb, for which Salter’s
Cradle is very convenient (see fig. 42), or an ordinary bed cradle
answers very well, from which the limb can be slung on pieces of
bandage carried underneath the splint at the knee and ankle.
_b._ Instead of elevating the limb by a sling, it is also customary
to raise and fix the splint on a block (fig. 43), 6, 8, 10, or even
12 inches high, as may be necessary; this block slides in a groove
on a board 3 feet square, put between the mattress and bedstead, to
afford a firm support for the block.
In ordinary cases the limb is kept on the splint three weeks, until
the irritation has subsided, and partial union is attained; the
splint may then be replaced by a starch bandage, and the patient may
leave his bed.
=Transverse Fracture= of the _tibia_ alone, or even of both bones,
when the displacement is small, is very well treated by a hollow
splint on each side. Both splints are cut away opposite the malleoli,
and the foot-piece of the inside one should not extend beyond the
tarsus; that of the outside passes to the toes. The splints reach on
each side to the head of the tibia, but ought not to extend above the
knee-joint (see fig. 44).
[Illustration: Fig. 44.—Outside lateral Splint for the Tibia.]
Step 1. They are padded lightly and evenly along their whole length,
and applied to the limb on each side.
Step 2. They should then be fastened by figure of 8 round the foot
and ankle until the foot is securely fixed in them. The bandage
should then be fastened off, and extension made by an assistant, who
grasps the foot and ankle with both hands while the surgeon fixes
the splints to the limb above the fracture, beginning his roller
at the top just below the knee, and continuing it downwards with
spiral turns until the fracture is reached, above which it should
terminate (fig. 45). After the apparatus is applied, the limb may
be either supported upright by sand-bags, or slung in a cradle, for
three weeks, after which the splints are advantageously replaced by a
starch bandage for three weeks longer.
[Illustration: Fig. 45.—Lateral Splints for simple transverse
fracture of the Tibia.]
_Flexing the Leg for Fracture of the Tibia._
Sometimes, when there is unusual difficulty in preventing
displacement of the fragments while the limb is nearly straight, the
bones can be readily kept in position if the patient lies on the same
side as the injured limb and the knee is well flexed. For such cases
these splints are very suitable; they should be applied after the
limb has been bent and the fragments brought into apposition. When
the splints have been put on, a roller may be carried round the leg
and thigh to keep the limb in its bent position.
=Fracture of the Patella.=—When this bone is broken there is usually
much swelling from effusion into the knee-joint; while this is
present, rest, with cold lotions, and elevation of the foot, are
alone applicable. When the effusion has subsided, the upper fragment
must be brought down to the lower one, by some means like the
following.
_Apparatus._—1. Straight wooden splint with a foot-piece.
2. Pads.
3. Diachylon plaster.
4. Roller.
5. Lint and wool.
6. Two hooks or screws, gimlet, and screw-driver.
Step 1. The splint is first fitted; it should reach from the buttock
to the heel, at which point a foot-piece rises for the foot to rest
against; at the back of the splint a line should be marked 3 inches
above, and another 3 inches below the knee-cap, into which a stout
screw or hook is inserted before the splint is put on. It is then
well padded, to support the calf and leg, while the heel is left
free, and a pad is put between the sole and the foot-piece. A firm
crescent-shaped pad is prepared to sit like a saddle above the upper
fragment.
Step 2. The limb is laid on the splint; an assistant draws the
patella as nearly as possible into its place, and the surgeon lays
the crescentic pad on the thigh above the patella, and takes a strap
of plaster 2 inches broad and 20 long, warms it, and lays the middle
across the compress, drawing each end tightly around the limb, and
then downwards and forwards in a figure of 8; a similar strap is then
fixed below the lower fragment. The knee, shin, ankle, and foot are
then protected by a layer of cotton wool, and the bandaging begins.
Step 3. The roller first fastens the foot against the foot-piece by
figures of 8, then passes up the leg by reverses until opposite the
lower hook, where it is fastened.
[Illustration: Fig. 46.—Fractured Patella, drawing down the upper
fragment.]
Step 4. A second roller is then begun at the top of the thigh and
brought down the limb till it reaches the compress over the patella;
from this point it passes below the lower screw at the back of the
splint and makes one circular turn round the limb; the roller is then
taken upwards across the compress (as shown in fig. 46) to the upper
screw, where it also makes a circular turn; having done this it again
descends to reach the lower screw, and is returned as before. Each
of these turns should be drawn tightly to bring the upper fragment
as near the lower one as possible; when this is done the bandage is
completed over the knee by figures of 8. It suffices to fix the lower
fragment, which cannot be drawn up to meet the upper one; the latter
must descend to it.
Step 5. The limb is lastly put into position by elevating the heel
and by raising the body with pillows till it is in a half-sitting
position.
The patient wears this splint four weeks, during the first fortnight
of which the bandage should be perseveringly re-applied every three
or four days until the upper fragment is brought into apposition
with the lower one. After this the splint may be changed for a light
starch or gutta-percha case, to be worn for six weeks more, and
then replaced by a back splint of leather and knee-cap, that must
not be laid aside for another period of three or four weeks. If the
patient can be persuaded not to bend his knee for four months, the
union of the fragments will be less likely to yield afterwards. He
should be also warned that much stiffness will result from the long
fixed position necessary to procure good union between the fragments;
but the stiffness will all subside in time, notwithstanding the
long-enforced rigidity.
_Strap and Spiral Bandage._
_E. K. Samborne’s Plan of drawing Patella Fragments together._—A
strip of diachylon plaster 4 feet long and 2½ in. wide is applied to
the front of the limb from 2 in. below the groin to the small of the
leg, leaving a free loop or doubling opposite the patella. Beneath
this loop a firm compress or horseshoe pad is placed above the upper
fragment. A roller is then carried round the limb to keep the strap
in place, but leaving the loop at the knee exposed. This done, the
body is propped up in a half-sitting position, and the limb elevated
on an incline. A stick, 6 inches long and ½ inch thick, is inserted
into the loop of plaster, and then twisted round and round till, by
shortening the loop, the loose tissues of the thigh, and with them
the upper fragment of the patella, are drawn down to the knee. The
stick is prevented from untwisting by a roller lightly carried round
the knee. As the plaster slackens, the stick may be tightened from
time to time and the fragment brought in a few days into its proper
place.
[Illustration: Fig. 47.—Malgaigne’s Hooks.]
_Malgaigne’s Hooks_ (fig. 47), for drawing closely and holding
together the fragments in transverse fracture of the patella, or of
the olecranon, often procure a closer union than any other method.
They should not be inserted until effusion is absorbed and the
soreness has subsided. To insert them, one pair of hooks should be
bedded in the ligamentum patellæ, and catch against the lower edge of
the bone; the skin is then drawn up the limb, while the upper pair
of hooks is passed through it and behind the upper fragment; the
two ends are then approximated by turning the screw. The fragments
usually do not come quite close the first day, but the next they can
be drawn so firmly together that if one is moved the other goes with
it. In applying the hooks care should be taken that the upper pair go
well through the skin and fascia behind the bone, or when they are
screwed up the upper fragment is apt to ride unevenly over the other,
and exact junction is lost. The pain of the insertion soon passes
off, and the hooks can commonly be worn without annoyance for five
or six weeks, until union is secured.
=Fracture of the Shaft of the Thigh-bone.=—_The long Splint._
_Apparatus._—1. A wooden splint.
2. Rollers, 3 inches wide.
3. Perineal band.
4. Strapping, needle, and thread.
5. Pad and wool.
The splint for an adult should be 2½ or 3 inches wide, and long
enough to reach from the nipple to 4 or 5 inches beyond the heel;
two round holes ¾ inch diameter are cut at its upper end, and at the
lower one two notches 2 inches deep.
_Liston’s Mode of applying the Long Splint._
Step 1. The end of a roller is split for a few inches, and tied in
the holes at the upper end. The roller itself is carried down the
inside of the splint and attached temporarily to the notches at the
other end; a pad is then fastened on, by drawing the margins together
with needle and thread across the outside of the splint, or by tying
strips of bandage round the pad and splint at short distances.
Step 2. The limb having been washed with soap and water, well dried,
and afterwards dusted with starch powder, especially at the perinæum,
the ankle and dorsum of the foot are wrapped in a layer of cotton
wool, and the splint applied along the outside of the body. The
bandage which was fastened to the splint is now released from the
notch; and, taking with it the end of the pad, is carried under the
sole, then over the ankle joint to the splint, and behind the ankle
round the internal malleolus to the dorsum of the foot, then through
the lower notch of the splint to the inside of the foot again. This
figure of 8 is carried four times over the dorsum of the foot, twice
through each notch of the splint, and is made fast by a pin or a
stitch. In doing this, care must be taken to keep the leg and splint
parallel, and that the splint does not ride over the back of the
foot; the external malleolus should be midway between the margins;
moreover, the bandage must fit firmly round the ankle and splint, not
spreading over the dorsum more than can be helped, to avoid straining
the front of the ankle. Means for more effectually preventing this
will be afterwards detailed.
Step 3. Next apply counter-extension; for this, the perineal band
is used. The band consists of a silk handkerchief or napkin folded
into a _flat_ ribbon, 1 inch wide and covered for about 1 foot of
its length with oiled silk. A piece of smooth brown paper, 1 foot
long and 4 inches wide, folded into a ribbon one inch wide, makes an
excellent foundation for the silk handkerchief to be folded upon. A
band thus prepared is too stiff to become a cord after it has been
worn a few days, which a simple handkerchief is apt to do. One end of
the band is passed in front in the groin, and one behind the buttock,
so that it bears on the tuber ischii in the perinæum; the ends are
then drawn separately through the holes in the splint. All being
ready for extension, an assistant, grasping the leg and splint above
the ankle, pulls out the shortening till the broken bone is in a good
position; the ends of the band are then tightened and made fast in a
knot.
Step 4. First protecting the bony points with cotton wool, the
muscles about the hip are confined by a spica carried round the body
and the splint, not merely a simple figure of 8 as depicted in the
figure, but a series of overlapping turns which ascend and cover in
the hips well. Afterwards the upper end of the splint is drawn close
to the body by a few turns of a broad roller carried round the chest
from _above downwards_ (see fig. 48).
[Illustration:
Fig. 48.—The long splint, with elastic stirrup extension at the
foot. Bandage carried up to the seat of fracture.
]
Step 5. It is customary to carry the bandage further than the ankle,
but this is not an essential part of the apparatus, which is simply
to keep up the extension in the direction of the axis of the limb.
This subsidiary bandage has the disadvantage of concealing the limb,
and the position of the broken ends of the bone; but it steadies the
limb on the splint, and confines the muscles, thereby preventing pain
and perhaps hindering rotation outwards of the upper fragment. Before
putting it on, some cotton wool is wrapped round the knee, and laid
along the shin; the application of the roller is then begun at the
ankle where it first terminated, and is carried up the leg, over the
knee, and along the thigh by reverses until the groin is reached,
where it finishes.
The perineal band must be changed whenever it gets soiled, and the
skin washed before a clean one is adjusted. After the first few days
the band need not be very tight; it suffices if not slack or loose.
Mr. Coxeter makes india-rubber tubes in the shape of a perineal band;
these are filled with water when in use (see fig. 49).
[Illustration: Fig. 49.—Coxeter’s elastic perineal band.]
_Stirrup extension_ is a mode of relieving the strain on the front of
the ankle, caused by the lower end of the splint being attached to
it. A 3-inch wide roller or bit of wood of the same breadth is laid
against the sole of the foot, and a stout india-rubber ring 2 inches
in diameter is slipped over it. A piece of strapping plaster, 2½ feet
long and 2 inches wide, is passed half-way through the ring, and its
ends carried up the leg inside and outside; the plaster is kept in
place by a roller or second strip laid on in spirals up the limb as
in fig. 50, and the india-rubber ring is hitched against a hook at
the end of the splint. By this means the strain is transferred to the
leg, and the ankle is quite free. It is perfectly successful, and
very easy to the patient.
The long splint is to be worn continuously for six weeks; or, what
is better, after the first three weeks it may be replaced by a starch
bandage, and the patient allowed to get about on crutches with his
leg slung from his neck.
[Illustration:
Fig. 50.—Mode of fastening the stirrup to the leg, to avoid
straining the ankle.
]
=Continuous Extension with the Limb flexed.=—The muscles attached
to the upper end of the femur sometimes cause so much flexion and
rotation outwards of the upper fragment that union of the bones in
this position produces a result approaching that in fig. 51, drawn
from a preparation in the museum of University College.
This crooked union is prevented by bending the thigh and relaxing the
muscles of the hip. This object is accomplished by using the _double
incline planes_ or the _double incline planes, slung_, shown in figs.
52 and 53.
[Illustration:
Fig. 51.—Fracture below the trochanters; bone in angular union.
]
_Double incline planes_ are sometimes employed alone. The limb is
raised over a wooden frame about 8 inches broad, with a double slope
high enough at the apex for the leg and foot to hang unsupported down
the further side (fig. 52). It is well padded before being applied,
and the leg and thigh secured to it by a roller passed round the
limb and plane, or better, a trough of gutta-percha may be moulded to
the limb while it is on the plane, and when set, screwed down to the
wood at one or two points; in this the limb rests securely.
[Illustration: Fig. 52.—Double incline planes.]
=Slinging the double incline planes= was practised many years ago
by Mayor of Lausanne, and has been much used recently. It is an
apparatus very easy for the patient, and particularly well suited for
compound fractures of the thigh, for fractures near the trochanters
that require a flexed position, or for fractures of the neck of the
femur where the patient’s feebleness does not permit the constraint
of the long splint.
_Apparatus._—1. A bent wire frame (see fig. 53) with a separate
foot-piece.
2. Two pulleys, a rope with tent stretchers passing up to hooks in
the ceiling, or some suitable support.
3. One long and one short soft pad.
4. Strapping plaster, and some ends of bandage.
Step 1. The limb is washed and dried, and the short pad fitted to the
foot-piece, which is furnished with some hooks at its lower surface,
where ends of bandage or tape can be fastened, for fixing it to the
wire frame. The frame is next prepared by passing strips of bandage
across it from side to side at short intervals, to make a support
on which the limb is laid; if there is no wound, a soft pad may be
put on the frame first, but if one be present, the limb should rest
immediately on the strips of bandage, which can be changed whenever
soiled, and replaced by clean ones without disturbing the limb. These
strips should be tacked on with a needle and thread, that, when the
limb is placed on the apparatus, they can be shortened or lengthened
till the leg bears evenly on them (see fig. 53).
[Illustration: Fig. 53.—Double incline plane, slung.]
Step 2. The foot-piece is adjusted and fastened to the foot by straps
of plaster carried round it and up each side of the leg, as was done
for the stirrup extension in the “long splint” (p. 76).
Step 3. The limb is next placed in the cradle formed for it, to the
lower end of which the foot-piece is tied securely; the ropes are
rove through the pulleys and tightened till the limb swings easily.
The point of attachment of the ropes must not be just above the
limb, but beyond it, that the leg may be drawn away from the body
along its own axis. The weight of the body makes counter-extension
sufficient to remove all shortening in a few days. The relief from
the constraint attending the absolute immobility of the long splint,
renders this apparatus a particularly easy one for the patient; and
union is found to take place without any shortening of the limb.
Where there is no wound, the limb and frame may be kept together by
a roller bandage carried round them from the toes to the knee, after
the limb has been adjusted in the splint.
=Continuous Extension in the straight position= is employed for
fractures of the femur and in hip-disease. It is procured as follows.
A stirrup is fastened to the leg in the way described at page 76;
to this a cord and weight are attached below the sole of the foot,
and passed over a pulley fixed to a tripod frame (fig. 54), or any
convenient object below the bed, in a line with the axis of the
limb. The weight should balance the contraction of the muscles, and
usually varies between 2 and 6 lbs. A perineal band fastened behind
the patient’s head keeps the body from following the limb. The weight
may be a common scale weight, or a bag with a hole at the bottom
closed by a string, and filled with shot or sand, or a can with a tap
at the bottom filled with water: these arrangements allow increase or
lessening of the weight, without slackening the cord and moving the
limb. This apparatus requires no bandages, which are so difficult to
keep clean in children, and exerts a very even and continuous strain
on the limb.
[Illustration: Fig. 54.—Fracture of the femur. Extension by weight
and pulley.]
The perineal band may be often dispensed with, by laying the patient
on a flat mattress and raising the foot of the bedstead a few inches
higher than the head; the body then sinks towards the head of the bed
and resists the extension of the leg.
=Starch Bandage.=—The following mode of applying the starch bandage
and pasteboard splints may be used in all varieties of fracture;
the length of the splints and the number of joints that should be
included depend on the bone that is broken.
Some surgeons apply the starch apparatus immediately after the
fracture has happened, others wait until partial union is procured
and the irritability of the muscles has subsided.
_Apparatus._—1. Sheets of bookbinder’s millboard.
2. Rollers suitable for the size of the limb.
3. Cotton wool.
4. A basin of freshly scalded starch.
5. A long strip of plaster, to reach as high as the bandage will
extend up the limb.
6. If the fracture be recent, a wooden splint will generally be
necessary to keep up extension while the starch is drying.
As a general rule, the joint at the lower end of the fractured bone
should always be fixed, and that at the upper end also, if the
fracture is near that point. For an example of the mode of fitting,
let us suppose the femur is broken between the middle and lower
thirds as in fig. 56.
Step 1. The limb is first measured for the splints. The length from
the top of the sacrum to the heel, from the tuber ischii to the
inside of the foot, and from the iliac crest to the outside of the
foot, should be taken, and three strips of millboard prepared of
corresponding lengths; the posterior one being 3 inches wide above
and 2 inches, or, if the limb is small, 1½ inches wide at the heel.
The inner and outer strips of similar width must be cut with side
pieces for the foot, and these side-pieces stop short of the roots
of the toes. For a child’s thigh, the foot need not be included, it
suffices for the splints to reach the small of the leg, though to
prevent shortening in an adult it is usually necessary to include the
whole limb. The splints are readily cut, by first marking on the
sheet of millboard, the required width and length of the strips, then
bending the sheet over the edge of a table along these lines. The two
lateral splints may be first taken from the sheet in one wide strip,
after allowing for the foot-piece; the two strips are separated
through a diagonal line, so that the broad end of one splint is taken
from the other (see fig. 55).
[Illustration: Fig. 55.—Diagram showing the mode of cutting out
splints from a sheet of millboard.]
When the strips are cut they should be laid on a large tea-tray,
boiling water poured over them, and a minute or two later, some
boiling hot thin starch; this soon soaks into and softens the
millboard till it is thoroughly pliant. When somewhat softened, the
edges should be thinned by peeling off little strips along them,
after which some more boiling water may be poured on and allowed to
soak in while the limb is prepared.
Two or three rollers should then be unwound, and passed as they are
rolled up again through the basin of starch; these, thoroughly soaked
in starch, are used for the first layer, dry rollers serve very well
for the second layer.
Step 2. The limb is washed and dried; a strip of diachylon plaster
one inch wide is laid along the front to protect the skin when the
case is being cut open after it is dry; the limb is next wrapped
evenly in cotton wool, putting a scrap between each toe. This is
best done by unrolling a sheet of wadding, splitting the sheet into
a layer of suitable thickness, which is torn into strips about three
inches broad, that are then wound evenly round the limb as high as
the splints will reach.
Step 3. The splints are next adjusted and moulded to the limb, being
temporarily secured by a few ends of bandage tied round them. One
assistant grasps the splints and foot at the ankle and keeps up
extension, while another holds the thigh. The surgeon then proceeds
to roll the bandages, first round the foot and ankle, and then up the
leg, rubbing in the _warm_ starch as he proceeds. Each turn of the
roller should be made as tightly as possible, for when the case dries
it always grows loose by the evaporation of the water it holds. As
reverses are always difficult to cut through afterwards, they should
be avoided, and the bandage laid on in simple spiral or figure of
8 turns. When the perinæum is reached, the surgeon wraps round the
pelvis a broad strip of cotton wool, while an assistant on each side
of the patient supports his body on a folded sheet or jack-towel, and
a third holds the broken limb. The bandaging is then continued in a
well-fitting spica, and ended by a few circular turns round the body.
If the splint touches the crest of the ilium it should be shortened
till it clears that point, or it will gall the patient afterwards.
A fold of soft lint in addition to the cotton wool should line the
splint at the perinæum, or the sharp edge of the bandage, when it is
dry, will chafe there also. When the first bandage is complete, the
limb should be smeared again with starch, and a dry bandage rolled
over it from below upwards, which must be similarly saturated with
starch as it is laid on the limb, and when finished the whole is well
covered with starch.
If the fracture is recent, and no union has taken place, a long
splint should be put on outside the case, fastened to the foot and
extended by a perineal band, while the starch is drying, that the
limb may not shorten. With children it is best to apply the wooden
splint in all cases, as they are apt to wriggle about, or sit up in
bed and disarrange the case while it is in a pliant condition. If
the wood splint is not used, the limb should be supported in a good
position by sand-bags laid along its sides.
[Illustration: Fig. 56.—Starch Bandage.]
In three days the starch is quite dry, but the drying may be hastened
by hot-water bottles or hot sand-bags laid in the bed. It must then
be cut up along the front from bottom to top; it will often be
found loose, especially where swelling had existed before; this is
best remedied by paring the overlapping edges with scissors. If any
projecting part is chafed, an accident that ought not to happen,
the case may be lifted from the sore part by a little more wool laid
around, _not on_ the part pinched. The limb being in a satisfactory
position, and the case fitting properly, a roller is carried up over
the whole to keep it in place while it is worn (fig. 56).
The patient need not now be confined to bed; on the contrary, the
limb should be supported by a sling round his neck, while he gets
about with crutches, if his leg be the part injured.
The fracture should be examined from time to time, and at the end of
three weeks some of the joints previously confined in the splint may
be released by cutting off the part covering them; but if the part is
a dependent one, such as the leg, it should be supported by a bandage
after the splint has been removed. The limb may also be washed with
soap and water, and then anointed with simple ointment, if the skin
be roughened or irritated by long confinement.
In six weeks the starch splint may usually be discarded, and a roller
alone worn for a few weeks longer.
=Plaster of Paris Bandage.=
_Apparatus._—1. Freshly burned white plaster of Paris. If the plaster
have become stale by keeping in improperly closed vessels, and it
be impossible to obtain fresh plaster, the water the plaster has
absorbed from the atmosphere can be driven off by heating the powder
in a dry oven to about 200° F. to 260° F., but not higher, as greater
heat destroys the power of “setting.”
2. Rollers, about 2¼ inches wide, of muslin with a coarse open
texture.
3. A roller of Welsh flannel 3 inches wide and 6 yards long.
4. Basin of cold water, sponge, and a kitchen spoon.
5. Soft lard or spermaceti ointment.
Step 1. The muslin rollers are prepared by being loaded with dry
powder just before they are used. To do this the roller should be
gradually unrolled on a table while one person rubs in the powder,
and a second rolls the loaded bandage up again. When three or four
are loaded they should be plunged for a minute into cold water, and
then are ready for use. While this is being done the limb should be
thoroughly washed and dried, supported, if the fracture be recent, by
sand-bags.
[Illustration: Fig. 57.—Plaster of Paris Bandage, for simple fracture
of the tibia, and common bed cradle.]
Step 2. The surgeon carefully greases the limb wherever the plaster
will reach, and rolls a Welsh flannel roller round it for about
3 inches at the point where the plaster roller will cease. This
protects the skin from the rough edge of the plaster splint when the
apparatus is set and hard. Indeed, if the whole of the surface to be
covered with plaster be enveloped in a flannel roller, the apparatus
is more comfortable to the patient, and in this case the grease may
be dispensed with. When the limb is prepared the surgeon intrusts
it to assistants, who will maintain reduction while he lays on the
plaster rollers, wetting them freely as they are laid on, with a
sponge at hand in a basin of cold water. Usually two layers of roller
give sufficient rigidity to the apparatus; but if the limb is heavy,
the case should be strengthened, by smearing over it a coating of
plaster, prepared by shaking the powder into a basin of water kept
constantly stirred, till it has the consistence of cream. The surgeon
must watch that the fractured bones are kept in position till the
plaster is set, a process sufficiently advanced in five minutes, when
the bandage, supported by sand-bags, may be left to dry.
When the plaster is quite set the bone is immoveable and may be
carried about without risk of displacement. In deciding what joints
should be included in the bandage, the same rules obtain in this as
for the starch bandage; no more joints should be rendered immoveable
than are necessary to obtain command of the broken bone; when the
fracture is near a joint, that must be confined to prevent the bones
being moved with the movements of the joint; when the fracture is far
away from it, sufficient control can be exercised over the bone to
prevent the broken ends moving, and the joint may remain free.
If the plaster apparatus is applied over a wound, the latter
should be covered with greased lint, and its position noted before
the rollers are applied; when the apparatus is set, the plaster
must be dissolved around the wound by touching it with strong
nitro-hydrochloric acid; when this is carried completely round, the
isolated fragment of plaster may be removed, and the wound exposed.
For removal, the roller can be unwound again readily, or it can be
softened by acid along a line, and slit up with scissors, when the
apparatus comes off in a piece.
Should bandages of loose texture not be at hand, _common rollers_ can
be made to answer the purpose tolerably well in the following way.
Having washed and dried the limb, and reduced the fracture; the bones
are held in position by assistants, while the limb is greased and
enveloped in a dry roller by simple turns and figures of 8. A basin
of plaster is prepared by shaking the powder into water till a thin
cream is formed, which is laid on the bandage with a spoon, or the
hands. Then a second but wetted roller is put on in the same way
quickly before the plaster has set, and covered in its turn, until a
case of sufficient thickness is procured.
This bandage is much improved if the first roller be of flannel
instead of calico. The flannel roller may be unrolled and loaded with
dry plaster, like the muslin, and wetted before using; in this way
it contains nearly as much plaster as the loose webbing rollers of
muslin.
In the Army Medical Reports for 1865 (1867), Mr. Moffitt describes
a very ready method of employing the plaster splints for recent
fractures. Instead of bandaging the limb, an envelope of Welsh
flannel is fitted to the part to be supported.
The flannel should envelope the limb, except for a longitudinal
space about ½ inch in width between the edges of the flannel. The
dotted lines in the accompanying figure show the shape of the flannel
when fitted to the leg. The limb being thoroughly greased, the
flannel is well soaked in thin plaster cream, and laid on a table
while the creases are smoothed out of it.
When ready it is applied accurately to the limb, so as to fit
everywhere, but leaving a narrow open space along the whole length of
the limb. The flannel must be held steadily till the plaster is set,
which takes place in about five minutes, and the splint is complete.
If one layer is not stiff enough, a second may be laid over the first
in the same way. When the splints are fitted, they are kept in place
by a roller applied lightly over them. If instead of soaking the
second layer of flannel in plaster, it be thickly spread with strong
solution of British gum (dextrine), and the gummed side laid next
the first flannel, the splint is tough enough to stand any ordinary
strain without breaking.
[Illustration:
Fig. 58.—Moffitt’s method of applying plaster of Paris splints.
Copied from Army Medical Reports for 1865.
]
Gum thickened with powdered chalk, glue, silicate of soda, Hides’
leather felt and stiffening solution, paraffine, &c., are also
employed for stiffening bandages and flexible splints, after they
are moulded to a limb, but none of them are as readily procured or
have much advantage over starch and plaster of Paris. A detailed
description of the mode of using them is unnecessary.
=Sand-bags= are very useful, when laid along an injured limb, to prop
it up on either side. For this purpose they are better than pillows,
as their weight prevents their slipping from under the part they
support. They should be made of macintosh cloth about 4 or 6 inches
diameter, and in lengths varying from 1 to 4 feet, well closed that
the sand may not escape through the seams; the macintosh should be
covered with flannel, renewed from time to time. The sand should be
washed and well dried before the bags are filled, that it may not
rot the cloth containing it. Moreover, the bags should be only three
quarters full, or they will be too hard to adapt themselves to the
limb when in use.
=Cradles= are light arched frames of wire or cane to support the
bedclothes over an injured limb. On emergency an efficient cradle
can be constructed from a band-box, by knocking out the bottom and
putting the leg through it. If used to protect a foot, a notch may be
cut with strong scissors, _not_ a knife, for that splits the wood.
If the cradle is stout enough, it is useful to sling a broken limb in
its splint, and often great relief is thus given to the patient. Dr.
Salter’s Swing Cradle is specially contrived for the purpose, and is
shown, fig. 42, page 64.
=Leather Splints.=—For these sole leather, to be purchased at any
leather dealer’s, is used. In preparing them, the required length
should be first noted down, then a series of transverse measurements
taken at the widest and narrowest parts of the limb and over the
projections of joints, &c., or a pattern may be first cut in paper
and laid on the sheet of leather from which a corresponding piece
is cut. The splint should always be so arranged that _its edges_
do not bear on any bony point, the shin, or malleoli, for example,
but either fall short of or pass beyond them. The hair side of the
leather should go next the skin, as it is the smoothest and least
irritating. The edges of the splint must be thinned by bevelling off
the outside for about an inch all round, and no sharp corners should
be left. When the leather is prepared it should be soaked, if the
time can be spared, for twenty-four hours in cold water, but when
wanted quickly it can be softened in a few minutes by soaking it in
warm water to which a little vinegar is added—this, however, renders
the leather brittle when dry, and apt to curl at the edges. When the
leather is softened, a very thin even layer of cotton wadding or of
lint is laid on next the skin; the splint is then moulded to the
limb with the hands, and bandaged firmly; in twelve hours it will
be dry and rigid. The roller is then unwound, and any parts of the
splint pressing on bony projections are marked before removal. It is
then trimmed, and laid between two layers of wash-leather stitched
together round the edges. The splint is now finished, and can be
either fastened on by a roller or by two or more straps and buckles
stitched to it.
When support is required for a joint, the splint should be fitted
on the sides, where the leather may have the rigidity of its width
rather than only that of its thickness to prevent bending.
=Leather Splint for the Hip.=—This joint is by far the most difficult
to fit. The hip splint should obtain a good grasp of its fixed point,
the pelvis, and a stiff bearing on the front of the thigh where
its pressure is to be exerted. There are many plans of procuring a
satisfactory fit; the following is one of the best.
First cut a pattern on a sheet of paper from which to shape the
leather. If possible the patient should stand while the pattern is
fitting. Take a sheet of paper large enough to reach round the body,
and long enough to extend from the waist to the leg below the knee.
Lay it against the diseased hip, carry its vertical margin a little
beyond the middle line in front towards the sound side, and the other
part round the body behind, till the front is reached on the sound
side. Feel for the anterior iliac spine, and mark with a pencil the
point midway between it and the pubis; from this draw one horizontal
line inwards to the border of the paper, and a second obliquely to
the perinæum. Then seek for the junction of the sacrum and iliac bone
behind, which corresponds pretty nearly to the point first found in
front; from this mark the gluteal fold. Next carry a line vertically
from the upper border of the sheet of paper to the great trochanter;
and lastly, mark the level of the pelvis. Lay the sheet on a table
and slit it with scissors along the lines marked, apply it a second
time to the body and bend the thigh part round the thigh, making
its anterior margin reach well to the inside of the limb, while
the posterior part should almost meet it from behind. The splint
should also reach downwards to the back of the knee. The paper is
then trimmed down to these dimensions. The hip part is next trimmed
so that it clears the buttock on the sound side and passes round to
the anterior iliac spine of that side. The pattern being complete,
cut a piece of sole-leather to correspond, arranging that the hair
or _short_ side of the leather will lie next the skin; bevel off the
outer edge all round, and soak the leather till thoroughly soft in
water, wipe it dry, and bandage it carefully first to the trunk and
next to the thigh. When it is set, superfluous and overlapping edges
must be marked before removal; lastly, the sides of the vertical
notch, between the hip and trochanter, are stitched together, and the
splint is covered with wash-leather.
[Illustration: Fig. 59.—Leather splint for the hip.]
When extension of the hip is required (see page 80), it can be
applied to the leg below the splint without lessening the support
that affords.
The accompanying figure, 59, is drawn from a splint fitted by Mr.
Heather Bigg on the plan just described.
_Gutta-Percha_ may always be substituted for leather in these
splints, and the same plan of fitting is used, except that the
notching requisite in leather is not necessary in using gutta-percha;
for the directions to use this material see page 50.