SPLINTING OF WAR FRACTURES

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BY

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CAPTAIN HENRY G. CARLISLE, M.D.

 

I. SPLINTING FOR TRANSPORT.

 

II. SPLINTING OF FRACTURES OF THE FEMUR AT BASE HOSPITALS.

 

SPLINTING OF WAR FRACTURES

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Scope of Chapter. In the following pages it is proposed to indicate very briefly the guiding principles that should be followed with regard to the splinting of various classes of fracture from the first possible moment after the injury has occurred, with particular reference to the methods that may be adopted in order to reduce as far as possible the amount of deformity that is liable to occur in so many of the more severe war injuries. It must be borne in mind that every case of fracture passes through three chief stages, in each of which the principles of splinting are the same but details will vary according to circumstances.

 

The three stages are as follows :

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I. In the line and from it to the C.C.S. Here every effort is concentrated on rapid evacuation, combined with arrest of haemorrhage and efficient fixation of any injured bone. Cases of fracture usually require at this stage most active treatment for the prevention of shock, particularly fractures of the femur.

 

II. At the C.C.S. At the C.C.S. there is more time and opportunity to care for the patient than in the previous stage, and it is here that most can be done by the surgeon to limit sepsis, prevent gas gangrene, deal with the injuries to bone and soft parts, and remove foreign bodies. The guiding surgical principles at this stage are to remove as little injured bone as possible, to combat the sepsis by efficient drainage and the wide excision of damaged tissue (as introduced by .Colonel Gray), and to initiate any special treatment that may be indicated, e.g. B.I. P. P. and Carrel. These surgical details are dealt with in another chapter (pp. 27-37).

 

III. At the Base and home hospitals. The main treatment of the injury is undertaken here, and all definitely reconstructive surgery is necessarily performed at this stage ; but it is during the preceding stages that so much can be done to minimize the amount of deformity that may ultimately require correction ; and this object is in the main achieved by the application from the earliest possible moment after the receipt of injury of efficient methods of splinting. It is proposed to consider here some of the forms of splinting that are particularly suitable for application at each of the three stages outlined above.

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General Principles governing Splinting.

 

The principles that guide all splinting at every stage are :

 

1. Replacement of fragments into their former anatomical position.

 

2. Prevention of the excursion of the fractured ends into undamaged tissue.

 

3. Immobilization of the joint above and below the site of fracture so that there shall be no muscle movement across the injured area.

 

4. Fixation of the limb in such a position that should ankylosis of a joint occur it will be in the ' posture of election ' that is, the position in which, in spite of deformity, the limb will be of most use to the patient.

 

5. Anticipation and prevention of deformities following scar contraction during healing.

 

6. Avoidance of compression of an injured limb above the site of fracture.

 

7. Provision of easy access to all dressings of wounds.

 

These principles allow of only one method of holding a fractured bone, and that is by extension ; and a splint used in any of the three stages must depend upon adequate extension for its efficiency. It is beyond the scope of this chapter to enumerate the many excellent splints which are being used for fractures during the first two stages, therefore a single method of splinting which combines many advantages with very few disadvantages has been selected for description in full detail as a standard type of treatment.

 

I. SPLINTING FOR TRANSPORT.

 

(I) SPLINTING OF FRACTURES IN THE LINE

 

Type of Splints required.

 

It will at once be recognized that in any injury caused either directly by a missile or indirectly by the crushing force of an explosion, the amount of damage to bone and to the soft tissues is often much less immediately after the injury occurs than when the patient arrives at a hospital. It requires a very small effort of the imagination to picture the aggravation of the injury that takes place, for instance, round the sharp splintered ends of a badly comminuted femur when the case is being dragged across the open or carried to the regimental aid post. In order to minimize such aggravation of injury, it is of the utmost importance that some form of splinting should be adopted which will secure efficient fixation of the fracture as soon as possible after the receipt of injury, and if possible before the journey to the regimental aid post is begun. The splinting at this stage will naturally be temporary, because the splint must be applied before the wound is investigated, and attention must be concentrated solely upon securing immediate and efficient fixation. A splint therefore at this stage must be (i) simple, (2) easily applied, and (3) easily carried. The splints which appear to meet these requirements most satisfactorily are the Thomas splints for the arm and for the leg. As experience has shown that the Thomas splints are capable of such wide application, it is proposed to select them and the method of their application for description.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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FIG. 10.                                                       1                    2

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1. Swivelled Thomas arm splint, showing the side bars pivoted direct to the ring.

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2. Thomas leg splint. With a small ring suitable for later stages in the treatment of fractures of the lower limb.

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Thomas Arm and Leg Splints.

 

The ' swivelled Thomas arm splint '.

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This splint consists of a ring 7 in. in diameter which is padded and covered with soft leather, and side bars of T 5 e in. iron which are pivoted direct to this ring or hinged i in. from it. The side bars end in a notch or V over which extensions are tied (Fig. 10).

 

The 'Thomas leg splint'.

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This consists of an oval ring set obliquely to two side bars. The ring varies in size from 16 in. to 30 in. in circumference and is carefully and firmly padded with leather. The side bars are of | in. round iron and end in a notch or V at the foot end. Various additions, such as foot suspension pieces, splint props, &c., are fitted to the Thomas splint when indicated. (Figs. 10 and n.)

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FIG. 11.

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1. Small ringed Thomas leg splint.

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2. Suspension foot-piece.

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3. Splint prop, fixed to the end of the splint and used for fixing the leg extensions below the level of the side bars of the splint.

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4. Serrated wooden foot-piece.

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5. 4 in. paper clips for holding supporting bands.

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Splinting of different Classes of Fracture.

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A. The Upper Limb.

 

1. In all cases of injury to the scapula, clavicle, and the head of the humerus, no splint is required from the line to the C.C.S. and from the C.C.S. to the Base : efficient fixation of the arm on the injured side should be secured by means of a firmly applied bandage. The associated lesion of lung, vessel, nerve, or muscle is the more important injury, and with the arm bound to the side no further damage can be done by the injured bone.

 

2. In fractures of the shaft of the humerus, in all injuries round the elbow- joint, and in fractures of the bones of the forearm, a swivelled Thomas arm splint gives as good results as any other, and is extremely efficient in immobilizing the fracture. It depends upon extension alone to keep the fractured ends from ploughing up the soft tissues, and does not cause any circular compression of the limb. The mode of application is as follows :

 

The arm is held away from the body, the splint is then slipped over it with the bars opposite the coracoid process and the spine of scapula respectively ; a carefully padded bandage extension is put round the wrist and fixed over the V in the end of the splint. Too great extension must be carefully avoided ; all that is required at this stage is sufficient extension to keep the bones immobile and the splint in position, and effort should be directed to securing these ends and not too much towards overcoming shortening. The extension having been applied, a bandage is run round the arm, dressing, and splint. The swivelled ring of the splint allows it to be brought down to the man's side without increasing the extension or compressing the axilla. A patient can walk with this splint, and when a stretcher or ambulance is available he can lie down with his arm to his side in comfort. On the stretcher the splint should be suspended from a stretcher suspension bar.

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B. The Lower Limb.

 

1. In fractures of the lower limb the problems of transport during the first stages are extremely difficult. The Thomas leg splint is by far the most efficient method of dealing with all injuries below the upper third of the femur. Even fractures of the upper third and neck of the femur can be controlled by it provided a good extension be obtained from the tuber ischii, but the ring of the splint is very much in the way where there are large buttock or perineal wounds. From the line to a C.C.S. the Thomas leg splint is probably the only splint available for all fractures of the femur ; but if wounds are very severe and the fracture very high, the limb and trunk may be secured directly to the stretcher by the fixation of a perineal band to the head of the stretcher and traction of the leg to the foot of the stretcher by means of a padded bandage.

 

2. In all fractures of the lower two-thirds of the femur, injuries of the knee-joint, and fractures of the tibia and fibula, the Thomas leg splint should be applied at the earliest possible moment. From the line to the C.C.S. it should be put over the clothing, after the wound has received the first-aid dressing and haemorrhage has been dealt with. Extension must be obtained by some method that is extremely simple, because the splint has to be put on under appalling difficulties and usually by partly trained bearers. There are several rapid ways of getting extension.

 

One method is by means of a crossbar through the boot, the uppers being cut on either side just below the instep to allow a metal or wooden rod to be passed between the foot and the sole of the boot ; this rod rides on the side bars of the splint and efficient traction can be made from it (Figs. 12 and 13). Another method is by means of Tapson's sole- clip, which grips the sole of the man's boot.

 

Yet another method is that of taking a pull from the heel and dorsum of the boot by means of a webbing brace. After extension is applied a long gutter splint of gooch should be used as a ham splint, and slung from the sidebars of the Thomas, and the whole limb bandaged into the splint. (Fig. 13.)

 

3. Fractures of the ankle and tarsus can be efficiently immobilized at this stage by means of a posterior splint and foot-piece.

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(II) SPLINTING AT THE C.C.S. FOR TRANSPORT

 

At the C.C.S. the real work of the prevention of future deformity is taken in hand. The saving of life and limb is the primary consideration, and that can be done best by bringing the bones into as nearly anatomical reposition as possible. The purely surgical side of the treatment is dealt with elsewhere in this book, and attention is directed here solely towards the splinting.

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After the surgical toilet of the wound and the general cleansing of the limb has been completed, the Thomas splints described above may be applied in a more permanent manner to ensure the patient's travelling in comfort, and to give perfect access to dressings.

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The Glue and Gauze Method of Extension. A permanent method of applying extensions is necessary for all fractures and can be obtained by the use of zinc oxide strapping or adhesive plaster ; but the best and most efficient method is by means of a new adhesive now known as Sinclair's glue. The details of its preparation and mode of application are as follows :

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(a) Preparation of Glue. The glue is made according to the following formula :

 

Very good glue . . . . . . . .50 parts 1

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Water . . . . . . . . . . . . . .  50 parts 2

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Glycerine. . . . . . . . . . . . .4 parts 

or

glucose . . . . . . . . . . . . .  to       

or

calcium chloride . . . . . . .6 parts 3

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Menthol . . . .  . . . . . . . . .1 part

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Stand for 12 hours, then melt on a water bath. Neutralize to litmus with sodium hydrate, because commercial glue contains at times free hydrochloric acid. The whole preparation should be made sterile. 4

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(b) Application of Glue and Gauze. The gauze extension should be applied as follows :

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(1) Do not shave the skin.

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(2) Wash the skin carefully with soap and hot water which contains about 4 drams of washing soda to the pint, to convert the oil of the skin into soap. Glue will not adhere to a greasy surface.

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(3) Dry the skin.

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(4) Apply the warm glue evenly by means of a shaving brush or the hand, taking care that it is not too hot, and brushing all the hairs of the limb in an upward direction.

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1 Only very good glue should be used, and it may be tested as follows :

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Place 4 oz. of glue in 4 Ib. of cold water and leave in a cool place for 12 hours.

If after this period it is completely dissolved, the glue is bad.

If it forms a mass coherent and gelatinous, weighing 8 oz., the glue is good.

,,                         ,,                                                     16 ,, ,, very good.

,,                          ,,           ,,            ,,                          20 ,, ,, excellent.

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2 Frequent heating evaporates the water, which should be added from time to time. When re-heated many times the adhesive power is lost.

 

3 Add 4 parts in summer and 6 parts in winter. The calcium or glycerine is used to prevent the adhesive becoming brittle, and the proportion may be varied in accordance with the sample of glue used. These ingredients allow of a certain amount of transpiration from the skin by their deliquescent qualities, so that there is never any sodden condition of the epithelium underneath when the extension is removed.

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4 The menthol acts as a mild antiseptic.

Note that the adhesive can be made waterproof if necessary by painting with a 2 per cent, solution of potassium bichromate. This must be painted over the extension in the dark and immediately afterwards exposed to the light. Painting with a 10 per cent, solution of formalin also renders glue insoluble. These points are useful when the Carrel treatment is being used for wounds near the extension.

 

(5) Take white gauze from a sterile package, folding it so that it is 8 layers in thickness, and cut it to the desired length. Keep a tension on the gauze and bring it quickly but carefully into contact with the limb (inner and outer surfaces) ; then apply neatly a loose-woven bandage, taking care that there are no folds or creases in the gauze. (In the case of the leg another method is to apply a length of Maw's elastic cotton stockinet ; then glue thoroughly and apply the gauze outside it, and bandage as before.)

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(6) When dry, apply traction. Ordinarily traction may be applied within a few moments of application ; but if a heavy pull is required, as is the case when there is much overlapping of bone, it is better to wait a few hours before the full strain is put on.

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The gauze extension must always be applied very carefully, in which case it will be an extremely rare occurrence to have blistering, or indeed any trouble. It is, however, apt to slip when the injured limb atrophies. Whenever this happens an entirely fresh extension should be applied, otherwise the whole pull is along the lines of contact between gauze and skin and a blister occurs which is purely traumatic in origin. Tickling or burning under the extension is the sign of irritation and an indication that the extension must be changed. In cases of fracture of the femur this is usually necessary about the tenth, twentieth, and fortieth days.

 

Splinting of different Classes of Fracture.

 

A. The Upper Limb.

 

1. In fractures of the humerus, in injuries round the elbow, and in fractures of the forearm, the swivelled Thomas arm splint should be applied as follows :

 

In fractures of the humerus and in injuries round the elbow extensions are applied to the radial and ulnar margins of the forearm, so that when the splint is put on, the hand will be in the same plane as the side bars. In fractures of the forearm or the carpus the extension is taken from the palm and dorsum of the hand by means either of gauze or of a thin cotton glove with extension tapes from the finger tips. When the extension has been applied, the splint is put on with the arm at right angles to the body, and the bars of the splint opposite the coracoid and spine of the scapula respectively. The extension is then tied directly over the end of the splint, and can be adjusted to keep the forearm in full supination.

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The injured limb is slung to the upper bar by means of flannel bands, passed round the arm and over the upper bar, where they are pinned or clipped ; then across the back of the arm to the lower bar, where they are again pinned or clipped (Figs. 14 and 15). Care must be taken to sling the elbow well clear of the lower bar so that the internal epicondyle will not bear upon it, and to have the edges of the bands touching so that no zones of oedema will occur. The whole limb now rests upon a gutter made by the flannel bands. When in a ward the splint should be rotated so that the palm of the hand looks directly upward, and the arm should..................

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FIG. 14. Fracture of lower third humerus: showing

(1) glue and gauze extensions applied to forearm;

 

(2) method of slinging arm to upper bar of splint.

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FIG. 15. Same as Fig. 14. Showing arm brought to the side, the position for transport. The centre band is unpinned to show detail of application.

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. . . . . . . .be brought out to an angle from the body either by means of an overhead suspension or by placing the end of the splint on a locker. For travelling the whole limb and splint should be covered by padding and a bandage, and the arm brought down to the side of the patient.

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At this stage it requires very little extension to get the ends of a shattered humerus in good position, and dressing the wounds is extremely easy. An assistant holds the arm at right angles to the body ; the slings at the site of injury are loosened, the wound cleaned, and fresh dressings and slings applied. The subsequent splinting of these fractures will be dealt with elsewhere (p. 119). The method just described is designed primarily for transport and to tide the patient over the initial sepsis.

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It is, however, useful for permanent treatment when slung to an overhead suspension ; but, in this case, immediately the temperature and pulse show that sepsis has been overcome, the elbow must be gradually flexed by some such means as a Sinclair flexion attachment. The elbow must not be kept in full extension for longer than three or four weeks.

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2. Fractures of the metacarpus are easily fixed by an anterior splint, either of wire or gooch, the splint being padded so that the wrist is in dorsiflexion and the fingers in full extension.

 

 

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FIG. 16. Jones's abduction frame, as used for fracture of the upper third of the femur.

Showing 'groin strap' on uninjured side and extensions on both limbs.

 

B. The Lower Limb.

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1. In fractures of the upper third of the femur, if the case can bear the journey, Jones's abduction frame, with a movable leg-piece, is undoubtedly the best method of transport (Fig. 16). In the application of the frame the most important points are :

 

(i) That the trunk be not too far down on the saddle. The internatal cleft should be just clear of the edge of the saddle.

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(ii) That the groin strap be kept tight.

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(iii) That extension be applied to both limbs.

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When in the ambulance or train the injured limb must be adducted in its leg piece so that the patient may be fairly easily handled. (This splint, when provided with an interruption over the wound area, can be used for permanent treatment if a net frame to be described later is not available.)

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2. All fractures of the shaft of the femur, all injuries to the knee-joint and fractures of the tibia and fibula, bear transportation best in a Thomas splint, which should be applied immediately after the surgical toilet of the limb has been completed. In fractures of the shaft of the femur the following technique gives satisfactory results :

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A splint is chosen with a ring which just clears the dressings. Too large a ring is a great mistake, not only because it slips across the perineum, pressing upon the urethra and obstructing the anus, but also because it causes an adduction displacement of the lower end of the upper fragment, whenever extension is applied. A 27 in. ring is large enough for the biggest man even when the thigh is much swollen. Most cases are efficiently fixed by a 22 in. ring.

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Extensions are applied as detailed above (p. 99). The glue application to the leg should be from a hand's breadth above the malleoli to the knee-joint ; and gauze and glue should also be applied to the sole and dorsum of the foot so that it can be suspended. The splint is bent to an angle of 160 exactly at the level of the knee-joint, and is then slipped over the limb. (The reason for this bending of the splint will be dealt with later, p. 114.) A foot suspension piece is attached to the splint at the level of the sole by means of tapes or i in. adhesive.

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The first supporting band, consisting of a 4 in. strip of flannel bandage, is applied immediately at the site of fracture and fixed with safety-pins or with a 4 in. paper clip ; x and this band, the 'master band' should be tight enough to keep the bones at the level of the side bars of the splint. Full extension is now taken, counter-extension being made with the splint ring against the tuberosity and the ascending ramus of the ischium ; and the gauze, which is passed outside the foot suspension piece, is tied over the V at the end of the splint. The foot is slung at right angles by means of the strips of gauze previously applied to the sole and dorsum, which are tied to the top of the suspension piece, the malleoli being kept I in. below the level of the side bars. The rest of the flannel supporting bands are then carefully applied so as to form a perfect gutter from the ham to- the lower third of the leg. The knee, carefully padded on its lateral aspects, is finally bandaged into the splint (Fig. 17).

 

1 For the fixing of all supporting bands to a Thomas splint 4 in. paper clips are greatly superior to pins

 

(1) because of the great ease -with which they can be applied,

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(2) because by their use absolutely perfect adjustment of the bands to the folds of the limb can be assured,

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(3) because the risk to the surgeon or staff of septic infection due to pricks from safety-pins is removed.

 

The great advantage of this method of splinting is that while the fracture is absolutely fixed, access to the wound is most easy. The dressings can without difficulty be changed anywhere en route. It is most important to insist that the posterior bands are loosened one at a time when dressings are done.

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When on a stretcher, the ends of the splint should be slung to two stretcher suspension bars, to give comfort by providing an easy swing of the injured limb, and to prevent any jarring. It has been found that cases coming from the C.C.S. splinted in this way always arrive at the Base in most excellent condition.

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FIG. 17. A fractured femur splinted at a C.C.S. for transport to the Base. Showing

(i) gauze and glue extension to leg ; (2) suspension of foot ; (3) use of 4 in. paper clips to hold the supporting bands.

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FIG. 18. A G.S.W. of external condyle involving the knee-joint, splinted at the C.C.S. for transport. Dressings, padding, and bandage have still to be applied.

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3. In injuries to the knee and in high fractures of the tibia and fibula exactly the same method of splinting may be adopted, except that the splint need not be bent, and that, in the case of the tibia and fibula, the extension may only be carried half-way up the leg (Fig. 18).

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4. In fractures of the tibia and fibula, except those which are near the knee, and in injuries in the region of the ankle the Thomas splint is also the best means of transport ; and extension may be obtained by means of a ' serrated wooden foot-piece ' which rides on the side bars of the Thomas and is attached to the foot in the following manner :

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FIG. 19. Serrated wooden foot-piece, showing

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1. The foot-piece, metal cross-bar, carrying tapes for extension. (Note method of padding the foot-piece.)

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2. Metal triangles with tapes attached.

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3. Flannel strips for glueing across the sole.

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4. Extension tapes.

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5. Splint prop.

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The serrated wooden foot-piece. The requirements are (Fig. 19) :

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1. A wooden foot-piece 12 in. by 4 in. by f in. with a serrated margin and a slot down the centre in which is a bolt holding a movable transverse bar.

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2. Twelve to fourteen metal triangles. These are made out of i in. curtain rings squeezed into a triangular shape.

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3. Strips of flannel f in. broad and about 8 in. long.

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4. Some 1\2 in. tape.

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5. A splint prop.

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The foot is thoroughly cleaned and glue applied over the sole and dorsum as far as the malleoli. The strips of flannel, each threaded through two small brass triangles, are fixed across the sole of the foot with the triangles forming a line on either side of the sole and the flannel carried as far up the sides of the foot as possible (Fig. 20). Two very important points must be recognized, viz. :

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(1) There should be as many flannel bands as possible without overlapping usually six or seven -the first behind the malleolus, the second up to the malleolus, the third in front of the malleolus, the fourth, fifth, sixth, and seventh along the sides of the instep.

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(2) The bands must not touch across the instep ; if they do, a pressure sore is certain to develop there. The serrated wooden foot-piece is padded with a layer of cotton-wool held in position by a strip of flannel bandage placed lengthwise over the wool and pinned to the distal surface by means of drawing-pins (Fig. 19).

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FIG. 20. The serrated wooden foot-piece applied. (Note the method of fixing the foot-piece by means of the flannel strips glued to foot, metal triangles, and tapes.)

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The application of the splint and foot-piece is as follows : the limb is threaded into the Thomas splint in the usual way, and the thigh supported by flannel bands. A large pad of cotton-wool is placed inside the bars round the knee and firmly bandaged : this gives stability and support to the upper fragment. The foot-piece is fixed to the sole of the foot by means of tapes attached to the brass triangles on either side and then tied below the foot-piece. The metal cross-piece, to which the tapes for making extension are tied, rides on the side bars of the splint (Fig. 20).

 

This metal cross-piece, being fixed by means of a bolt and butterfly nut, allows rotation outwards to the desired extent, and inversion is obtained by adjusting the extension tapes attached to each end.

 

The extension tapes are tied over the V at the end of the Thomas. Flannel bands are adjusted under the leg to give support and to prevent oedema.

 

A splint prop is attached to prevent the possibility of the wooden foot-piece catching upon bedclothes or stretcher.

 

During transport the whole splint is slung from two stretcher suspension bars as in the case of fractures of the femur. (The serrated wooden foot-piece is also applied in the above manner for the permanent treatment of fractures of the femur, and will be found illustrated in that section, p. 120.)

 

5. Fractures of the tarsus and metatarsus travel best in a Thomas splint with the foot suspended from a foot-piece by means of gauze glued to the dorsum and sole of the foot, or even glued to the toes alone ; the splint being kept in place by means of glue and gauze extensions from the ankle to the knee, and the whole limb supported by flannel bands clipped to the side bars. These cases require the foot to be kept at right angles and immovable.

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II. SPLINTING OF FRACTURES OF THE FEMUR AT BASE HOSPITALS

 

Upon arrival at the hospital where the main treatment of a fracture is to be carried out, it is first of all necessary to make a very careful examination of the injuries. A good X-ray in two directions is essential. It is frequently advisable to take the patient into the theatre and to give a general anaesthetic so that the wounds may be thoroughly examined, the position of the bone fragments as shown by the X-ray plate carefully verified by external palpation, any further drainage or septic foci attended to, and the limb splinted. Many cases coming down from the C.C.S. on the fourth to the fifth days, however, when properly splinted, only require fresh extensions put on in the ward and the limb slung to the suspension frame ; but a raised temperature and pulse rate upon the morning after admission always calls for a thorough investigation under an anaesthetic by the surgeon. The earlier the cases arrive at a permanent hospital, the better as a rule is the prognosis.

 

Throughout this stage of treatment frequent X-ray examinations  of the fracture are essential. The X-ray plant must be portable so that the patient need not be moved from his bed until there is some bony union (Fig. 40). The methods of splinting used at the Base often do not permit of the patient being moved except for major operations.

 

A. Fractures of the upper third of the Femur. A net frame has been found the most satisfactory method of treating these extremely serious injuries. The great difficulties in dealing with this class of fracture have lain in the treatment of the wound itself, and in the grave danger of shock from pain when dressings have to be done. The problem throughout has been that of devising some form of splint which necessitates as little movement of the patient as possible during the dressing of the wound or for nursing purposes. Various splints have been used at different times, such as the Hodgen splint, two Thomas splints tied at the rings to ensure abduction, and special beds of canvas slings : these and other different devices have led to the evolution of the net frame, which excels them all in ease to the patient, in prevention of deformity, and in securing accessibility to the injured area with the minimum of movement. The frame is best understood by a study of the accompanying photographs (Figs. 21 and 22).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIG. 21. The net frame.

 

1. Body net hooked over the round-headed screws at sides and at head of frame.

2. Handle for patient to raise his shoulders.

3. Handle, cords running over pulley and body sling (for patient to raise pelvis).

4. Umbilical bar.

5. Leg abduction bars.

6. Cord used for pulling edge of body net downwards.

7. Overhead suspension frame.

 

Description of the Net Frame. The apparatus consists of :

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(i) An oblong wooden frame 6 ft. 6 in. long by 4 ft. 6 in. wide with a transverse bar, called the umbilical bar, 3 ft. from the head end of the frame. From this umbilical bar to the foot end of the frame run the two leg abduction bars, which are adjustable, both at the umbilical bar and at the foot of the frame. The head and sides of the frame and the leg abduction bars are studded at i in. intervals with round-headed screws, over which the netting is attached. The foot of the frame is pierced with holes, through which the extensions are taken according to the degree of abduction required. Three pieces of netting, of i| in. mesh, made of J in. cord, support the body and the two legs. Attached to the body net are two cords which are used to pull the edge of the net over the buttocks.

 

(ii) A handle for the patient to lift his shoulders.

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FIG. 22. Patient in net frame.

Note method of obtaining extension by tying leg extensions through foot of frame,

and by lowering the head of the frame.

 

(iii) A handle and cords running over pulleys and attached to a canvas body sling. It is by this means that the patient himself holds up the pelvis whilst dressings are being done or a bed-pan used. The canvas sling should be just wider than the body with a metal rod or spreader at each side. The S hooks on the cords can be fixed to these metal rods, and the cords run over the pulley which is attached to the suspension frame. The whole frame is suspended by the four corners either to the roof of a hut or to a four-post suspension as in the photographs.

 

The method of application is extremely simple. The patient can be fixed in the frame immediately after any operation has been performed and while still under an anaesthetic. (During transport from the theatre to the ward, an ordinary Thomas should be used.) If operative work is unnecessary, the frame can be applied without an anaesthetic.

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Application of the Frame.

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The following is the method of application :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIGS. 23, 24, and 25. X-rays to illustrate fractures of the upper third of the femur.

Fig. 23. Cpl. B; two weeks after injury.

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A hard table (a trestle table) is prepared by putting on it the body net covered with a blanket folded into four and a draw sheet folded into two. The leg nettings are put into place in an abducted position and padded either by means of a double layer of gamgee, or by a long narrow feather pillow. The patient is prepared by having glue and gauze extensions applied to both legs as far up as the knee, and glue and gauze in suspensions to both feet, and is then lifted on to the table and laid on to the padded netting. The frame, held by two or four orderlies, is put over him and lowered until the umbilical bar is over and touching the umbilicus.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 24. Cpl. B. six months after injury.

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The amount of abduction is determined and the abduction bars are fixed accordingly. (Usually this is in full abduction, but the amount will be corrected by the X-ray, which should be taken immediately after the patient has been finally fixed in the frame:) The extensions are carried through holes at the foot of the frame and tied. The feet are suspended to the abduction bars. The body net is fixed over the round-headed screws along the sides and head of the frame and pulled as taut as possible. Each leg net is fixed over the screws on the abduction bars.

 

When suspended, the umbilicus should be 4 in. from the umbilical bar and the patellae 4 in. from the abduction bars.

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Fig. 25. Pte. J. two months after injury.

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Lastly, the cords attached to the edge of the body net are firmly pulled down, bringing the net over the buttock and are fixed to the foot end of the frame. The frame and patient are now lifted from the table and suspended with the head of the frame at a lower level than the foot. The amount of extension on the injured limb will depend on the amount that the head of the frame is lowered below the foot of the frame. The amount required is usually 12 in. to 18 in., and is determined by the state of the fracture as shown by the X-ray and also by the measurements of the limb. The extension caused by lowering the head of the frame 18 in. is sufficient to pull out any fracture of the upper third of the femur to full length within three days. When the limbs are equal in length it may be advisable to raise the head until it is 12 in. below the feet.

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Special Points to be observed in using the Net Frame.

 

1. There is one deformity which may occur, and which only has to be known to be guarded against, viz. an adduction deformity of the upper fragment, which is caused by too much extension. In this deformity, when shown by X-ray, lengthening on the injured side has always been found.

 

2. Care must be taken that there be no inward rotation of the lower fragment. This is guarded against by keeping the foot well everted. The amount of rotation outwards of the upper fragment is shown by the extent to which the lesser trochanter is seen on an X-ray plate taken with the tube placed absolutely vertical to the fracture.

 

3. The umbilicus and patellae should always be kept at a fixed distance from the umbilical and leg bars, usually about 4 in.

 

4. It is most important that the patient should have only one small head pillow. If a mass of pillows flex his trunk on his thighs the whole action of the frame is lost.

 

5. The patient should be taught to help as much as possible by raising his body during dressings.

 

The net frame should be used until union, as shown by fairly dense callus on a good X-ray plate, has occurred. This takes place in about 8 to 10 weeks. Thereafter, treatment is carried out on a Thomas leg splint, as described in dealing with the second stage of fractures of the shaft (p. 119).

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3. Fractures of the Shaft of the Femur.

 

Application of the bent Thomas Splint. The splinting of fractures of the shaft of the femur may be carried out as follows : A Thomas splint with a well-fitting ring, a serrated wooden foot-piece, and a splint prop are the essentials (Fig. n). Glue and gauze extensions (p. 99) should be applied from the ankle up to the knee, and preparations made for the application of a serrated wooden foot-piece by gluing the flannel strips with the metal triangles on to the foot (p. 103). The reason for having two extensions is that after about ten days there is so much atrophy of the injured limb that the leg extensions become loose, and require to be re-applied just at the time when the least bit of movement of the fractured bones will do much harm. By this means all the strain can be put on the foot-piece during the time necessary to apply the leg extensions. A further advantage of the two extensions is that, if the patient complains of pain from either extension, a greater pull can be put on the less painful one for a few hours.

 

The Thomas splint is bent to an angle of 160 exactly at the level of the knee-joint. The reason for this bending is twofold:

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1. it relaxes the muscles of the calf, thus lessening the tendency to posterior displacement of the lower fragment,

2. it brings the axis of traction of the extension into the line of the lower portion of a normal femur, and thus tends to restore the normal anterior bowing.

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FIG. 26. Application of the bent Thomas splint at the Base. Showing master band in position, other bands supporting limb, and double extension, the leg extension being tied round the splint prop below level of side bars.

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In applying the splint, the surgeon makes firm traction in a line well above that of the lower end of the splint, and counter-extension by pushing the ring of the splint against the ischium. The first suspension flannel band (the ' master band ' ) , which should be of double thickness of flannel, is fixed at the level of the fracture, and the limb is lowered across this band until the malleoli are below the level of the side bars. This ensures the reposition of the normal anterior bowing of the femur. Full extension is maintained while the extension gauze is fixed by tying it round the splint prop, which is attached to the end of the splint. The limb is firmly supported whilst the rest of the suspensory flannel bands are applied.

 

These must touch edge to edge from the buttock to a hand's breadth above the heel, but must not be put on so tight as to render the ' master band ' loose. These bands form a perfect posterior splint.

 

The wooden foot-piece is now tied on to the foot and rotated out according to the amount of rotation outward of the upper fragment (Fig. 26).

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In all fractures of the shaft of the femur the upper fragment tends to rotate outwards through the arc of a circle the radius of which is formed by the neck of the femur : therefore to get an anatomical reposition it is often necessary to rotate the lower fragment outward very considerably. The posterior displacement is governed by the lift from the ' master band '. By bending the splint and carrying the extensions below the level of the side bars (Fig. 26), the tendency towards posterior displacement of the upper end of the lower fragment is reduced.

 

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FIG. 27. The method of suspension. Vertical pull obtained by means of weights and pulleys, horizontal pull by raising foot of bed and tying splint to vertical bar.

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Provided the ring be reasonably small there is never any trouble with alignment so long as sufficient extension is maintained. The limb must be measured frequently to make sure that the length is correct.

 

Importance of the Suspension of Splints. The above method of splinting depends almost entirely upon extension to maintain a good position of the bone, and the amount of extension required is usually very considerable ; therefore the counter-extension on the ischium involves grave danger of pressure sores under the ring. 1

 

1 At all times most careful instructions must be given with reference to the cleaning of the ring. This should be done twice a day by means of a strip of soaped bandage worked transversely round the ring, and by cleaning and shifting the skin under the ring.

 

On the other hand, when the ring is large enough not to cause any circular constriction of the thigh, any movement of the patient, even twisting in bed, moves the upper fragment slightly. It is for these reasons that an essential part of the treatment of these fractures, introduced with such successful results by Major Maurice Sinclair, is to suspend the limb and splints so that the splint will easily follow all movements of the body.

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The two important factors in this method of suspending a fracture are :

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1. A vertical pull, by means of counterpoise weights attached to the ring and end of the splint by cords and pulleys, to lift the limb and splint from the bed;

 

and

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2.  A horizontal pull by making the body weight pull against a fixed point, which must be beyond the end of the splint in order to relieve the pressure of the ring upon the skin (Fig. 27).

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FIG. 28. Suspensions in a ' Hutted Hospital '.

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In hutted hospitals these suspensions and extensions can be made from the roof and from a vertical bar fixed at the end of the bed (Fig. 28), but in home hospitals it is necessary to have some sort of suspension apparatus such as a Sinclair suspension frame (Fig. 27) or Balkan bar.

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The suspension frame is, up to the present time, the most efficient method.

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FIGS. 29 and 30. X-rays illustrating fractures of the shaft of the femur.

Fig. 29. L/C. P. on admission.

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It consists of a four-post frame, 18 in. longer than the bed and an inch or two wider. It must be well made and stable.

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(1) The vertical pulls are attached to cross bars which are adjustable in order that they may be directly above both ends of the splint. The counterpoise weights are carried to the end of the frame so as to be out of the way. These weights should not be too heavy a 5 Ib. and a 4 Ib. weight from the ring, the heavier being on the inner side, and two 4 Ib. weights from the foot of the splint are usually sufficient. Any tendency of the splint to tilt inward or outward can be dealt with by adjusting the amount of weight on the inner or outer sides.

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(2) The horizontal pull is obtained as follows : A movable vertical bar opposite the end of the bed serves to fix the lower end of the splint.

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Fig. 30 a. L/C. P. after three months' treatment. A. P. View.

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Fig. 30 b. L/C. P. after three months' treatment. Lateral View.

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The foot of the bed is raised 10 in. from the floor and the end of the splint 10 in. above the bed. The bar is adjusted so as to be exactly opposite to the end of the splint. The patient is brought as far as possible towards the foot of the bed and the end of the splint is tied firmly to the bar. The shortness and rigidity of this tie are important in order that, during the acute stage at least, the lower end of the splint should not swing.

 

All movements of the patient will tend to pull on the upper fragment, the body and limb moving in the radius of a circle having the upright bar at the end of the splint as its centre. For the past two years no weight and pulley extension has been used, it being found that the fixed point of extension at the end of the splint holds everything so much more rigid. As well as giving comfort to the patient and great improvement in controlling the fracture, the suspension of the Thomas splint is an enormous saving when nursing is considered, because dressings and bed changing can be done by one nurse.

 

Further, the general condition of the patient is invariably improved by his being able to move himself about in bed without giving rise to pain. It is most important that one head pillow only be used whilst full extension is being maintained.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Fig. 30 c. Lateral Skiagram of end result of fracture of lower third of femur.

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Usually acute sepsis will have subsided within a week of the patient being splinted. In cases received during the first week after injury, full length is invariably obtained by the end of 24 hours, and frequent re-measurements should be taken to guard against over-extension.

 

In dressing any of these fractures, it is most important to make sufficient strain on the bands above and below the fracture so that, when the ' master band ' is released in order to get at the dressing, the limb will not sag. If there is a long wound, sectional dressings 4 in. wide should be used and only one band removed at a time (cf. Fig. 31).

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Further Treatment in straight Thomas Splints.

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As soon as there are clinical signs of union and the X-rays show a marked shadow of callus (usually after a period of six or eight weeks), the splint may be changed to a straight Thomas with a leg extension and a serrated wooden foot-piece as described above (p. 106) (Figs. 32 and 33). Under these circumstances there is very little danger of shortening, therefore the amount of traction may be lessened. Extension from the leg alone is sufficient to hold the splint in position, but the foot must be rotated outward by means of the serrated foot-piece to prevent torsion of the newly forming callus.

 

Massage and graduated contraction of the quadriceps and passive movements of the joints can now be carried out, and when muscle tone begins to return mechanical means of allowing flexion at the knee-joint may be used.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIG. 31. Showing a sectional 4 in. dressing and the method of application when a long posterior wound is present.

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FIG. 32. Later treatment of fracture of femur in straight Thomas splint. Note double extension and outward rotation of foot.

 

A good method is to hinge a duplicate of the lower portion of the Thomas splint exactly at the knee-joint (Figs. 34 and 35) ; the extensions and supporting bands are attached to this hinged portion. The amount of flexion is limited by tying the end of the hinged portion to the end of the straight splint.

 

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FIG. 33. Straight Thomas splint suspended during later stage of treatment

 

When 30 or 40 of flexion have been obtained passively, the hinged portion may be of fractured femur attached to a cord running over a pulley and the patient encouraged to extend his knee himself by pulling upon the cord (Figs. 34 and 35).

 

C. Fractures of the lower third of the Shaft and in Region of the Knee-joint.

 

The treatment of these fractures is complicated by the proximity of the knee-joint. The original injury often involves the knee-joint either by fissures running from the site of fracture into the joint, or by the track of the missile opening up the joint after having gone through the bone ; or the synovial cavity may have been opened through tearing of its prolongations by bone splinters.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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FIGS. 34 and 35. Knee-flexing attachment. The amount of flexion is limited by the cord between the splint and the flexing bar. The cord and pulleys enable the patient to move his own knee.

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The treatment of the acutely septic knee-joint is dealt with in another chapter (p. 297). In the splinting of these cases it is very necessary to overcome the posterior displacement of the upper end of the lower fragment. This is done by efficient early extension. A small-ringed Thomas leg splint should be used, bent to an angle of 160, and both foot and leg extensions applied. Full use must be made of the body weight by fixing the end of the splint and by raising the foot of the bed, and the ' master band ' must be most carefully adjusted. After the patient has been splinted and traction maintained for 48 hours a lateral X-ray must be taken, and, if there be still posterior displacement of the lower fragment, it may be overcome in two ways : (a) extension may be increased by tilting the foot of the bed higher ; or (b) increased flexion of the knee may be obtained by lowering the foot on the foot-piece and loosening the bands supporting the leg. Efficient extension and a tight band behind the fracture invariably reduce the deformity in its early stages, unless the X-rays show fragments of bone blocking reposition.

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In such a case these fragments must be removed. When sepsis has subsided and there is some evidence of callus, these knee cases should be gradually brought into full extension. This is done by gradual adjustment of the bands and foot-piece in the bent Thomas until a straight splint can be applied. Sometimes several weeks are spent in this straightening process and the rate of progress is guided by any sign of reaction such as pain or temperature.

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FIG. 36. Walking calliper splint and boot. The boot illustrated above has been raised to compensate partially for shortening of an injured limb.

 

 

 

Walking Calliper Splints. The next stage in the treatment of a fractured femur is that of getting the patient walking in a walking calliper splint (Figs. 36 and 37). The best time for this varies with the amount of destruction of the bone. If there has been much comminution it is necessary to wait until a good X-ray plate shows trabeculation through the callus. This does not occur until the fourth or filth month. If there has been a clean fracture, and by palpation the bone feels firm, and there is very little tenderness at the site of fracture, and the X-rays show good callus formation, a walking calliper may be applied even at the end of the third month.

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A walking calliper splint consists of a ring, carefully padded and covered with leather, and two side bars of 1-in. round iron attached to either side of the ring and fitted at the other end into the heel of a boot.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIG. 37. Walking calliper splint applied.

 

Leather supports to fix the knee in a position of full extension are also necessary (Fig. 36). Essential points in the fitting of a calliper splint are: (i) that the ring must exactly fit the upper portion of the patient's thigh, taking its pressure from the tuber ischii, and (2) that the side bars must be just longer than the length of the injured limb, in order that when the boot is fitted and the splint applied the patient's heel shall bear no weight. (If there be much shortening the boot should be raised to compensate for a part of this.) It is most important that no weight should be borne by the recently united bone. The callus of septic fractures remains soft and easily becomes deformed for many months after it is apparently firm. The most efficient stimulus to rapid hardening of the union is to make the patient use the limb, but care must be taken that no bending can occur at the fracture. The patient is allowed up and encouraged to walk with a stick only. After any severe infection, the patient must be kept in his walking calliper for at least six months. This point is most important, because months of the most careful attention are wasted by the removal of a walking calliper too soon : the indications as to when to leave, it off are good muscular development of the limb, no pain in the callus on deep pressure, and an X-ray plate showing trabeculation right through the new bone formation.

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During the period that the patient walks with the calliper every effort must be made to obtain good controlled movement of his joints, especially of the knee-joint. This is done by massage, &c. with the calliper removed, and by encouraging the patient to move the limb freely when in bed.

 

The heel and sole of the boot on the sound limb should be raised so that the total length of the limb and boot is | in. longer than on the injured side. This prevents the toe on the injured side catching the ground during walking.

 

Difficulties encountered in the Splinting of Fractured Femurs. Many difficulties arise during the treatment of cases of fractured femur, such as :

 

1. Incorrect Alignment. This can be adjusted by fitting a small ringed splint, by increasing the extension on the lower fragment to get full length, and by the use of bands pulling the fragments towards the side bars of the splint according to the direction indicated by the X-ray.

 

2. Posterior Displacement of the upper end of the lower fragment, or the loss of the normal anterior bowing of the femur. This can be corrected by (a) increasing the extension, (b) tightening the ' master band ', (c) dropping the malleoli still farther below the side bars.

 

3. The most serious difficulty arises where there are multiple wounds or multiple fractures which prevent the ordinary extension being used.

 

It is only in these cases that the use of other methods of obtaining extension is to be recommended.

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Mechanical Methods of Extension.

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The following are some of the mechanical means of obtaining the extension when the glue and gauze method is found impracticable (Fig. 33) :

 

i. Extension calliper and guards for the malleoli or condyles.

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ii. Major Pearson's method with ice-tongs calliper.

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iii. Major Sinclair's stirrup.

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iv. Screws into the tibia and a direct pull.

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1. Extension Calliper and Guards (Figs. 38 and 39). A well-made suitable sized engineers' measuring calliper is fitted with two ' extension guards '. These extension guards are made of a 3 in. by -in. flat rod of metal with a small metal tube welded at the centre through which the ends of the calliper are to be inserted into the bone.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIG. 38.

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1. Extension calliper for use in the condyles. Shows one guard in place.

2. Extension calliper for use in the malleoli.

3. Metal stirrup for use over the tendo Achillis.

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FIG. 39. Splint, calliper, and foot-piece, extension tapes tied to foot-piece and calliper.

 

The technique of the operation is as follows : Incisions i in. long are made (a) if for the malleoli, at a point i in. above the tip of the internal malleolus and at a point exactly opposite, above the external malleolus ; (6) if for the condyles of the femur, at a point just above the adductor tubercle and at a point exactly opposite on the outer condyle.

 

The skin and subjacent structures at these points are cleanly cut through down to the bone ; the small tube on the extension guard is being used, slipped into the incision with its end bearing upon the bone ; a jVin. drill marked at the point that will be reached when it projects f-in. beyond the end of the tube is used to make a hole into the outer layer of the bone, the assistant taking great care that the guard does not move. The calliper is then fitted through each guard with its end projecting into the bone, and a sterile dressing is put under the flanges of the guard and round the limb, the whole being very carefully padded and bandaged, Traction is made by means of strong tape from the extension guard (Fig. 40).

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FIG. 40. Splint, calliper, and foot-piece applied, portable X-ray apparatus

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This form of extension can be left in position until bony union has begun. The danger from osteomyelitis is slight because of the small amount of bone affected by the operation. The further treatment of the fracture is upon the same principles as when glue and gauze is used, the extension from the calliper taking the place of the extension from the leg. It is advisable to apply a serrated wooden foot-piece which will maintain the outward rotation of the lower fragment and keep the foot at right angles.

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