Toarniqaet
pleasure, without diminishing the tension of the extending or counter-
extending bands."
In compound fractures of the leg, Dr. Gilbert recommends a modifi-
cation of the common fracture-box. In this apparatus the foot-board
is^omitted, and a block for the reception of the frame of the tourniquet
is.substituted. Each side of the box consists of three separate seg-
1 Philadelphia Med. Exam., vol. xi. p. 580, 1855.
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FRACTURES OF THE TIBIA AND FIBULA.
469
ments. Of these the upper and lower are permanently screwed to the
bottom-board, and the central one is attached by hinges. By this
arrangement there is full access to the wound, which may be dressed
from day to day without disturbing the extension and counter-exten-
sion, maintained by the permanently attached upper and lower seg-
ments.
The following wood-cuts are intended to illustrate an apparatus
invented by R. O. Crandall, for the purpose of making permanent
Fig. 211.
SectioD of GrsndaU*8 apparatoi, applied to the limb ; showing adhenire plaster connter-extendlng bandi
and gaiter for extension, &e.
Fig. 212.
Cnodsirt apparmtnt complete. The connter-extendlng straps are passed over a block of wood sap-
ported aboTe the knee, to prerent their pressure upon the sides of the knee.
Fig. 213.
Posterior riew of the lower portion of Crandall's apparatns.
extension. The extension is represented as being made by a gaiter,
but Dr. Crandall leaves it to the choice of the surgeon whether he
sliall employ the gaiter or adhesive strips.^
Without intending to deny to these contrivances much ingenuity
and considerable practical value, I am far from conceding that they
^vill be found capable of overcoming altogether the action of the mus-
' Crandall, Phil. Med. Joum., vol. iv. p. 193, Jan. 1856 ; also Transac. of Med.
^«soc. of Southern and Central New York, 1855, pp. 81, 82.
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470 FRACTUBES OP THE TIBIA AND FIBULA.
cles where the ends of the fragments do not support each other. Their
mode of action is such that they can scarcely do more than to steady
the limb, and if they operate upon the fragments at all in the direction
of their axes, it must be only in the most inconsiderable degree. The
adhesive plasters are substituted for the circular knee bands and the
gaiters, with a view to avoid ligation ; but in order to do this they
must not encircle the limb, but only be laid parallel to its long axis.
The leg of an adult, or that portion to which the adhesive plasters
can be applied; supposing the fracture to be exactly at the centre,
may be sixteen inches, that is, eight inches for extension and eight for
counter-extension ; but when we employ the same means for extension
in fractures of the thigh, we find it necessary to apply the strips over
the whole of these sixteen inches, the entire length of the leg, or thej
will not hold. It will be apparent also that we cannot use even the
eight inches which we have, for the purpose of argument, allowed
these gentlemen in fractures of the leg. There must be at least a
space of eight inches between the ends of the two opposing strips, in
order that they may operate at all upon the fragments; indeed, I do
not believe that even then their influence would reach beyond the
skin to which they were directly applied ; but if a space of eight inches
is left, only four remain for the strips at either end; and this is an
amount of surface wholly insuflBcient for our purpose. What^ then,
shall we do when the fracture is near one of the extremities of the
bone? These gentlemen seem to have forgotten, moreover, that the
whole leg is tender, and that the skin easily vesicates. In short, they
have not seen the many points of diflference between the application
of these means in fractures of the thigh and leg, and which, while
they allow us to accomplish all that we could desire with the one, are
of little or no use in the other. We shall then always come to the
same conclusion ; whatever means we may employ to make permanent
extension in fractures of the leg, we must either fail to accomplish
all that we desire, or incur the hazards incident to complete and firm
ligation of the limb; and if the preference is given to any form of
apparatus to accomplish these ends, it must be to some form of the
double-inclined plane, by which we may at least avoid ligation in the
upper part of the limb, the counter-extension being made against the
under surface of the thigh while it is resting upon the thigh piece; or
to one of the long straight thigh-splints, which will enable us to make
the counter-extension from the thigh and perineum.
If a double-inclined plane is used, I prefer either a plain apparatus,
such as we have already described as in use for fractures of the thigh,
constructed of boards, joined together by hinges opposite the knee,
and with an upright foot-board, upon which a carefully arranged and
thick cushion has been placed, or the more elegant double-inclined
plane of Liston.
In using Listen's apparatus, it must not be inferred that the knee is
always to be bent. The apparatus is designed to be used occasionally
as a straight splint; and there will be found many cases of fractures
of the legs in which the straight position will be most suitable : this
is especially true of such fractures as, occurring just below the knee.
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FRACTURES OP THE TIBIA AND FIBULA. 471
joint, "have the line of fracture directed obliquely downwards and for-
"wards. But there are many compound fractures which demand the
Fig. 214.
I«l8ton'8 donble-inellned plane ; applied to the leg in a ease of eomponnd fracture. (From Miller.)
same extended position ; and in nearly all cases where this form of
apparatus is used as a double-inclined plane, the lower end of the
splint should be elevated so that the heel shall not be much below the
level of the knee.
Bauer's wire splints, used also for side splints, when they are formed
to fit the limb accurately, possess some advantages which must recom-
mend them to the attention of surgeons ; but neither these splints nor
Fig. 215.
Lonie Baaer*8 wire splints for the leg.*
any others, however accurately fitted, ought to be applied directly to
the naked skin. They require always the interposition of a well-
padded lining.
Boxes are rarely useful except in certain compound fractures. They
are heavy and awkward machines, which prevent the patient from
moving readily in bed ; or which, being fixed, if he does move, allow
the upper fragmemt only to descend, or to move upon the lower as a
fixed point. If used at all, they ought generally to be suspended or
made to move on a suspended railway. But, however they are ar-
* Bauer, Buffalo Medical Journal, April, 1857, vol. zii.
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472 FRACTURES OF THE TIBIA AND FIBULA.
ranged, the limb 19 a great part of the time concealed from sight, and
the surgeon is prevented from making use of such means to rectify
Fig. 216.
Swing box or " cradle." (From Skej.)
deviations in the line of the bone as he would probably have other-
wise employed.
The swing invented by James Salter, of London, is constructed so
as to allow not only a lateral motion, but also a more complete motion
in the direction of the axis of the limb, by which the danger of push-
Pig. 217.
Salter's cradle. (From FergOMon.)
ing the fragments upon each other is obviated. This is accomplished
by the rolling of two pulley- wheels upon a horizontal bar. The case
in which the leg rests may be made of metal or of wood, and the frame
of iron, for the sake of lightness and strength.
Dr. Hodgen, of St. Louis, suspends the box over a pulley placjed
transversely, so that by drawing the rope to the right or to the left,
the box may be turned upon either side.
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FRACTURES OF THE TIBIA AND FIBULA.
478
Fig. 318.
Fractare-boz, with moyable sidet.
rriiese boxes are sometimes filled with bran, the bran being closely
paclced upon all sides so as to support the limb uniformly and gently.
This method of treating compound fractures of the leg was first sug-
gested by J. Rhea Barton, of Phila-
delphia,^ and has been much used in
the Pennsylvania Hospital; and lat-
terly it has been introduced into the
Bellevue and New York City Hospi-
tals. It possesses the advantage of
affording a perfect protection against
flies in the summer season, and of
absorbing the matter as it escapes.
^Whenever any portion of it becomes
soiled by blood or pus, it may be
dipped out with a spoon, and its
place supplied with fresh bran. The support which it gives to the
limb is also uniform without being at any time excessive, and Dr.
Coates states that the escape of blood in rapid hemorrhages has been
known to increase the bulk of the bran sufficiently to arrest the
bleeding by its accumulated pressure.
In whatever position the leg is placed, and with many of the forms
of apparatus which we have enumerated, it will be found necessary to
protect the limb from the weight of the bed-
clothes by some contrivance similar to that Fig. 219.
figured in the accompanying drawing; or by a
rack, such as is represented for suspending
the leg when leather splints or the immovable
apparatus is employed.
Malgaigne, who declares that every surgeon
knows how impossible it is, in an immense wire nek for fracture of leg.
majority of cases, to overcome the projection
of the superior fragment when the limb is placed in the extended
position (over a double-inclined plane), and who affirms that neither
Pott's position, nor Dupuytren's modification of it, will do much if
Fig. 230.
Malgalgne's apparatu for oblique fractures of the lef. (Trom Malsaigne.)
any better, nor, indeed, that Laugier's plan of cutting the tendo
Achillis possesses in this respect any real advantage, concludes at
» Barton, Amer. Joum. of Med. Sci., vol. xvi. p. 31, and vol. xix. p. 515.
81
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474 PBACTURBS OP THE TIBIA AND FIBULA,
last to resort to a new and really ingenious method, the value of
which, also, he claims to have already fully demonstrated. His spp^-
ratus consists simply of a steel band of sufficient size to encircle three-
fourths of the limb, at the two extremities of which are two horizontal
mortises through which a band is passed, and which may be buckled
upon itself behind. The centre of the metallic arch, in front, is
penetrated with a firm metallic screw, terminating in a very sharp
point, and which is moved by a flat thumb-piece.
The limb being laid over a douUe-inclined plane, and the pads
being carefully adjusted, as we have already directed when speakiDg
of other forms of apparatus, and the limb properly extended, the
apparatus of Malgaigne is placed over the limb, with the sharp point
of the screw resting upon the upper fragment, a few lines above the
point of fracture ; and at the same moment that this point is pressed
firmly down to the bone, the fragments being held together by an
assistant, the strap is buckled as tightly as possible under the splint
A few turns of the screw will now make its point penetrate more
deeply into the bone, and insure the most complete apposition of the
broken extremities. ''This is accomplished," says Malgaigne, ^with
very little pain to the patient;" and, as will be seen, the steel arch
effectually prevents any ligation of the limb. I cannot say that the
plan receives my unqualified approval ; yet I have employed it to
advantage in some cases of old, ununited fractures.
Fig. 221.
Halgalgne's appftratns applied. (From Ifalgalgne.)
Befraciure and Resection of Crooked Legs. — In some cases of extreme
deformity of the legs consequent upon badly united fractures, re-
section of the bones has been practised with more or less success.
The first case of which I have seen any mention made, where the
bones were actually resected, is reported by Charles Parry, of Indian-
apolis, Ind. A young man, set. 15, having broken his leg near its
middle, the fragments united, from some cause, nearly at right angles
with each other. Some years afterwards, on the 15th day of January,
1838, Dr. Parry operated, by removing a wedge-shaped portion from
both the tibia and fibula. The recovery was t^ious^ bat satisfactory^
> Pany, Amer. Joum. Med. Sd., Aug. 1889, p. 884.
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FRACTURES OP THE TIBIA AND FIBULA. 476
Mr. Key, of London, made an operation of this kind upon a gentle-
man who had suffered a fracture of the right tibia from a musket-ball.
The limb was nearly useless, since he could only bring his toes to
the ground. Mr. Key operated in Oct. 1838, and when the report of
the case was made, five months subsequently, the patient was doing
well.^
In Sept. 1840, Dr. Mutter, of Philadelphia, made a similar operation
Ti{>on a patient, whose leg was shortened three inches and a half, and
very much deformed ; by which operation, when the recovery was
complete, the shortening was considerably reduced.^
Cases may occur which will justify a resort to these extreme mea-
sures, or in which they may be preferred to amputation ; but an ex-
amination of the several examples reported will show that these ope-
rations are not unattended with danger to the life of the patient;
indeed, in this respect, amputation has greatly the advantage. If,
moreover, the surgeon expects, by this method, to lengthen a limb
much, where it is merely overlapped and shortened, he is, I am certain,
destined to disappointment, at least in all cases where sufficient time
has elapsed for tne bones to have become firmly united. I have myself
several times refractured a bone; and I have several times met with
cases of old fractures newly broken, and I have constantly observed
that I could never, in the end, make it but very little if any longer
than it was before the last fracture. The muscles had contracted to
that point, and their contraction would not be overcome. In the case
reported by Mutter, he believed that he stretched the muscles two
inches. With all deference for the skill and honesty of this gentle-
man, I think that he was mistaken.
If, however, the object of the operation is to straighten the limb,
then no doubt it may be sometimes accomplished ; and in some degree
also by the straightening of the limb the shortening may be over-
come ; but, in our opinion, such procedures ought to be reserved for
extraordinary circumstances.
An instructive case of refracture is reported by Dr. Horner, of
Philadelphia, in the Medical Examiner. The limb had been broken
eight weeks, and was quite crooked, but was not very firmly united,
and Dr. Horner having refractured it, was able at once to restore it
to a nearly straight line.'
> Key, Amer. Joum. Med. Sci., Aug. 1839, p. 889, from Gtiy^s Hospital Reports,
April, 1889.
* M&tter, Amer. Joum. Med. Sci., April, 1843, p. 859. Three similar cases
may also be found in the Oct. No. for 1841, and the April No. for 1842 of the same
Journal, in which the operations were made by Portal, of Palermo. Malgaigne
mentions two other examples.
» Homer, New York Joum. Med., May, 1851, p. 482.
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476 FRACTURES OF THE TARSAL BONES.
CHAPTER XXXIII.
FRACTURES OF THE TARSAL BONES.
Causes.-^The astragalus is generally broken by a fall from a beight,
the patient having struck upon the bottom of the foot. Monaban, in
an analysis of ten cases, found it had been broken by a fall upon the
foot nine times/ and only once by a crushing accident.
The calcaneum is also occasionally broken by violent lateral pres-
sure, but much more often by a fall upon the foot, or rather upon the
heel. In some instances both heel-bones have been broken at the
same moment ; but Malgaigne has collected eight cases of fracture of
this bone by muscular action, as in jumping upon the toes, the pos-
terior portion of the bone being thus violently acted upon by the
tendo Achillis. South, in his Notes to Chelius, has mentioned two
other cases, one of which was seen by Lawrence, and has been reported
in the second volume of the Lancet. This person had received the
injury by jumping ofiF a stage-coach. The fragment was found to be
drawn upwards slightly, but not so far as to prevent crepitus when
the muscles on the back of the leg were relaxed. The other example
mentioned by South is a cabinet specimen contained in the museum
of St. Bartholomew's Hospital. The fracture had taken place just
below the attachment of the tendo Achillis, but the upper fragment
was not displaced.* Mr. Cooper mentions two other cases, both pro-
duced by violent efforts on the part of the patients to sustain them-
selves when falling. In one of these the fragment was immediately
drawn up three inches.*
The other bones of the tarsus are generally broken by crushing
accidents, such as the fall of heavy weights upon them, by the passage
of loaded vehicles, &c.
Pathology, — The astragalus often, indeed generally, escapes without
injury in those crushing accidents which break many or most of the
other bones of the foot, and, as we have seen, it is seldom broken
except when the patient has fallen upon the bottom of his foot ; bat
at the same moment, the foot being turned forcibly out or in, a dislo-
cation of the tibia takes place, and the fibula is broken. In nine of
the cases collected by Monahan, one or the other of these forms of
dislocation had occurred, in eight of which the dislocation was com-
pound. The direction of the fracture is found to vary greatly; thus,
* Fracture of the astragalus, with analysis of the recorded cases of this injniy.
An inaugural thesis presented to the faculty of the Buffalo Med. Col., March, 1858,
by Bernard Monahan, M.D.
» South, Notes to Chelius*s Surgery, vol. i. p. 639, Amer. ed.
' B. Cooper's ed. of Sir Astley, Amer. ed., p. 811.
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FRACTURES OF THE TARSAL BONES. 477
'it has been found broken in its length antero-posteriorly, in its breadth
or transversely, and in one instance it has been divided nearly hori-
zsontally, so as to separate the upper face completely from the lower.
Sometimes it suffers a species of impaction, the fragments being actu-
ally driven into each other ; at other times, as in one case related
"by Amesbury, the bone may be split without the occurrence of any
displacement.
The calcaneum also may be broken in any direction, and it is" equally
nvith the astragalus liable to impaction, by which its vertical diameter
is sensibly diminished, while its transverse diameter is increased. IP
the fracture is a consequence of muscular action, the line of fracture is
always posterior to the astragalus, and in some cases only that portion
is broken off to which the tendo Achillis has its attachments. It may
bo broken also vertically, directly underneath the astragalus, in which
case the lateral and interosseous ligaments will prevent anything more
than a slight displacement of the posterior fragment. When the
fracture takes place posterior to the lateral ligaments, the detached
fragment is liable to be drawn very far from the body of the bone, even
to the extent of four or five inches, and possibly farther when the leg
is extended upon the thigh and the foot flexed upon the leg. Con-
stance relates a case in which the tuberosity, having been broken off
by a direct blow, was drawn up five inches.^
Fractures of the calcaneum produced by contraction of the sural
muscles are generally simple, but those which result from a crushing
of the bone are more often compound. The same remark is applicable
also to the other bones of the tarsus, the fractures of which, being
only produced by direct blows, are generally complicated with exter-
nal wounds.
Symptoms, — All fractures of the bones of the tarsus demand especial
care in their diagnosis, since only a few of the usual signs of fracture
are in a majority of the cases presented. The explanation of this
fact will be found in the number, size, and strength of the bones of
the tarsus, and in their close and firm union by ligaments, by which
they give to each other a mutual support, so that the fracture of a
single bone does not necessarily or usually result in displacement or
deformity, and even crepitus is with difficulty detected ; and when we
consider, moreover, that the fracture is generally produced by great
violence, directly applied, in consequence of which the foot in most
cases becomes rapidly and enormously swollen, we shall understand
the true nature of the difficulties which are usually presented in the
way. of an accurate diagnosis.
Of all the usual signs of fracture, crepitus alone is pretty generally
present^ but even this often fails to tell us which bone is broken, and
still more often does it fail to inform us as to the direction and extent
of the bony lesions. .
If the whole or a portion of the tuberosity of the calcaneum is sepa-
rated by the action of the muscles, and the fragment is drawn up-
' Constance, Amer. Jonm. Med. Scl., vol. v. p. 222, Nov. 1829, from the Midland
Med. and Surg. Reporter.
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478 FBAGTUBES OF THB TARSAL BONES.
wards, it may be discovered in its new position, and the heel will be
flattened or shortened, but no crepitus can be felt unless the fragments
are again brought in contact.
Treatment. — Not any of the fractures of the tarsal bones in tbem-
selves demand the use of splints, and it is only when complicated with
a dislocation of the ankle and fracture of the fibula that it is proper
to employ apparatus of this sort ; certainly the exceptions to this rule
must be very rare ; so that our practice in these oases will be oonfioed
chiefly to the prevention and reduction of inflammation. The limb
must be placed in the most easy position, and cold water lotions assidu-
ously applied. This will be the sum of the treatment demanded daring
the first few days after the receipt of the injury in probably aU oases
of simple fracture, and in many cases of compound fracture.
If single bones, or fragments of single bones, are displaced to any
considerable extent, and there is an external wound communicating
with the fracture, I have no doubt it would be best in all cases to re-
move at once by dissection the projecting bone, even although it were
possible, or perhaps easy, to force it back again to its place, as has
been done successfully by Ashhurst, of Philadelphia.^ The same
rule I would apply to examples of fracture uncomplicated with any
external wound, if the fragments were very much displaced, and ooold
not by the application of moderate force be replaced, since the bone
lefb to project would prevent the patient from ever wearing a boot
with comfort, and would entail as much weakness upon the limb as
would be likely to follow from its complete separation. But such
cases as I have last supposed are exceedingly rare; indeed, I have
never met with a simple fracture of a tarsal bone accompanied with
displacement.
Norris has^ however, reported a case of fracture of the astragalus
accompanied with displacement of about one-half of the bone, but
without any lesion of the soft parts. This was in the person of a man
aet. 30, who was admitted into the Pennsylvania Hospital on the 26th
of Sept. 1831. ''An hour previous to admission, while descending a
ladder, he slipped and fell in such a manner as to throw the entire
weight of his body upon the outer part of his left foot. Upon exami-
nation, the foot was found to be turned inwards and nearly immovable.
A slight depression existed immediately below the lower end of the
tibia, and there was a considerable hard and rounded projection on the
outer part of the foot, a little below and in front of the extremity of
the fibula. The skin covering this projection was reddened, but not
excoriated. There was no fracture of either bones of the leg." .
These appearances led Drs. Norris and Barton, under whose care
the patient was placed, to regard the accident as a simple luxation of
the astragalus forwards and outwards ; and a short time after admis-
sion efibrts were made to reduce it. "This was done after relaxing ia
as great a degree as possible the muscles of the leg, by fixing the knee,
and having assistants to keep up extension, by seizing the heel and
front part of the foot ; at the same time the bone being pushed inwards
> Ashhurst, Amer. Joum. Med. Sci., April, 1863.
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FRACTURES OF THE TARSAL BONES. 479
hand toward the joint by the surgeon. These eflForts were continued