Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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with the fingers, or with a blunt hook. This simple procedure has
often succeeded with me in a moment, when others have been trying
in vain to accomplish the same end by pulling upon the limb. If
this fails, then the skin should be cut sufficiently to allow the bone to
retire, or if the point is sharp, and especially if it is stripped of its
periosteum, it may be sawn off. Besecting thus the end of an oblique
fragment does not generally affect in any degree the length of the
limb, or interfere with a prompt and perfect cure, but, on the contrary,
it often is advantageous in every point of view.

Having restored the fragments to their places as well as we may,
the limb is laid carefully on its outside upon the long wooden splint.
We shall now find it necessary generally to add two or three thin
pads, in order to supply vacancies which we have not perfectly pro-
vided for in the preparation of the splint. Generally we shall also
see the necessity of placing a pretty thick pad under the outer margin
of the foot or toes, so as to bring the great toe in line with the inner
edge of the patella and spine of the tibia. The other side splint is
now laid along the inner or tibial side of the limb, and with successive
turns of a roller, or with a number of narrow and separate strips of
cloth, the whole are bound together, and the limb is left to repose
upon its outer side.

The patient may, if necessary, lie upon his back, but it is better
that he should be turned a little toward the side of the broken limb.
The danger of twisting the fragments upon each other is lessened by
lying upon the same side with the broken limb, but I have frequently
permitted patients to lie upon their backs, and found no such result.
If the long under splint extends a little way upon the thigh, and is
well fastened to the thigh, the twist cannot very well occur.

By adopting this general plan of treatment we avoid all chances of
gangrene or swelling of the foot from excessive ligation, and it is to



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FRACTURES OP THE TIBIA AND FIBULA. 461

these accidents, especially, that the remarks of Dr.. Norris, already
quoted, are applicable. The larger size and irregular forin of the
"bones of the leg, the small amount of muscular tissue covering them,
especially near the articulations, the severity of the injuries to which
they are liable, with their remoteness from the centre of circulation —
'these circumstances altogether, render them exceedingly exposed to
injury from the too great or unequal pressure of splints or of bandages ;
and it has often occurred to myself, as it has to Dr. Norris, to find the
skin vesicated, or even ulcerated and sloughing, when the patients are
first admitted to the hospital; a condition which, in nine cases out of
ten, is due to the mal-adjustment of the splints, or to the tightness of
the bandages.

If bandages are used under the splints, and next to the skin, they
must be applied very moderately tight, and loosened or cut as the
swelling augments; and, from the first day of treatment to the last,
the surgeon must be careful to loosen or tighten the dressings when
the swelling increases or subsides, just as the prudent boatman trims
his sails to the rising and falling breeze.

Dr. Krackowitzer presented to the New York Pathological Society,
June 10, 1863, a leg which he had amputated for gangrene occasioned
by tight bandages. A boy, five years old, sustained an injury of the
ankle-joint, which his medical attendant pronounced a fracture of the
fibula, and for which he applied only a tight bandage. The child
sufifered a good deal after the bandage was applied, and the following
morning the toes were blue, but the doctor paid no attention to this
circumstance. The pain subsided on the third day, and on the fourth
the bandages were removed, and the limb found to be gangrenous.

The specimen showed that the fibula was not broken, but that there
was a fissure or crack in the lower part of the shaft of the tibia.^

The following case, which has been communicated to me by Dr.
Fuller, of Wyoming, N. Y., with permission to make such use of it
as I choose, is sufficiently pertinent for the instruction of others, and
deserves a public record : —

A man, aet. 71, fell from a tree, striking upon his foot, Aug. 27,
1855, producing a backward dislocation of both the tibia and fibula
upon the os calcis, and also a fracture of both bones of the leg a few
inches above the ankle.

An empiric took charge of this unfortunate man, and immediately
applied, lateral splints and a firm roller from the toes to the knee.
Notwithstanding the remonstrances and prayers of the patient to have
the bandage loosened, it was kept on until the ninth day, when the
doctor cut the bandage upon the top of the foot, and it was found
vesicated. Ignorant, however, as to the cause of this vesication, and
of the danger which it threatened, he omitted to loosen the remainder
of the bandages, and the limb was left in this condition until the
twenty-third day, when Dr. Fuller being called, and having removed
all the dressings, found the integuments covering the whole foot dead
and dried down to the bones. The dislocations bad not been reduced.

» Krackowitzer, Amer. Med. Times, Nov. 7, 1868.



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462 FRACTURES OF THE TIBIA AND FIBULA,

Soorr after this the limb became oederaatous, and on the twenty-seventh
of October the leg was amputated by Dr. Barrett, of Le Roy ; from
which time the patient recovered rapidly.

But it is to the advantages of the posture recommended by Pott
that I wish especially to direct attention. The position hitherto gene-
rally preferred by surgeons has been that in which the limb rests
upon its back, either in a box or upon a double-inclined plane ; bat all
of the examples of ulcers upon the heel which I have seen have been
after treatment in this position. Indeed, it is almost impossible for
this accident to happen in any other way, and it has therefore never
occurred to me to see it in cases treated by Pott's method. It is true
that, with great care, such a result might generally be prevented while
the leg is resting upon its calf, yet experience shows that it is by no
means easy to avoia it always. And if, in our anxiety to obviate this
evil, we place p^ds underneath the tendo Achillis, above the heel, we
incur the risk pf pressing the fragments forwards, and of compelling
them to unite with the whole lower part of the leg inclined backwards.
I have mentioned already that this has happened, in cases that have
subsequently come under my observation, no less than seven times»
while an attempt to correct this fault by placing the support under
the heel has either produced ulcers of the heel, or driven the lower
part of the limb in the opposite direction.

The same thing — that is, a deviation backwards or forwards — might
happen in any posture, but I am sure it is much less liable to in Pott's
position than in any other.

Then, again, a twist or rotation of the lower fragment is more liable
to take place when the toes point upwards, and the limb rests upon the
calf and heel, than when the limb reposes upon its side. In the one
case it is resting upon a narrow surface, with the whole weight of the
foot disposing it to either eversion or inversion, while in the other it
lies upon a broad surface, with the foot entirely at rest, and demanding
no extraordihary support.

In short, Pott's position is less irksome to the patient, and vastly less
troublesome to the surgeon. Ugly and crooked limbs are sometimes
inevitable, and they are often the consequences of unskilful manage-
ment or of inattention on the part of the surgeon ; but, other things
being equal, the best legs have, in my experience, come out of Pott's
position, and the worst out of the double-inclined plane and the box.

As to the tendency of the upper fragment to rise at the point
of fracture, it depends, no doubt, upon the usual direction of the
fracture, and the action of the muscles both in front and behind ; so
far as the former circumstance is the cause — that is, the direction of
the line of fracture — ^no position is sufficient to remedy it ; and in rela-
tion to the action of the muscles, the indications are as easily and
naturally fulfilled with the limb upon its side as upon its back. Gene-
rally the leg needs to be flexed upon the thigh ; but if the fracture is
high up, and its direction is obliquely downwards and forwards, it
must be made nearly or quite straight, so as to overcome the action
of the anterior muscles of the thigh, acting, through the ligamentum
patellae, upon the upper fra^ent. The simple rule which I recom-



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FBACTUBES OP THE TIBIA AND FIBULA. 463

xnend and adopt is, to flex or extend the limb more or less untrl it is
ascertained in what position the apposition of the fragments is most
complete.

As has already been intimated, I have of late less frequently re-
sorted to the method of treatment just described, and have substituted
the following : —

The fragments being adjusted, two lateral splints of leather, long
enough to extend from near the knee-joint to the metatarso-phalangeal
articulations, and wide enough to nearly encircle the limb, are moulded
to the limb on each side, and secured in place by successive turns of
the roller. When the skin is delicate or tender, these should be un-
derlaid with a thin sheet of cotton wadding or of patent lint. A soft
woollen cloth may answer the purpose equally well. A rack is then
placed over the limb, such as will be seen figured for the suspension
of the limb when dressed with plaster of Paris, and /rom this the leg
is suspended. The objects to be attained by the suspension are three-
fold : first, to avoid the danger of pressure upon the heel, and conse-
quent ulceration ; second, to prevent that driving down of the upper
fragment upon the lower which constantly ensues when the foot rests
upon the bed or in a box which is immovable; third, to obviate
movement of the fragments upon each other when the patient sits up
or lies down in bed. This movement, I observe, is peculiar. It is not
simply a motion of the fragments upon each other, as upon a pivot at
the point of fracture, which motion seldom interferes materially with
consolidation, but it is a rising and falling of the upper fragment, or
a motion to and from of the fragments, and also a riding motion ;
either of which latter movements necessarily delays or defeats bony
union. It is because these motions are generally permitted to occur .
in the usual modes of %dressing these fractures, more than for any other
reasons, that union is so often delayed in the case of these bones. In
my own practice, when this plan of suspension is enforced, delay never
occurs, but nothing is more common than for me to meet with it when
other surgeons have had charge of the limb, and the suspension has
been omitted.

In suspending the limb, it is only necessary that the leg should
float clear of the bed ; and I think it worth while to say that when
leather is used for splints, a broad oval piece of leather or of some other
firm material should receive the limb in suspension, rather than pieces
of bandage, which soon become cords, and press unequally. To the
sides of these oval pieces bands are attached, and their ends tied over
the top of the rack. One must be placed under the knee and one
under the ankle.

If the fracture is above the middle of the leg, complete quietude of
the fragments can only be obtained by carrying the splints and the
bandages above the knee.

I have already, in my remarks on the treatment of fractures in
general, declared my acceptance of the so-called " immovable appa-
ratus" in the treatment of certain fractures of the leg below the knee,
and especially of the plaster of Paris dressings. In hospital practice,
where these dressings can be applied by experts, and where the limb



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464 FBACTURES OF THE TIBIA AND FIBULA.

can be watched daily and hourly, most or all of the dangers incident
to this form of dressing may be avoided ; but even here I have occa-
sionally seen, from a little too much delay in opening the dressings,
serious trouble ensue. Its most devoted advocates, Seutin, Velpeaa,
and others, have never denied the necessity of caution in its use.
To-day I hear of a surgeon in a neighboring State who has been pro-
secuted for damages in consequence of the death of the limb caused,
as is alleged, by this form of dressing. On the other hand, when
applied judiciously, even immediately after the receipt of the injury,
and when carefully watched and opened freely on the first notice of
danger, it has, in my wards, and in the hands of my excellent honse i
surgeons, often served its purpose more completely than any other \
apparatus or splints I have ever seen employed. It has steadied )i
and supported all parts of the limb more completely, and permitted
it to be handled, more freely, than anything else could do. In simple
fractures patients have been permitted to walk about upon crutches \
after the third or fourth day, and generally no harm has resulted. In
one case, however, I believe this liberty caused a serious delay in the
union ; and in another an abscess resulted, which would have been
avoided if he had remained in bed. For myself, I do not think any -.
great advantage is derived from allowing the patient to leave his bed, J
and it is certainly attended with some additional dangers; I therefore ^
seldom recommend it. j

But it is in the management of compound fractures of the 1^ that
I have of late seen the greatest advantage in this mode of dressing; |
and it was in precisely these cases that I formerly believed the im- ■
movable apparatus most objectionable. I do not wish to retract any-
thing I have heretofore said as to its dangers, but I have not until ,
lately fully appreciated to what a degree these dangers might be
overcome by skill and attention.

The following careful description of the proper mode of applying
plaster of Paris bandages in fractures of the leg has been prepared at |
my request by Dr. S. B. St. John, one of our house surgeons. His
large experience and his habits of accurate observation render his |
statements peculiarly trustworthy.

" The materials necessary are, blanket or cotton wadding, blanket |
being preferable, and plaster of Paris bandages, which are prepared
by rubbing dry plaster into the meshes of a bandage of coarse tex-
ture, and rolling it up so as to make it convenient of application.
(These may be kept ready for use in tin cans.) The bones having
been placed in position, the leg is placed upon the blanket, which is
cut and folded neatly around it, and secured by a few pins. The
blanket should extend from the base of the toes to the knee, or in
case of fracture above the middle or of compound fracture at any point,
a few inches above the knee. The plaster bandages should then be
immersed in hot water, to which a little salt has been added to hasten
the setting, and while in the water they may be gently kneaded to
insure moistening of every part. In about three minutes, or when
bubbles of air cease to rise from them, they will be ready for use, and
should be taken out as they are wanted, and gently squeezed to get



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FRACTURES OF THE TIBIA AND FIBULA. 465

Tid of superfluous water. They are then to be applied after the fashion
of an ordinary bandage, over the blanket, with just sufficient firmness
to insure a complete fit. If, at any revolution of the bandage, the
plaster is seen to be dry, it should be moistened by dipping the hand
in water and rubbing it over the dry surface. Extra turns of the
bandage should be taken at the places where it is necessary to secure
extra strength to the splint. Three or four bandages (six yards long)
are usually sufficient to make a firm splint. The splint will usually
be sufficiently pliable just after its application to allow of rectification
of any faulty position which may have occurred during its application.
It should then be kept in shape by the pressure of the hands until it
tardens> which will be in from ten to thirty minutes, according to the
freshness of the plaster and texture of the bandages used. If, for any
rea^n, it is desirable to cut the splint so as to admit of its removal,
or to cut a fenestra through which to observe any part, this may best
be done before the plaster becomes perfectly dry, say in from two to
five hours after its application, depending upon the quality and fresh-
ness of the plaster. It will then cut like hard cheese, and a gtout
sharp knife should be used. In splitting a splint anteriorly, it is con-
venient at the same time to take out a piece about an inch wide, by
making two parallel cuts one inch apart, one on either side of the me-
dian line, extending nearly through to the blanket, and then by raising
the strip at the upper edge, and cutting on either side alternately, the
section may be completed, and the central slip removed without
danger of cutting through the blanket and wounding the patient.
The blanket may then be cut with scissors and the splint sprung off
to examine the limb, if necessary. When replaced, a bandage should
be applied over it. If it should be necessary to cut a splint which
has already become dry, and cuts with great difficulty, it may be
softened with hot water, applied by a sponge in the track of the pro-
posed section for ten or fifteen minutes.

"If it is necessary to cut such a large fenestra that only a small strip
of the splint would be left connecting its upper and lower portions, it
is better to adopt a different plan of application. For this it is neces-
sary to have a solution of plaster of Paris in water of the consistency
of cream. A piece of blanket is then cut long enough to reach from
the toes to the top of the proposed splint, and about fifteen inches
wide. This is to be thoroughly soaked in the solution, and folded
several times so as to be about two or three inches wide when folded.
This is to be applied along that part of the limb which it is not
necessary to keep under observation (if convenient, along its posterior
aspect), and it is then to be secured in position by circular turns of
the plaster bandage above and below the portion to be left exposed.
Whenever a plaster apparatus extends above the knee, and it is pro-
posed to sling the leg from a cradle, the leg should be flexed sligntly
upon the thigh, so that it may be swung horizontally. Any portion
of a plaster splint exposed to the moisture of discharges or of water
used in dressing, should be carefully protected by oil silk and cotton
wadding.

"In cases where not much swelling is anticipated, blanket is pre-



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466 FKACTUKES OF THE TIBIA AND FIBULA.

ferable to cotton wadding, as an elastic medium between the splint and
skin, because it is of more even thickness and retains its place better
when the splint is removed, but cotton answers better when much
swelling is anticipated, as being more elastic."

The accompanying illustration has also been made for me by Dr.
St. John, and furnishes a faithful picture of one of the many similar
cases now under treatment by this method at Bellevue HospitaL

Pig. 206.



Plaster of Parle dressing, and saspension.

There are a few cases in which a very much better position of the
fragments can be secured by placing the patient under the influence
of an anaesthetic, and by applying the dressing during complete an-
aesthesia. But the surgeon needs to be warned of two things in this
connection : first, that just as much harm can be done to the soft parts
by violent wrenching and pushing when he is insensible as when he
is fully conscious ; second, that while the patient is passing under the
influence of an anaesthetic he is liable to violent muscular spasms,
which may do serious injury.

In such few cases as demand or warrant a resort to extension and
counter-extension, a double-inclined plane furnishes a convenient mode
for its accomplishment ; but it is only occasionally that, in fractures
of the leg, permanent extension and counter-extension can be em-
ployed ; an assertion which, however much it may excite surprise,
experience will prove true. If the fracture is near the middle of the
leg, quite remote from the points upon which the appliances for ex-
tension, &c., are to be made fast, and the inflammation is moderate,
something may be done in this way ; but when the point of fracture
approaches the ankle-joint, as it actually does in a great majority of
cases, a gaiter, made of any material whatever, if it has suflScient firm-
ness to overcome completely the action of the muscles, will inevitably
cause congestion and swelling, accompanied sooner or later with great
pain and with ulcerations, and simply because the extension is made
directly upon parts already tender and inflamed from the accident
itself; arid when we add to this complete and violent ligation of the
limb near the seat of fracture, a similar ligation of the limb just below
the knee, for the purpose of making counter-extension, as is done in
what is known among American surgeons as " Hutchinson's splint,"*

» Elements of Surgery, by John Syng Dorsey, vol. i. p. 181. Philadelphia, 1818.

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FRACTURES OF THE TIBIA AND FIBULA.



467



we are prepared to understand how the worst consequences may ensue.
I have once seen, when this abominable apparatus had been used,
a complete ring of ulceration below the knee, and another as complete
around the foot and ankle. The limb was twice girdled, and yet the
surgeon thought he was performing a duty for the omission of which
he would scarcely have been regarded as excusable.

Pig. 207.




mi



J&met Hntehinson's splint for extension, ete., in fractures of the leg. (From Oilwon.)

Jarvis's adjuster, a still more mischievous, inasmuch as it is a more
powerful instrument, operating in a similar manner, has been pro-
ductive of like consequences ; but Jarvis's adjuster is liable to the
additional objection that by its great weight it drags off the limb,
turning the toes outwards, an objection which no care or diligence can
generally overcome.

I could wish that neither of these appliances would ever again be
impressed into the service of broken legs.

Neill, of Philadelphia, and others have sought to overcome some of
the difficulties in the way of making extension in fractures of the



Fig. 208.




John 5elirs apparatus for fk'aetnree of the leg reqalring extension and oonntereztenslon.

legs, by substituting adhesive plaster for the usual extending or
counter-extending bands.

Says Dr. Neill : " For simple fractures of both bones of the leg, at-
tended with shortening and deformity not easily overcome, the limb
should be placed in a long fracture-box with sides extending as high
as the middle of the thigh, and a pillow should be used for compresses.

" The counter-extension is made by strips of adhesive plaster, one
inch and a half in breadth, secured on each side of the leg below the



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468 FKACTURES OF THE TIBIA AND FIBULA.

knee, and above the seat of fracture, by narrower strips of plaster
applied circularly. The end of the counter-extending strips may then
be secured to holes in the upper end of the sides of the fractore-box,
by which the line of the counter-extension is rendered nearly parallel with
the limb,

" The extension is also to be made by adhesive strips, in a mode
which is now well known and understood. The ends of the extending
bands may be fastened to the foot-board of the box."*

Dr. Neill further remarks: " In compound fractures of the leg, short-
ening and deformity are often difficult to overcome, as is well known




Joha Nelirs appantas for oompoand fraetares of th« leg.

to experienced surgeons. In such cases we may wish to dress the
wounded soft parts, and, at the same time, maintain a certain amount
of extension and counter-extension.

" This can be readily accomplished by having the sides of the frac-
ture-box sawed in two parts at the knee, so that the sides of the box
above the knee, from the upper ends of which the counter-extension
is made, need not be disturbed during the dressing, while that portion
of the side of the box corresponding to the leg may be opened at

Pig. 210.



Oilbbst'i Box for Cuxpoukd FaAcrcKn op thk Lbq.
1. The foar eonnter-«xteDding adhmlre strip*, at If enoirellng the knee and upper part of leg. 1
The two exteadlng adhesive stripe erossing at the bottom of the foot, readj to be applied to the foot S.



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 54 of 100)