Chapter III: Fractures (1)

HEAD AND TRUNK.

=Fracture of the lower Jaw.—The External Splint and Bandage.=—A method requiring the lower jaw to be firmly fixed against the upper one while the broken bone knits.

_Apparatus_.—1. One and a half yards of bandage four inches wide.

2. A piece of gutta-percha, sole leather, or binder’s millboard.

3. Dentists’ silk or wire.

4. Boiling hot, and cold water.

Step 1. The fracture is first reduced. While the apparatus is being fitted, the recurrence of the displacement is prevented by the hands of an assistant, or by lacing the teeth together with stout silk or wire. It is well also to wet the patient’s chin with a sponge and cold water, to prevent the gutta-percha from sticking to his beard while it is soft.

Step 2. A piece of gutta-percha is prepared 2½ inches wide and long enough to reach from one angle of the jaw to the other when passing in front of the chin. This is softened thoroughly by immersion in boiling water, and when quite pliable should be quickly removed from the hot and plunged for a moment into cold water: if a towel be previously laid in the hot basin, the gutta-percha can be lifted on it without stretching. It should be laid on a table, and its surface sponged with cold water to prevent it sticking to the skin, it is then slit from each end into tails 1 inch and 1½ inch wide, leaving 2 inches uncut at the centre. So prepared, the splint is applied to the jaw with the middle pressing against the chin, the narrower ends being carried horizontally backwards to the angles of the jaw; the broader part is next bent up beneath the chin, its ends overlapping the horizontal ones. While the splint is still soft, the surgeon presses it firmly upwards that the gutta-percha may mould itself accurately to the chin. When set, the splint is removed, trimmed, and punched with holes here and there for evaporation. A covering of wash-leather may be added, if desired. When the splint is finished, it is replaced on the chin. If sole leather or pasteboard be used instead of gutta-percha, they must be prepared in the same way, but allowed to remain on the chin twenty-four hours that they may set before the final trimming and adjustment.

Step 3. A bandage, 4 inches wide and 1½ yard long, and slit from each end to about 2 inches from the centre, is then applied to the splint, and a small pad of folded flannel should be placed at the nape of the neck to protect the skin from the crossed bandage. When all is ready, the two upper ends are carried behind the neck, crossed, drawn tight, and tied or pinned on the forehead; the lower ends are carried upwards, taking a turn round the first pair at the temples, and fastened at the vertex (see fig. 23).

The ligatures that may have been used on the teeth can now be removed, or if they cause no pain, they may be left for a week or two.

It is a useful precaution to place a piece of soap plaster spread on soft leather, under the chin and along the throat, to protect the skin from the chafing of the splint while it is worn.

Sometimes the jaws close too nearly to allow food to be taken between them. It is then necessary to place a thin wedge of softened gutta-percha, 1½ inch long, ½ inch wide, and about ⅓ inch thick, between the molars on each side. The gutta-percha must not be softened much, or when the bite is taken the teeth will pass through it. These plugs should be omitted unless absolutely required, as the fragments keep a better position without them.

On emergency, when gutta-percha, leather, or pasteboard are not at hand, the jaw may be set, and then kept in position by a four-tail bandage, made from a pocket-handkerchief, until more complicated apparatus can be prepared.

The apparatus must be worn five weeks before it is laid aside and mastication permitted.

=Interdental Splints.=—In cases of unusual difficulty, interdental splints may be employed. To fashion some of these, the mechanical skill of a dentist is requisite, unless _Morel Lavallée’s plan_ is resorted to. He applied a mould or socket to the line of the teeth, and kept it in place by pressure underneath the jaw. He first brought the fragments into apposition by means of threads and wire. Then he took a piece of gutta-percha, about ⅓ inch thick and ½ inch broad, and long enough to extend, when bent along the lower jaw, from one wisdom molar to the other. This was softened in water, and pressed on the teeth; next a well-padded horse-shoe plate was placed under the chin, reaching from one angle of the jaw to the other, and two wires were passed through the side of this plate opposite the angle of the mouth; these were drawn through the plate by a screw nut; their upper ends being curved into hooks with sharpened points. The points catch into the gutta-percha; by screwing up the nuts, the chinplate was raised, and the teeth driven up and bedded into the splint.

This method, however, has its disadvantages. If the fracture take place behind the first molar, the bearing on the upper fragment is too slight to keep it down in its place.

In the _New York Medical Journal_ for September and October, 1866, Mr. Gunning, of that city, has published a mode of applying caps fitted to the teeth for fracture of the jaw-bone. External support is abandoned wherever it is possible. In simple fractures, the caps or interdental splints, being accurately fitted, require no fastening to the teeth.

The jaw should be adjusted in its splint as quickly as possible after the accident. The fragments are first brought into their true position. Gaps through loss of teeth at the line of fracture, are filled by plugs of hard wood, and the fragments kept in place by wiring the teeth together tightly. Continued strain on the teeth causes much pain; hence all means for keeping the fragments in place while the splint is being fitted should be removed when that is accomplished, though ligatures used solely to support loosened teeth may be left, as there is no traction upon them. Stumps, and teeth loose before the accident are best taken out, if they interfere with the arrangement of the splint.

Fig. 24.—Vulcanite Interdental Splint to fit the arch of the teeth
of the lower jaw, seen upside down. The holes marked a pass through
to the upper surface, to allow water to be injected between the
splint and the teeth, while it is worn, for cleaning.
]

The next thing is to take a mould of the lower jaw in wax softened by heat, holding the wax in an ordinary dentist’s tray. From this mould a plaster cast of the jaw is made. If the line of teeth be uneven in the cast, it is to be sawn through, the pieces raised to the right level, and cast again. In this cast a vulcanite plate is made exactly fitting the teeth (see fig. 24). The margins of the mould or splint should be carried down below the line of the gums, to grasp the jaw beyond the alveolar border; and when the fracture takes place behind the teeth, its outer side should be prolonged backwards as far as the muscles will allow, to prevent the displacement of the anterior fragment outwards which muscular action produces in these fractures. Holes should be made in the top of the splint, to permit a stream of water to be sent between the splint and the teeth daily, for cleanliness. Also, in difficult cases, a hole should be cut opposite a tooth in each fragment, for ascertaining from time to time that each part continues in its proper position while the splint is worn.

Metal is used for the plate by English dentists, instead of vulcanite. It can be made thinner, and is less brittle than the latter.

The perfect fit thus secured suffices, in simple fracture, to keep the parts in close apposition; while the movements of eating and speaking are very little interfered with.

Fig. 25.—Showing the method for supporting externally the jaws in
the splint, when the teeth are not fastened to it by screws, E.
Upper wing; G. Lower wing; H. Mental band to keep the jaw up in the
splint; I. Neck-strap to keep the band back; K. Balance-strap to
hold skull-cap in place. The upper wings are of course dispensed
with, when a single splint only is used.
]

When the displacement is considerable the fragments are held in place by riveting one or more teeth to the cap, or, when circumstances prevent support being obtained in this way, external support is supplied to the splint by steel wings, fixed into the splint at the angles of the mouth (see fig. 25), and carried outside the cheek to the angles of the jaw. A piece of stout jean or canvas, cut to fit under the chin, is then connected with these wings, and also fastened by a tape behind the neck.

If the case require that a bearing be made on the upper jaw as well as the lower one, as in fracture of both jaws in edentulous persons, the two splints are articulated behind, so that they may open and shut with the lower jaw. Each piece then carries a wing, the lower one supporting a chin-piece, and the upper one being connected by strings attached at the temples to a close-fitting skull-cap. The skull-cap is prevented from slipping forward by connexion with a strap fastened to both shoulders.

=A fractured Rib= is very well treated by strapping the injured side alone, without enrolling the chest in a tight bandage, which harasses the patient by impeding respiration.

_Apparatus._—1. Diachylon plaster.

2. Can of boiling water.

Strips of plaster long enough to reach from the spinal column to the sternum, and 2 inches wide, are to be firmly drawn round the injured side. The first strip should be carried as high as can be managed under the arm-pit. The next strip overlaps it about an inch (fig. 26), each succeeding strip overlapping and fixing the preceding one until the lower ribs are covered in. The arm should then be bandaged to the side, and supported in a sling.

A _second mode_ of treating fractured ribs, is to take a flannel roller 6 inches wide, and 8 yards long, and carry it firmly round the chest in successive spirals, beginning at the armpits, and passing down till the waist is reached. The turns of the roller may be kept from slipping down by throwing across the shoulders two strips of bandage like a pair of braces, and stitching each turn to the brace in front and behind. The arm should be confined to the side as in the other method. This plan has the inconvenience before mentioned of interfering with respiration.

=In Fracture of the Pelvis=, the fragments are kept in position by a broad roller carried several times round the pelvis and fastened.

THE UPPER EXTREMITY.

=Fracture of the Metacarpal Bones.=

_Apparatus._—1. A piece of gutta-percha.

2. A roller 2 inches wide.

In treating this fracture it is important to keep the broken bone in place without confining the wrist or fingers.

A pattern of the palm and dorsum of the hand is cut out of paper, which is doubled round the radial side, letting the thumb out through a hole of convenient size to clear it (see fig. 27). The piece of paper is then laid on a sheet of gutta-percha ¼ inch thick, and the requisite quantity cut off; a hole as big as a pea is next punched in the gutta-percha in the middle, about 1 inch from the lower border, or at a point corresponding to the hole in the paper for the thumb. The fragments are then pushed into place and held so by an assistant, while the surgeon softens the gutta-percha in boiling water; when thoroughly soft, he draws the thumb through the little hole punched in the gutta-percha, and moulds the splint to the palm and back of the hand, bringing the ends of the gutta-percha together at the ulnar side of the hand; the fragments are held carefully in position till the splint is set. The splint is afterwards removed and trimmed. A few holes should be punched in it after it is moulded to allow perspiration to escape. The splint may then be covered with wash-leather, and a pair of straps with buckles stitched on to keep it in place. It is worn for three or four weeks, or until the fragments are united.

Should gutta-percha not be at hand, another plan is effectual.

_Apparatus._—1. A firm ball of tow large enough to fill the palm, stitched in old linen.

2. A roller 2 inches wide.

The broken bone is first replaced; then the hand and fingers bound on to the ball by carrying the roller around them until they are all immoveably confined.

This plan has the disadvantage of confining the whole hand for the fracture of one metacarpal bone; the gutta-percha allows free use of all but the metacarpal bones.

=Broken phalanges= are treated by bandaging them on to a slip of wood long enough to reach into the palm; the slip must be well padded, that the somewhat concave anterior surface of the digit may accommodate itself on the flat splint. If more than one finger be injured, and the fracture be compound, the splint should then reach up the palmar aspect of the forearm and hand. Fingers should be cut in it to correspond with the fingers to be fastened to the splint.

=Fracture of the lower end of the Radius.=—_Colles’ Fracture._—The displacement in this fracture is mainly due to the lower end of the radius and the carpus being carried backwards while the shaft projects in front.

_Apparatus._—1. A straight splint of wood. A second splint, curved at its lower end.

2. Pads and cotton wool.

3. A roller 2 inches wide.

4. A sling.

5. A strip of plaster.

The objects to be attained in treating this fracture are to press the lower fragment forwards and to draw (adduct) the hand towards the ulnar side of the limb. For this purpose a straight and a curved splint are used.

No bandage should be placed under the splints in treating any fracture of the shaft of the radius or ulna, lest the broken ends be pressed into the interosseous space.

Step 1. Prepare the splints. The straight splint should reach, when the arm is bent, to a right angle with the thumb upwards, from a little below the inner condyle to the lower end of the upper fragment or shaft; the curved or pistol splint extends from the outer condyle to the joint of the first and second phalanges. The width of both splints should slightly exceed that of the forearm. The bend of the lower end of the pistol splint should be abrupt, and directed towards the ulnar border opposite the wrist, where the margin of the splint should make an obtuse angle of about 1½ right angles (see fig. 28).

Pads used with these and other wooden splints are made of layers of cotton wool, carded sheep’s wool, tow, or folds of old blanket. These materials should be stitched in old linen or calico, and covered outside with oiled silk where likely to be stained with the discharge from wounds.

The pads must be thicker below than above, to keep the splints parallel along the forearm; and that of the pistol splint is thickest opposite the carpus, to push the lower fragment forwards.

Fixed deformity opposite the wrist is usually present from impaction of the fragments; moderate extension may be employed to remove this, but forcible or continued efforts give great pain and do harm, by further straining the already wrenched ligaments. After these preparations the splints are applied.

Step 2. Put a very little cotton wool in the palm and across the root of the thumb, before the roller is begun, lest it chafe the carpus in front. The curved splint, with the barrel or longer part inclined downwards below the forearm, is next attached to the back of the hand by a roller carried in figures of 8 round the hand and root of the thumb, but not above the wrist (see fig. 29). This is made fast by a pin.

Step 3. Raise the straight part of the outside splint till parallel to the forearm, thus adducting the hand to the ulnar side; and fix the splint by a strap of plaster an inch wide carried round it and the forearm below the elbow.

Step 4. Apply the inside straight splint next, keeping the front of the carpus and of the lower fragment exposed. Draw the two splints together by simple spiral turns of a roller, begun just below the elbow and carried down to the lower end of the inside splint, there fasten it off.

Step 5. Put a narrow sling under the forearm between the elbow and the wrist to support the limb comfortably.

When the apparatus is finished the position of the broken fragments should be visible (see fig. 29) and not concealed by bandage. The hand should also be quite free of the sling, lest it be drawn from its proper adducted position. The fragments are in good position when the hollow on the anterior aspect of the wrist and the prominence on the corresponding posterior surface are removed.

=The Gutta-percha Gauntlet= is another plan of treating fracture of the lower end of the radius that may often be adopted from the first, and may always replace the wooden splints and bandage when the swelling has subsided. It was contrived by Mr. Heather Bigg, and permits the patient to use his hand to some extent while the bone is uniting.

_Apparatus._—1. A piece of gutta-percha ¼ inch thick, wide enough to enwrap the metacarpus and wrist, and long enough to reach up the lower half of the forearm. Two thirds across the width, and about 1 inch from the lower end, a small round hole is punched. The sheet is then softened in hot water, and applied to the hand, the thumb being thrust through the hole punched to receive it, which rapidly enlarges when soft. The gutta-percha is then adjusted to the hand and forearm, its borders meeting at the ulnar side of the limb, rather nearer the inner border of the arm than is depicted in fig. 30.

If the fracture is recent, it must be reduced while the splint is soft by extending the hand and holding the parts in the required position until the gutta-percha is set. Before removing the splints superfluous edges should be marked, and, when the splint is off, trimmed away with a knife. Holes must also be punched at frequent intervals that the perspiration may escape. The splint is next lined with wash-leather, and fitted with a pair of straps and buckles to keep it in place.

By this plan the fingers are left free, and some motion allowed also to the thumb. The only joints kept immoveable are those of the carpus and wrist.

Apparatus of some kind must be worn three weeks continuously; then for a fortnight longer, while it is removed every day to allow passive motion of the fingers and gradually of the wrist also to be practised. Care should be taken to warn the patient that pain and stiffness last long in these fractures, lest he blame the surgeon because he does not quickly recover full use of his arm.

=Fracture of the Shaft of one or both Bones of the Forearm.=

_Apparatus._—1. Two straight wooden splints.

2. Pads and wool.

3. 2-inch wide roller.

4. Sling.

The treatment is the same whether one or both bones are broken. Caution has been already given against bandaging the forearm underneath the splints.

Step 1. Prepare two straight wooden splints; one to go in front of, and one behind the forearm. The posterior or outside reaches from the external condyle to the end of the metacarpus; the anterior or inside splint from a little below the internal condyle only as far as the wrist, keeping clear of the ball of the thumb. The splints should be slightly broader than the forearm, and well padded; towards the lower end the padding should be thicker than above. The forearm is bent to a right angle and the thumb put upwards.

Step 2. Reduce the fracture by gentle slow extension at the wrist; this being effected, apply the splints to the forearm, and let an assistant hold them while the bandage is rolled on.

Step 3. When a little wool has been wrapped round the hand and wrist, fasten the dorsal splint by figures of 8 carried round those parts; then draw the two splints together by simple spirals continued to the elbow (see fig. 31).

Step 4. Support the forearm in a sling, to complete the apparatus.

The splints are worn three weeks; after this, passive motion may be practised daily, and the splints finally abandoned ten days later. But a sling is still required some ten days after the splints are laid aside.

When the ulna alone is broken, an anterior splint reaching from the inner condyle to the tips of the fingers often suffices without a second one.

_When the shaft of the radius is broken high up_ (a rare accident) the displacement is sometimes very difficult of reduction unless the wrist be well supinated. To preserve this position it may be necessary to use a wooden angular splint, and to fix the vertical part to the arm behind the elbow, while the horizontal part is carried along the back of the forearm.

=Fracture of the Olecranon.=—This fracture, if seen early before effusion takes place, may be put up at once, but if delay till the joint is swollen has occurred, the limb must be kept quiet on a pillow, or on a splint in an easy position with evaporating lotions, until the effusion is absorbed, before any means can be taken to restore the position of the olecranon. Though the straight position of the elbow is usually employed, it is not essential for even very close union of the fragments.

In treating this fracture the following plan is useful.

_Apparatus._—1. Straight hollow splint.

2. 2-inch rollers and finger rollers.

3. Pad, wool, and lint.

4. Strapping plaster.

5. Pins.

Step 1. Bandage the fingers; wrap the hand in cotton wool and bandage it. When the wrist is passed, fasten the bandage for a time by a pin, and straighten the arm.

Step 2. Push the olecranon down as close as possible to the rest of the ulna, and put a dossil of lint over it. Place the middle of a strap of plaster an inch wide and 16 inches long, on the lint, and carry its ends round the forearm in a figure of 8; to some extent this alone fixes the fragment.

Step 3. Continue the bandage up the forearm by reverses, keeping the elbow straight; and pass the joint by figures of 8 carried over the compress of lint and the forearm, to draw down the olecranon (see fig. 32). When this is secured, prolong the bandage to the deltoid, to confine the action of the triceps muscle.

Step 4. Pad lightly a hollow splint about 2 inches wide, reaching from the axilla nearly to the wrist, and apply it along the anterior aspect of the limb, then fix it by a second roller. This completes the apparatus.

The splints and rollers should be removed on the fourth or fifth day, that the positions of the fragments may be examined and the roller again applied to draw them closer together. After ten or twelve days, passive motion of the wrist and fingers, with pronation and supination of the radius, should be adopted, but great care is to be taken that the patient does not inadvertently bend the elbow joint while free of the splint. The splint must be worn, with the frequent removals directed above, for five weeks, by which time gentle flexion of the elbow may be practised.

Hamilton notches his splint at each border about its middle so that the notches shall be 3 inches below the tip of the olecranon (see fig. 33). He begins the bandaging by fastening his splint on to the hand and forearm, as high as the notches; here the roller is carried above the olecranon and again down to the notches; this is repeated again and again, each turn below the last, until the notches are all covered, he then continues the bandage upwards by circular turns until the top of the splint is reached.

=Fractures of the Humerus near the Elbow.=—These resemble dislocations of the ulna and radius backwards, but are distinguished from them by the ease with which the bones slip into place and again slip back from it when left to themselves; by crepitus; and, when the fracture is above the condyles, the common accident, by those projections retaining their natural relation to the olecranon. In children and youths the articulating surface of the humerus may separate from the shaft without carrying the rest of the lower epiphysis with them. In this rare accident the main distinctions from the usual fracture are, the projection of the olecranon behind the condyles; from dislocation, the absence of the hollow of the sigmoid notch, and facility of reduction.

In ordinary cases, where the deformity is reduced without much difficulty, and the injury to the joint is not severe, lateral rectangular splints of leather, hollowed wood, or wire gauze, answer very well. These are placed both inside and outside the limb, and reach from the axilla and shoulder to the wrist. They are applied in the following manner:—

_Apparatus._—1. Lateral hollowed angular splints.

2. Pads and wool.

3. Rollers 2 inches wide for the arm, and 1 inch wide for the fingers.

4. Sling.

Step 1. The splints must be prepared.

Wooden and wire gauze splints are double. One, inside the arm, reaches from the axilla to the wrist, the forearm being bent to a right angle. The other extends, on the outside, from the deltoid to the wrist. They are better if provided with hinges opposite the elbow, so that their angle can be altered, if desired, in the later stage of the treatment. Splints of wood or wire gauze must be evenly and lightly padded before application.

Step 2. Bend the arm to a right angle with the thumb upwards. An assistant next reduces the fracture, and holds it in position. Then apply the splints. When adjusting the inside splint, care must be taken that the internal condyle is eased from pressure by sufficient padding above and below it. Next fasten on the splints by a roller begun at their lower end, leaving the hand free, and carried up to the elbow. Before turning round that joint a soft pad must be placed in the hollow of the elbow to push the lower end of the humerus back, and the length of the arm should be measured against the unbroken one to make sure that the shortening is reduced. Extension is kept up the whole time the splint is being fixed to the arm, which is done by carrying the roller round the elbow with figures of 8 and simple spirals up to the axilla, where it is finished off.

Step 3. Lastly, the forearm is supported in a sling under the wrist, leaving the elbow free (as in fig. 35, page 52).

After three weeks of complete immobility, passive motion should be applied to the elbow daily, during a fortnight or three weeks more in which the splint is still worn.

If the displacement returns very easily, it is better to use an L-shaped splint passing behind the arm and below the forearm. This may be made of wood, or of leather, or of gutta-percha, in the mode about to be described.

The =L-shaped splint= of gutta-percha, or leather, is made as follows:—

_Apparatus._—1. Sheet gutta-percha ¼ inch thick.

2. A tray or wide wash-hand basin.

3. A basin of cold water.

4. A kettle of boiling water.

5. A towel.

6. A knife.

7. A sheet of newspaper.

Cut a pattern of paper reaching, while the elbow is bent and the thumb upwards, from the arm-pit down the back of the arm and under the elbow and forearm to the wrist. The sides must be brought forward to the biceps and front of the forearm as seen in fig. 34. Next cut from the sheet of gutta-percha a piece to match the pattern. Prepare the tray with the hot water, lay in it the towel, and then soften the gutta-percha by laying it in the tray and covering it with almost boiling water, adding more water as the first cools; this may be done by an assistant, while the surgeon directs another assistant to grasp the forearm and reduce the fracture. The assistant keep extension while the surgeon lifts the softened gutta-percha with the towel from the hot and plunges it a moment into cold water, then lays it on the limb, which the assistant keeps at a right angle, and the bone in place, while the splint is setting to the limb. This done, the splint is removed to be trimmed, perforated, and covered with wash-leather. It is then ready for use.

_Leather_ takes so much time to set that it should not be used in recent fractures. When the bone is partly set, leather is a useful substitute for wood. It is prepared from a pattern in the same manner as the gutta-percha, but is trimmed before soaking, not after it is moulded, like gutta-percha. If possible it should have twenty-four hours soaking in _water_ before being fitted to the limb; but when this cannot be done, immersion in hot water, into which a teacupful of vinegar has been thrown, will make the leather quite supple in a quarter of an hour. The leather splint must be worn twenty-four hours while it sets, and then be removed for covering (see Leather Splints).

=Fractured Shaft of the Humerus.=

_Apparatus._—1. Four straight hollow splints.

2. Rollers 2 inches wide, and 1 inch for the fingers, or straps and buckles.

3. Pads and wool.

4. Sling.

When broken below the attachment of the deltoid and coraco-brachialis muscles the displacement of the bone is commonly prevented with ease; neither shoulder nor elbow-joint need be fixed, and it is not necessary to apply the splints so tightly as to risk interference with the venous circulation. If the pectoral muscles or deltoid be connected with the lower fragment, the displacement is sometimes obstinate; in such cases it is necessary to buckle the splints lightly. For this to be done, the fingers, hand, and forearm must be previously bandaged to prevent œdema; with this addition, the method of treatment is the same in both varieties of fracture.

Step 1. Select the splints; they should be hollowed, of wood, perforated sheet zinc, or wire gauze, about 2 inches broad, lightly padded, and provided with straps and buckles.

The external one reaches from the acromion to the outer condyle; the inner one from the axilla to the inner condyle; a third shorter one is placed behind the arm, and if there is much projection forwards of the lower fragment, a fourth very short one is added in front. The patient should sit on a chair while the apparatus is being put on.

Step 2. The fingers and thumb are bandaged; then, the hand and forearm, first padded with a little wool in the palm and over the wrist, are evenly bandaged to the elbow, round which the roller is carried while the joint is well flexed; this being covered in, the roller is made fast.

The first step of bandaging the hand and forearm before applying the splints is better omitted if the compression requisite to procure the natural position of the bone does not interfere with the circulation.

Step 3. An assistant grasping the elbow in one hand, pulls down the lower fragment, while he steadies the shoulder with the other. The displacement thus reduced, the surgeon applies the splints, taking care that the inside splint does not reach too high into the axilla, lest it compress the axillary vein.

In simple cases, the splints should be drawn close by straps and buckles; where the muscles are powerful, a roller should be wound round the splints instead of straps.

Step 4. A 2 inch wide roller is fastened to the arm above the elbow, and then carried round the trunk to the arm again, to steady the limb against the body.

Step 5. The hand and wrist are supported by a sling over the shoulders, the elbow being allowed to hang (see fig. 35).

This apparatus is worn three weeks, when the bandages are removed from the forearm, and the splints replaced less tightly than before. They may be substituted by a sheath of gutta-percha moulded to the arm from the acromion to the elbow, and buckled on to the limb. The arm must be supported by splints for five weeks, but passive motion of the elbow and wrist should be adopted after the third week. The wrist especially should be set at liberty as soon as possible. In treating this fracture great care is necessary that the bone be kept in accurate and close position, as the humerus is specially prone to remain un-united for many months.

=Fracture of the Anatomical or Surgical Neck of the Humerus=, of the Great Tuberosity, and of the Neck of the Scapula. These fractures are similarly treated.

_Apparatus._—1. Paper for pattern.

2. Gutta-percha, leather, or millboard.

3. Pads. A soft thin pad, 10 inches long, 5 inches wide (a double fold of thick flannel or blanket answers very well), is wanted to line the axilla. If the cap is of leather or gutta-percha, a lining of wash-leather should be added after the splint is made.

4. Rollers, 2 inches and 1 inch wide for the fingers.

5. Scissors.

6. A tray, and kettle of hot water.

7. A towel, and basin of cold water.

8. Sling.

9. Cotton wool.

Step 1. Cut out a paper pattern of the splint on the limb to be fitted. The pattern should reach along the clavicle to the root of the neck, and over the scapula to its posterior border, and be continued down the arm to the elbow, tapering as it goes, but having its anterior and posterior margins brought sufficiently to the inner side of the arm to give the splint a good grasp of the limb in descending. The end should be left long enough to turn a couple of inches round the point of the elbow (see fig. 36). A notch must be cut at the upper end of the paper pattern to make it fit on the shoulder between the clavicle and the spine of the scapula; this should not be repeated in the gutta-percha, as that can be moulded on without; and for that reason the cap is much more serviceable when made of gutta-percha than of leather, where a notch must be cut and stitched together when the leather is set. The gutta-percha, when cut to pattern, must be softened in the manner described in making the splint for the elbow at page 50, fig. 34; then accurately adjusted to the shoulder as high as the root of the neck, and turned under the point of the elbow a couple of inches (see fig. 36), while the forearm is well raised across the chest.

When set, the splint must be removed that it may be trimmed and lined with wash-leather. If of gutta-percha, it must be perforated with small holes; if of leather, the notch at the shoulder must be stitched together. Next prepare a soft thin pad, 5 or 6 inches broad, and 8 or 10 inches long, to fill the axilla.

Step 2. Bandage the fingers and thumb separately, then, putting a little wool in the palm and round the wrist, bandage the hand and forearm to the elbow, where the bandage is fastened.

Step 3. Apply the splint. First get on the cap; then put the soft pad in the axilla, filling it out if the arm-pit is very hollow with cotton wool, and bend the elbow till the hand lies on the breast of the opposite side. Then, while an assistant holds the limb and apparatus in position, fasten them all in place by continuing the roller of the forearm in figures of 8 round the elbow until the splint is well fixed to it; and carry the roller up the arm by reverses to the axilla.

Step 4. A little wool or piece of flannel having been placed in the opposite arm-pit to prevent chafing, a spica for the shoulder is then applied (see page 16), beginning at the root of the neck and working downwards. Careful extension is continued by the assistant all the time this bandage is being put on, until the head of the bone is well drawn into the cap.

Step 5. The arm is drawn to the side, and the forearm fixed against the chest by a roller carried round the arm and trunk and over the shoulder (see fig. 37).

After three weeks the forearm may be released, but the cap and axillary pad must be continued to be worn two or three weeks longer while the arm is well drawn to the side, and the wrist carried in a sling.

=Fracture of the Great Tuberosity= of the humerus is difficult to treat, on account of the tuberosity being carried backwards by the muscles and the humerus being rotated forwards. Hence the parts must be braced together with a firm cap of gutta-percha moulded on to the shoulder while soft, and while the fractured parts are held in apposition, which may be done by the fingers, or by putting on a wet roller firmly over the shoulder as a spica before the splint is set. When the splint is hard the bandage may be taken off, and the splint removed and finished ready for application. In doing this, the steps are the same as for fracture of the surgical neck of the humerus, and the necessity for fixing the arm well to the side of the body as great as in that fracture.

=Fracture of the Acromion= is treated very much like fracture of the clavicle, that is, the arm is well raised by a sling under the elbow, and then fastened to the side. It is not necessary to fill the axilla with a pad, as in fracture of the clavicle, for in this case the shoulder is not drawn inwards.

=Fracture of the Clavicle.=

_Apparatus._—1. Axillary pad.

2. Roller, 3 inches wide.

3. Sling.

4. Wool.

Fractures of the clavicle nearly always leave some deformity after union; this is best avoided by keeping the patient on his back on a flat couch with the head alone supported by a cushion, and the arm fixed to the side until union has taken place. As most persons will not submit to a fortnight or three weeks’ confinement in bed for this accident, the fragments must be kept in position as nearly as possible by apparatus while the patient goes about.

The displacement of the outer fragment is _inwards_, _downwards_, and _forwards_. Many varieties of apparatus are employed to prevent this displacement during union; the following mode is perhaps as effectual as any other in accomplishing this object.

Step 1. Fix in the arm-pit a firm wedge-shaped pad of bedtick filled with chaff; 5 inches broad, 6 inches long, and 1½ or 2 inches thick at the thick end, or just enough to fill the axilla and throw out the humerus without compressing the axillary vein, hence the thickness varies with the hollowness of the axilla (see fig. 38). A band and buckle are stitched to the thick end, which is uppermost. When in use, this band is passed over the opposite shoulder and keeps the pad in place. A little wool should be put under the band, where it crosses the root of the neck, to prevent chafing.

Step 2. The elbow is elevated by an assistant, who keeps the arm vertical and lays the fingers on the breast bone. A roller attached to the arm by a couple of turns is carried behind the back round the trunk, and over the arm above the elbow, drawing that close to the side.

Step 3. To support the elbow, the longest border or base of a three-cornered handkerchief is carried under it, one end passes in front, the other behind the body; both are then drawn tightly and crossed over the opposite shoulder, where one end is taken under the axilla, and tied in front. In giving this direction the ring-pads shown in the figures are supposed not to be at hand. Lastly, the loose corner at the wrist is folded neatly and pinned up (see fig. 39).

This apparatus must be watched from time to time, and re-adjusted if any part slips. The sling and pad are to be worn for four weeks.

Union sometimes takes place in three weeks or less, in which case the pad may be removed so much the earlier; but a sling should be worn for a fortnight after the bandage and pad are laid aside. In children the pad must be very much thinner and shorter than that described; the sling should be replaced by a bandage carried alternately round the body, and over the opposite shoulder. After it is put on the turns should be well stitched together, and smeared over with stiff starch. In bandaging children, great care must be taken to protect with wool the parts likely to be chafed.

_Figure-of-8 bandage._—Many surgeons still employ a figure-of-8 bandage carried under each axilla and crossed behind the back. Under any circumstances this is exceedingly irksome to the patient, but is least so if two silk handkerchiefs be substituted for the bandage, one being passed round each shoulder and the ends of both braced tightly together behind the back. The wedge-shaped pad may be dispensed with if the shoulders are braced back, but the elbow must still be raised and drawn to the side.

The American surgeons have a very good plan for attaching the sling to the sound shoulder. Instead of carrying the ends of the sling round the shoulder and under the axilla, they pass over the shoulder a loose but well-stuffed collar or ring-pad (see fig. 38), to which they fasten the ends of the sling in front and behind; this prevents all cutting or chafing under the armpit, and distributes the strain evenly.

LOWER EXTREMITY.

=Ruptured tendo Achillis= is treated by extending the foot and flexing the knee; for this purpose the patient wears a high-heeled slipper. A band is sewn to the heel, drawn tight, and fastened to a buckle and strap round the thigh, just above the knee. The patient should not walk for a month unless he will use a wooden leg on which he can kneel, with the knee bent.

=Separation of the Epiphysis of the Calcaneum=, which sometimes occurs instead of rupture of the tendo Achillis, is treated in the same way.

=Fracture of the Fibula.=—_Dupuytren’s Splint._—When the fibula only is broken, it may be treated in several ways; this, however, is the common plan:—

_Apparatus._—1. Straight wooden splint.

2. Pad and wool.

3. A roller.

Step 1. The splint should be about 3 inches broad, and long enough to reach from the head of the tibia to 4 inches beyond the sole of the foot. A notch 1½ or 2 inches deep is generally cut at the lower end of the splint to catch the bandage in. The splint is then padded, care being taken that the padding is sufficiently thick to prevent galling at the upper end against the inner condyle of the tibia, and that it becomes thicker as it descends along the leg, for that to rest easily against the splint; lastly, the pad should end in a thick boss or projection opposite the internal malleolus, beyond which it should not reach, lest it interfere with the rotation and adduction of the foot inwards.

Step 2. The splint, when thus prepared, is applied along the inner side of the leg, taking care in doing this that the internal malleolus is against the middle of the splint, and not allowed by the assistant to slip towards the anterior or posterior border.

Step 3. A roller is then carried round the limb and splint, beginning below the knee and continuing in simple spirals for three or four turns, when it is fastened and cut off.

Step 4. A light layer of wool is wrapped round the outside of the ankle, heel, and dorsum of the foot. Then a roller, beginning at the splint, passes outwards in front of the ankle over the external malleolus, behind the heel and the splint; then over the dorsum to the outer margin of the foot, next under the sole through the notch of the splint to the front of the ankle joint again, where it repeats the same course three or four times. Each turn must be tightly applied and made to draw the foot well inwards to the splint, and in doing so to tilt outwards the broken part of the fibula (see fig. 40).

This splint is cumbersome, hence after two or three weeks, should be replaced by a light starch or gum casing for the foot and leg, leaving the knee free.

=Fractures of the Tibia= with or without the fibula, and fractures at the ankle joint.

These fractures are often from their obliquity difficult to keep in good position; in such cases _McIntyre’s Splint_ is very generally used in the early part of the treatment. For this splint the following _apparatus_ is required:—

1. McIntyre’s splint.

2. Pads for the double incline plane and foot-piece.

3. Sock of flannel for the foot.

4. Rollers, 3 inches wide.

5. Wool, pins, needle and thread, strapping plaster.

6_a_. A sling-cradle, or

6_b_. Board, block, gimlet, screws and screw-driver.

The McIntyre’s Splint may be used either bent or straight, whichever position of the knee most relaxes the tension of the muscles on the fragments. As a general rule the straight position is best if the fracture is high up, and the bent one, when near the ankle joint.

Step 1. A splint of suitable length is selected, by measuring the sound leg. The joint of the splint should be put opposite the patella, and space be left below the foot for the foot-piece to slide along the slot when extension is made.

The splint is next padded, the hollow where the lower part of the calf and small of the leg will come being well filled, that the leg may be thoroughly supported; but the space behind the heel and tendo Achillis must be left quite clear. A small pad is then fastened by a strip of strapping or by needle and thread to the foot-piece.

Step 2. The limb having been first cleaned and dried, the dorsum of the foot and ankle are wrapped in an even layer of cotton wool. A sock or boot made of flannel is next put on the foot. This may be readily extemporised by cutting off the foot of an angola stocking, slitting it up along the back to the toes, and sewing on to the sole, one inch in front of the heel, the middle of a piece of tape ¼ inch wide and 18 inches long. The foot is then wrapped in the sock, the edges drawn together by a needle and thread, care being taken that the sock fits closely round the ankle and dorsum of the foot. A little wool having been wrapped round the knee, the limb is next raised, while the splint is placed under it; the screw is turned until the inclined planes are at an angle suited for the maintenance of the fragments in position, and the foot-piece is pushed up to the foot with its screw-pin loose, that it may be adjusted to the amount of flexion or extension necessary for the foot; this being ascertained, the screw is tightened to keep it so while the foot is fastened to the foot-piece. For this the strings of the sock are brought over the top of the foot-piece, and drawn tight before tying them.

The position of the heel is very important. It should not sink below the splint, or it will rest on the bandage; neither should it be drawn up too high, or the weight of the leg will hang on the sock, instead of resting on the pad; both frequent causes of pain at the heel. When the proper position is obtained, the strings are made fast to the pin behind the foot-piece, and the foot is steadied by two or three turns of a roller carried round it and the foot-piece (fig. 41).

Step 3. The thigh is next fastened to the thigh-piece by a roller carried from the top of the splint downwards along the thigh to the knee, or below that joint if the fracture is near the ankle.

In doing this the roller is passed inside the screw, should that be placed underneath the splint, as in fig. 43 page 65, and not at the side as in fig. 41, for the screw will be wanted free for further adjustment.

Step 4. An assistant grasps with both hands the foot and foot-piece, and pulls them downwards until the shortening is removed. While doing this, he tilts the foot up or down as the surgeon finds necessary for adjusting the fragments, who also bends the knee and raises or lowers the foot until a good position is attained. The general rule is to keep the great toe in a line with the patella. This done, the surgeon tightens up the screw-pin of the foot-piece, and completes the attachment of the foot by continuing his roller with figures of 8 round the foot and ankle; these turns should not however pass above the fracture, and be no more than sufficient to secure the position of the foot and of the lower fragments (see fig. 42).

Step 5. The bandaging usually ceases with what has been already done; but if the limb swell, a separate roller may be carried along the leg to support the muscles and restrain œdema, otherwise the leg is best left bare, that the position of the fragments may be watched, and evaporating lotions applied.

Step 6_a_. This consists in slinging the limb, for which Salter’s Cradle is very convenient (see fig. 42), or an ordinary bed cradle answers very well, from which the limb can be slung on pieces of bandage carried underneath the splint at the knee and ankle.

_b._ Instead of elevating the limb by a sling, it is also customary to raise and fix the splint on a block (fig. 43), 6, 8, 10, or even 12 inches high, as may be necessary; this block slides in a groove on a board 3 feet square, put between the mattress and bedstead, to afford a firm support for the block.

In ordinary cases the limb is kept on the splint three weeks, until the irritation has subsided, and partial union is attained; the splint may then be replaced by a starch bandage, and the patient may leave his bed.

=Transverse Fracture= of the _tibia_ alone, or even of both bones, when the displacement is small, is very well treated by a hollow splint on each side. Both splints are cut away opposite the malleoli, and the foot-piece of the inside one should not extend beyond the tarsus; that of the outside passes to the toes. The splints reach on each side to the head of the tibia, but ought not to extend above the knee-joint (see fig. 44).

Step 1. They are padded lightly and evenly along their whole length, and applied to the limb on each side.

Step 2. They should then be fastened by figure of 8 round the foot and ankle until the foot is securely fixed in them. The bandage should then be fastened off, and extension made by an assistant, who grasps the foot and ankle with both hands while the surgeon fixes the splints to the limb above the fracture, beginning his roller at the top just below the knee, and continuing it downwards with spiral turns until the fracture is reached, above which it should terminate (fig. 45). After the apparatus is applied, the limb may be either supported upright by sand-bags, or slung in a cradle, for three weeks, after which the splints are advantageously replaced by a starch bandage for three weeks longer.

_Flexing the Leg for Fracture of the Tibia._