Chapter III: Fractures (2)

Sometimes, when there is unusual difficulty in preventing displacement of the fragments while the limb is nearly straight, the bones can be readily kept in position if the patient lies on the same side as the injured limb and the knee is well flexed. For such cases these splints are very suitable; they should be applied after the limb has been bent and the fragments brought into apposition. When the splints have been put on, a roller may be carried round the leg and thigh to keep the limb in its bent position.

=Fracture of the Patella.=—When this bone is broken there is usually much swelling from effusion into the knee-joint; while this is present, rest, with cold lotions, and elevation of the foot, are alone applicable. When the effusion has subsided, the upper fragment must be brought down to the lower one, by some means like the following.

_Apparatus._—1. Straight wooden splint with a foot-piece.

2. Pads.

3. Diachylon plaster.

4. Roller.

5. Lint and wool.

6. Two hooks or screws, gimlet, and screw-driver.

Step 1. The splint is first fitted; it should reach from the buttock to the heel, at which point a foot-piece rises for the foot to rest against; at the back of the splint a line should be marked 3 inches above, and another 3 inches below the knee-cap, into which a stout screw or hook is inserted before the splint is put on. It is then well padded, to support the calf and leg, while the heel is left free, and a pad is put between the sole and the foot-piece. A firm crescent-shaped pad is prepared to sit like a saddle above the upper fragment.

Step 2. The limb is laid on the splint; an assistant draws the patella as nearly as possible into its place, and the surgeon lays the crescentic pad on the thigh above the patella, and takes a strap of plaster 2 inches broad and 20 long, warms it, and lays the middle across the compress, drawing each end tightly around the limb, and then downwards and forwards in a figure of 8; a similar strap is then fixed below the lower fragment. The knee, shin, ankle, and foot are then protected by a layer of cotton wool, and the bandaging begins.

Step 3. The roller first fastens the foot against the foot-piece by figures of 8, then passes up the leg by reverses until opposite the lower hook, where it is fastened.

Step 4. A second roller is then begun at the top of the thigh and brought down the limb till it reaches the compress over the patella; from this point it passes below the lower screw at the back of the splint and makes one circular turn round the limb; the roller is then taken upwards across the compress (as shown in fig. 46) to the upper screw, where it also makes a circular turn; having done this it again descends to reach the lower screw, and is returned as before. Each of these turns should be drawn tightly to bring the upper fragment as near the lower one as possible; when this is done the bandage is completed over the knee by figures of 8. It suffices to fix the lower fragment, which cannot be drawn up to meet the upper one; the latter must descend to it.

Step 5. The limb is lastly put into position by elevating the heel and by raising the body with pillows till it is in a half-sitting position.

The patient wears this splint four weeks, during the first fortnight of which the bandage should be perseveringly re-applied every three or four days until the upper fragment is brought into apposition with the lower one. After this the splint may be changed for a light starch or gutta-percha case, to be worn for six weeks more, and then replaced by a back splint of leather and knee-cap, that must not be laid aside for another period of three or four weeks. If the patient can be persuaded not to bend his knee for four months, the union of the fragments will be less likely to yield afterwards. He should be also warned that much stiffness will result from the long fixed position necessary to procure good union between the fragments; but the stiffness will all subside in time, notwithstanding the long-enforced rigidity.

_Strap and Spiral Bandage._

_E. K. Samborne’s Plan of drawing Patella Fragments together._—A strip of diachylon plaster 4 feet long and 2½ in. wide is applied to the front of the limb from 2 in. below the groin to the small of the leg, leaving a free loop or doubling opposite the patella. Beneath this loop a firm compress or horseshoe pad is placed above the upper fragment. A roller is then carried round the limb to keep the strap in place, but leaving the loop at the knee exposed. This done, the body is propped up in a half-sitting position, and the limb elevated on an incline. A stick, 6 inches long and ½ inch thick, is inserted into the loop of plaster, and then twisted round and round till, by shortening the loop, the loose tissues of the thigh, and with them the upper fragment of the patella, are drawn down to the knee. The stick is prevented from untwisting by a roller lightly carried round the knee. As the plaster slackens, the stick may be tightened from time to time and the fragment brought in a few days into its proper place.

_Malgaigne’s Hooks_ (fig. 47), for drawing closely and holding together the fragments in transverse fracture of the patella, or of the olecranon, often procure a closer union than any other method. They should not be inserted until effusion is absorbed and the soreness has subsided. To insert them, one pair of hooks should be bedded in the ligamentum patellæ, and catch against the lower edge of the bone; the skin is then drawn up the limb, while the upper pair of hooks is passed through it and behind the upper fragment; the two ends are then approximated by turning the screw. The fragments usually do not come quite close the first day, but the next they can be drawn so firmly together that if one is moved the other goes with it. In applying the hooks care should be taken that the upper pair go well through the skin and fascia behind the bone, or when they are screwed up the upper fragment is apt to ride unevenly over the other, and exact junction is lost. The pain of the insertion soon passes off, and the hooks can commonly be worn without annoyance for five or six weeks, until union is secured.

=Fracture of the Shaft of the Thigh-bone.=—_The long Splint._

_Apparatus._—1. A wooden splint.

2. Rollers, 3 inches wide.

3. Perineal band.

4. Strapping, needle, and thread.

5. Pad and wool.

The splint for an adult should be 2½ or 3 inches wide, and long enough to reach from the nipple to 4 or 5 inches beyond the heel; two round holes ¾ inch diameter are cut at its upper end, and at the lower one two notches 2 inches deep.

_Liston’s Mode of applying the Long Splint._

Step 1. The end of a roller is split for a few inches, and tied in the holes at the upper end. The roller itself is carried down the inside of the splint and attached temporarily to the notches at the other end; a pad is then fastened on, by drawing the margins together with needle and thread across the outside of the splint, or by tying strips of bandage round the pad and splint at short distances.

Step 2. The limb having been washed with soap and water, well dried, and afterwards dusted with starch powder, especially at the perinæum, the ankle and dorsum of the foot are wrapped in a layer of cotton wool, and the splint applied along the outside of the body. The bandage which was fastened to the splint is now released from the notch; and, taking with it the end of the pad, is carried under the sole, then over the ankle joint to the splint, and behind the ankle round the internal malleolus to the dorsum of the foot, then through the lower notch of the splint to the inside of the foot again. This figure of 8 is carried four times over the dorsum of the foot, twice through each notch of the splint, and is made fast by a pin or a stitch. In doing this, care must be taken to keep the leg and splint parallel, and that the splint does not ride over the back of the foot; the external malleolus should be midway between the margins; moreover, the bandage must fit firmly round the ankle and splint, not spreading over the dorsum more than can be helped, to avoid straining the front of the ankle. Means for more effectually preventing this will be afterwards detailed.

Step 3. Next apply counter-extension; for this, the perineal band is used. The band consists of a silk handkerchief or napkin folded into a _flat_ ribbon, 1 inch wide and covered for about 1 foot of its length with oiled silk. A piece of smooth brown paper, 1 foot long and 4 inches wide, folded into a ribbon one inch wide, makes an excellent foundation for the silk handkerchief to be folded upon. A band thus prepared is too stiff to become a cord after it has been worn a few days, which a simple handkerchief is apt to do. One end of the band is passed in front in the groin, and one behind the buttock, so that it bears on the tuber ischii in the perinæum; the ends are then drawn separately through the holes in the splint. All being ready for extension, an assistant, grasping the leg and splint above the ankle, pulls out the shortening till the broken bone is in a good position; the ends of the band are then tightened and made fast in a knot.

Step 4. First protecting the bony points with cotton wool, the muscles about the hip are confined by a spica carried round the body and the splint, not merely a simple figure of 8 as depicted in the figure, but a series of overlapping turns which ascend and cover in the hips well. Afterwards the upper end of the splint is drawn close to the body by a few turns of a broad roller carried round the chest from _above downwards_ (see fig. 48).

Fig. 48.—The long splint, with elastic stirrup extension at the
foot. Bandage carried up to the seat of fracture.
]

Step 5. It is customary to carry the bandage further than the ankle, but this is not an essential part of the apparatus, which is simply to keep up the extension in the direction of the axis of the limb. This subsidiary bandage has the disadvantage of concealing the limb, and the position of the broken ends of the bone; but it steadies the limb on the splint, and confines the muscles, thereby preventing pain and perhaps hindering rotation outwards of the upper fragment. Before putting it on, some cotton wool is wrapped round the knee, and laid along the shin; the application of the roller is then begun at the ankle where it first terminated, and is carried up the leg, over the knee, and along the thigh by reverses until the groin is reached, where it finishes.

The perineal band must be changed whenever it gets soiled, and the skin washed before a clean one is adjusted. After the first few days the band need not be very tight; it suffices if not slack or loose. Mr. Coxeter makes india-rubber tubes in the shape of a perineal band; these are filled with water when in use (see fig. 49).

_Stirrup extension_ is a mode of relieving the strain on the front of the ankle, caused by the lower end of the splint being attached to it. A 3-inch wide roller or bit of wood of the same breadth is laid against the sole of the foot, and a stout india-rubber ring 2 inches in diameter is slipped over it. A piece of strapping plaster, 2½ feet long and 2 inches wide, is passed half-way through the ring, and its ends carried up the leg inside and outside; the plaster is kept in place by a roller or second strip laid on in spirals up the limb as in fig. 50, and the india-rubber ring is hitched against a hook at the end of the splint. By this means the strain is transferred to the leg, and the ankle is quite free. It is perfectly successful, and very easy to the patient.

The long splint is to be worn continuously for six weeks; or, what is better, after the first three weeks it may be replaced by a starch bandage, and the patient allowed to get about on crutches with his leg slung from his neck.

Fig. 50.—Mode of fastening the stirrup to the leg, to avoid
straining the ankle.
]

=Continuous Extension with the Limb flexed.=—The muscles attached to the upper end of the femur sometimes cause so much flexion and rotation outwards of the upper fragment that union of the bones in this position produces a result approaching that in fig. 51, drawn from a preparation in the museum of University College.

This crooked union is prevented by bending the thigh and relaxing the muscles of the hip. This object is accomplished by using the _double incline planes_ or the _double incline planes, slung_, shown in figs. 52 and 53.

Fig. 51.—Fracture below the trochanters; bone in angular union.
]

_Double incline planes_ are sometimes employed alone. The limb is raised over a wooden frame about 8 inches broad, with a double slope high enough at the apex for the leg and foot to hang unsupported down the further side (fig. 52). It is well padded before being applied, and the leg and thigh secured to it by a roller passed round the limb and plane, or better, a trough of gutta-percha may be moulded to the limb while it is on the plane, and when set, screwed down to the wood at one or two points; in this the limb rests securely.

=Slinging the double incline planes= was practised many years ago by Mayor of Lausanne, and has been much used recently. It is an apparatus very easy for the patient, and particularly well suited for compound fractures of the thigh, for fractures near the trochanters that require a flexed position, or for fractures of the neck of the femur where the patient’s feebleness does not permit the constraint of the long splint.

_Apparatus._—1. A bent wire frame (see fig. 53) with a separate foot-piece.

2. Two pulleys, a rope with tent stretchers passing up to hooks in the ceiling, or some suitable support.

3. One long and one short soft pad.

4. Strapping plaster, and some ends of bandage.

Step 1. The limb is washed and dried, and the short pad fitted to the foot-piece, which is furnished with some hooks at its lower surface, where ends of bandage or tape can be fastened, for fixing it to the wire frame. The frame is next prepared by passing strips of bandage across it from side to side at short intervals, to make a support on which the limb is laid; if there is no wound, a soft pad may be put on the frame first, but if one be present, the limb should rest immediately on the strips of bandage, which can be changed whenever soiled, and replaced by clean ones without disturbing the limb. These strips should be tacked on with a needle and thread, that, when the limb is placed on the apparatus, they can be shortened or lengthened till the leg bears evenly on them (see fig. 53).

Step 2. The foot-piece is adjusted and fastened to the foot by straps of plaster carried round it and up each side of the leg, as was done for the stirrup extension in the “long splint” (p. 76).

Step 3. The limb is next placed in the cradle formed for it, to the lower end of which the foot-piece is tied securely; the ropes are rove through the pulleys and tightened till the limb swings easily. The point of attachment of the ropes must not be just above the limb, but beyond it, that the leg may be drawn away from the body along its own axis. The weight of the body makes counter-extension sufficient to remove all shortening in a few days. The relief from the constraint attending the absolute immobility of the long splint, renders this apparatus a particularly easy one for the patient; and union is found to take place without any shortening of the limb. Where there is no wound, the limb and frame may be kept together by a roller bandage carried round them from the toes to the knee, after the limb has been adjusted in the splint.

=Continuous Extension in the straight position= is employed for fractures of the femur and in hip-disease. It is procured as follows. A stirrup is fastened to the leg in the way described at page 76; to this a cord and weight are attached below the sole of the foot, and passed over a pulley fixed to a tripod frame (fig. 54), or any convenient object below the bed, in a line with the axis of the limb. The weight should balance the contraction of the muscles, and usually varies between 2 and 6 lbs. A perineal band fastened behind the patient’s head keeps the body from following the limb. The weight may be a common scale weight, or a bag with a hole at the bottom closed by a string, and filled with shot or sand, or a can with a tap at the bottom filled with water: these arrangements allow increase or lessening of the weight, without slackening the cord and moving the limb. This apparatus requires no bandages, which are so difficult to keep clean in children, and exerts a very even and continuous strain on the limb.

The perineal band may be often dispensed with, by laying the patient on a flat mattress and raising the foot of the bedstead a few inches higher than the head; the body then sinks towards the head of the bed and resists the extension of the leg.

=Starch Bandage.=—The following mode of applying the starch bandage and pasteboard splints may be used in all varieties of fracture; the length of the splints and the number of joints that should be included depend on the bone that is broken.

Some surgeons apply the starch apparatus immediately after the fracture has happened, others wait until partial union is procured and the irritability of the muscles has subsided.

_Apparatus._—1. Sheets of bookbinder’s millboard.

2. Rollers suitable for the size of the limb.

3. Cotton wool.

4. A basin of freshly scalded starch.

5. A long strip of plaster, to reach as high as the bandage will extend up the limb.

6. If the fracture be recent, a wooden splint will generally be necessary to keep up extension while the starch is drying.

As a general rule, the joint at the lower end of the fractured bone should always be fixed, and that at the upper end also, if the fracture is near that point. For an example of the mode of fitting, let us suppose the femur is broken between the middle and lower thirds as in fig. 56.

Step 1. The limb is first measured for the splints. The length from the top of the sacrum to the heel, from the tuber ischii to the inside of the foot, and from the iliac crest to the outside of the foot, should be taken, and three strips of millboard prepared of corresponding lengths; the posterior one being 3 inches wide above and 2 inches, or, if the limb is small, 1½ inches wide at the heel. The inner and outer strips of similar width must be cut with side pieces for the foot, and these side-pieces stop short of the roots of the toes. For a child’s thigh, the foot need not be included, it suffices for the splints to reach the small of the leg, though to prevent shortening in an adult it is usually necessary to include the whole limb. The splints are readily cut, by first marking on the sheet of millboard, the required width and length of the strips, then bending the sheet over the edge of a table along these lines. The two lateral splints may be first taken from the sheet in one wide strip, after allowing for the foot-piece; the two strips are separated through a diagonal line, so that the broad end of one splint is taken from the other (see fig. 55).

When the strips are cut they should be laid on a large tea-tray, boiling water poured over them, and a minute or two later, some boiling hot thin starch; this soon soaks into and softens the millboard till it is thoroughly pliant. When somewhat softened, the edges should be thinned by peeling off little strips along them, after which some more boiling water may be poured on and allowed to soak in while the limb is prepared.

Two or three rollers should then be unwound, and passed as they are rolled up again through the basin of starch; these, thoroughly soaked in starch, are used for the first layer, dry rollers serve very well for the second layer.

Step 2. The limb is washed and dried; a strip of diachylon plaster one inch wide is laid along the front to protect the skin when the case is being cut open after it is dry; the limb is next wrapped evenly in cotton wool, putting a scrap between each toe. This is best done by unrolling a sheet of wadding, splitting the sheet into a layer of suitable thickness, which is torn into strips about three inches broad, that are then wound evenly round the limb as high as the splints will reach.

Step 3. The splints are next adjusted and moulded to the limb, being temporarily secured by a few ends of bandage tied round them. One assistant grasps the splints and foot at the ankle and keeps up extension, while another holds the thigh. The surgeon then proceeds to roll the bandages, first round the foot and ankle, and then up the leg, rubbing in the _warm_ starch as he proceeds. Each turn of the roller should be made as tightly as possible, for when the case dries it always grows loose by the evaporation of the water it holds. As reverses are always difficult to cut through afterwards, they should be avoided, and the bandage laid on in simple spiral or figure of 8 turns. When the perinæum is reached, the surgeon wraps round the pelvis a broad strip of cotton wool, while an assistant on each side of the patient supports his body on a folded sheet or jack-towel, and a third holds the broken limb. The bandaging is then continued in a well-fitting spica, and ended by a few circular turns round the body. If the splint touches the crest of the ilium it should be shortened till it clears that point, or it will gall the patient afterwards. A fold of soft lint in addition to the cotton wool should line the splint at the perinæum, or the sharp edge of the bandage, when it is dry, will chafe there also. When the first bandage is complete, the limb should be smeared again with starch, and a dry bandage rolled over it from below upwards, which must be similarly saturated with starch as it is laid on the limb, and when finished the whole is well covered with starch.

If the fracture is recent, and no union has taken place, a long splint should be put on outside the case, fastened to the foot and extended by a perineal band, while the starch is drying, that the limb may not shorten. With children it is best to apply the wooden splint in all cases, as they are apt to wriggle about, or sit up in bed and disarrange the case while it is in a pliant condition. If the wood splint is not used, the limb should be supported in a good position by sand-bags laid along its sides.

In three days the starch is quite dry, but the drying may be hastened by hot-water bottles or hot sand-bags laid in the bed. It must then be cut up along the front from bottom to top; it will often be found loose, especially where swelling had existed before; this is best remedied by paring the overlapping edges with scissors. If any projecting part is chafed, an accident that ought not to happen, the case may be lifted from the sore part by a little more wool laid around, _not on_ the part pinched. The limb being in a satisfactory position, and the case fitting properly, a roller is carried up over the whole to keep it in place while it is worn (fig. 56).

The patient need not now be confined to bed; on the contrary, the limb should be supported by a sling round his neck, while he gets about with crutches, if his leg be the part injured.

The fracture should be examined from time to time, and at the end of three weeks some of the joints previously confined in the splint may be released by cutting off the part covering them; but if the part is a dependent one, such as the leg, it should be supported by a bandage after the splint has been removed. The limb may also be washed with soap and water, and then anointed with simple ointment, if the skin be roughened or irritated by long confinement.

In six weeks the starch splint may usually be discarded, and a roller alone worn for a few weeks longer.

=Plaster of Paris Bandage.=

_Apparatus._—1. Freshly burned white plaster of Paris. If the plaster have become stale by keeping in improperly closed vessels, and it be impossible to obtain fresh plaster, the water the plaster has absorbed from the atmosphere can be driven off by heating the powder in a dry oven to about 200° F. to 260° F., but not higher, as greater heat destroys the power of “setting.”

2. Rollers, about 2¼ inches wide, of muslin with a coarse open texture.

3. A roller of Welsh flannel 3 inches wide and 6 yards long.

4. Basin of cold water, sponge, and a kitchen spoon.

5. Soft lard or spermaceti ointment.

Step 1. The muslin rollers are prepared by being loaded with dry powder just before they are used. To do this the roller should be gradually unrolled on a table while one person rubs in the powder, and a second rolls the loaded bandage up again. When three or four are loaded they should be plunged for a minute into cold water, and then are ready for use. While this is being done the limb should be thoroughly washed and dried, supported, if the fracture be recent, by sand-bags.

Step 2. The surgeon carefully greases the limb wherever the plaster will reach, and rolls a Welsh flannel roller round it for about 3 inches at the point where the plaster roller will cease. This protects the skin from the rough edge of the plaster splint when the apparatus is set and hard. Indeed, if the whole of the surface to be covered with plaster be enveloped in a flannel roller, the apparatus is more comfortable to the patient, and in this case the grease may be dispensed with. When the limb is prepared the surgeon intrusts it to assistants, who will maintain reduction while he lays on the plaster rollers, wetting them freely as they are laid on, with a sponge at hand in a basin of cold water. Usually two layers of roller give sufficient rigidity to the apparatus; but if the limb is heavy, the case should be strengthened, by smearing over it a coating of plaster, prepared by shaking the powder into a basin of water kept constantly stirred, till it has the consistence of cream. The surgeon must watch that the fractured bones are kept in position till the plaster is set, a process sufficiently advanced in five minutes, when the bandage, supported by sand-bags, may be left to dry.

When the plaster is quite set the bone is immoveable and may be carried about without risk of displacement. In deciding what joints should be included in the bandage, the same rules obtain in this as for the starch bandage; no more joints should be rendered immoveable than are necessary to obtain command of the broken bone; when the fracture is near a joint, that must be confined to prevent the bones being moved with the movements of the joint; when the fracture is far away from it, sufficient control can be exercised over the bone to prevent the broken ends moving, and the joint may remain free.

If the plaster apparatus is applied over a wound, the latter should be covered with greased lint, and its position noted before the rollers are applied; when the apparatus is set, the plaster must be dissolved around the wound by touching it with strong nitro-hydrochloric acid; when this is carried completely round, the isolated fragment of plaster may be removed, and the wound exposed.

For removal, the roller can be unwound again readily, or it can be softened by acid along a line, and slit up with scissors, when the apparatus comes off in a piece.

Should bandages of loose texture not be at hand, _common rollers_ can be made to answer the purpose tolerably well in the following way.

Having washed and dried the limb, and reduced the fracture; the bones are held in position by assistants, while the limb is greased and enveloped in a dry roller by simple turns and figures of 8. A basin of plaster is prepared by shaking the powder into water till a thin cream is formed, which is laid on the bandage with a spoon, or the hands. Then a second but wetted roller is put on in the same way quickly before the plaster has set, and covered in its turn, until a case of sufficient thickness is procured.

This bandage is much improved if the first roller be of flannel instead of calico. The flannel roller may be unrolled and loaded with dry plaster, like the muslin, and wetted before using; in this way it contains nearly as much plaster as the loose webbing rollers of muslin.

In the Army Medical Reports for 1865 (1867), Mr. Moffitt describes a very ready method of employing the plaster splints for recent fractures. Instead of bandaging the limb, an envelope of Welsh flannel is fitted to the part to be supported.

The flannel should envelope the limb, except for a longitudinal space about ½ inch in width between the edges of the flannel. The dotted lines in the accompanying figure show the shape of the flannel when fitted to the leg. The limb being thoroughly greased, the flannel is well soaked in thin plaster cream, and laid on a table while the creases are smoothed out of it.

When ready it is applied accurately to the limb, so as to fit everywhere, but leaving a narrow open space along the whole length of the limb. The flannel must be held steadily till the plaster is set, which takes place in about five minutes, and the splint is complete. If one layer is not stiff enough, a second may be laid over the first in the same way. When the splints are fitted, they are kept in place by a roller applied lightly over them. If instead of soaking the second layer of flannel in plaster, it be thickly spread with strong solution of British gum (dextrine), and the gummed side laid next the first flannel, the splint is tough enough to stand any ordinary strain without breaking.

Fig. 58.—Moffitt’s method of applying plaster of Paris splints.
Copied from Army Medical Reports for 1865.
]

Gum thickened with powdered chalk, glue, silicate of soda, Hides’ leather felt and stiffening solution, paraffine, &c., are also employed for stiffening bandages and flexible splints, after they are moulded to a limb, but none of them are as readily procured or have much advantage over starch and plaster of Paris. A detailed description of the mode of using them is unnecessary.

=Sand-bags= are very useful, when laid along an injured limb, to prop it up on either side. For this purpose they are better than pillows, as their weight prevents their slipping from under the part they support. They should be made of macintosh cloth about 4 or 6 inches diameter, and in lengths varying from 1 to 4 feet, well closed that the sand may not escape through the seams; the macintosh should be covered with flannel, renewed from time to time. The sand should be washed and well dried before the bags are filled, that it may not rot the cloth containing it. Moreover, the bags should be only three quarters full, or they will be too hard to adapt themselves to the limb when in use.

=Cradles= are light arched frames of wire or cane to support the bedclothes over an injured limb. On emergency an efficient cradle can be constructed from a band-box, by knocking out the bottom and putting the leg through it. If used to protect a foot, a notch may be cut with strong scissors, _not_ a knife, for that splits the wood.

If the cradle is stout enough, it is useful to sling a broken limb in its splint, and often great relief is thus given to the patient. Dr. Salter’s Swing Cradle is specially contrived for the purpose, and is shown, fig. 42, page 64.

=Leather Splints.=—For these sole leather, to be purchased at any leather dealer’s, is used. In preparing them, the required length should be first noted down, then a series of transverse measurements taken at the widest and narrowest parts of the limb and over the projections of joints, &c., or a pattern may be first cut in paper and laid on the sheet of leather from which a corresponding piece is cut. The splint should always be so arranged that _its edges_ do not bear on any bony point, the shin, or malleoli, for example, but either fall short of or pass beyond them. The hair side of the leather should go next the skin, as it is the smoothest and least irritating. The edges of the splint must be thinned by bevelling off the outside for about an inch all round, and no sharp corners should be left. When the leather is prepared it should be soaked, if the time can be spared, for twenty-four hours in cold water, but when wanted quickly it can be softened in a few minutes by soaking it in warm water to which a little vinegar is added—this, however, renders the leather brittle when dry, and apt to curl at the edges. When the leather is softened, a very thin even layer of cotton wadding or of lint is laid on next the skin; the splint is then moulded to the limb with the hands, and bandaged firmly; in twelve hours it will be dry and rigid. The roller is then unwound, and any parts of the splint pressing on bony projections are marked before removal. It is then trimmed, and laid between two layers of wash-leather stitched together round the edges. The splint is now finished, and can be either fastened on by a roller or by two or more straps and buckles stitched to it.

When support is required for a joint, the splint should be fitted on the sides, where the leather may have the rigidity of its width rather than only that of its thickness to prevent bending.

=Leather Splint for the Hip.=—This joint is by far the most difficult to fit. The hip splint should obtain a good grasp of its fixed point, the pelvis, and a stiff bearing on the front of the thigh where its pressure is to be exerted. There are many plans of procuring a satisfactory fit; the following is one of the best.

First cut a pattern on a sheet of paper from which to shape the leather. If possible the patient should stand while the pattern is fitting. Take a sheet of paper large enough to reach round the body, and long enough to extend from the waist to the leg below the knee. Lay it against the diseased hip, carry its vertical margin a little beyond the middle line in front towards the sound side, and the other part round the body behind, till the front is reached on the sound side. Feel for the anterior iliac spine, and mark with a pencil the point midway between it and the pubis; from this draw one horizontal line inwards to the border of the paper, and a second obliquely to the perinæum. Then seek for the junction of the sacrum and iliac bone behind, which corresponds pretty nearly to the point first found in front; from this mark the gluteal fold. Next carry a line vertically from the upper border of the sheet of paper to the great trochanter; and lastly, mark the level of the pelvis. Lay the sheet on a table and slit it with scissors along the lines marked, apply it a second time to the body and bend the thigh part round the thigh, making its anterior margin reach well to the inside of the limb, while the posterior part should almost meet it from behind. The splint should also reach downwards to the back of the knee. The paper is then trimmed down to these dimensions. The hip part is next trimmed so that it clears the buttock on the sound side and passes round to the anterior iliac spine of that side. The pattern being complete, cut a piece of sole-leather to correspond, arranging that the hair or _short_ side of the leather will lie next the skin; bevel off the outer edge all round, and soak the leather till thoroughly soft in water, wipe it dry, and bandage it carefully first to the trunk and next to the thigh. When it is set, superfluous and overlapping edges must be marked before removal; lastly, the sides of the vertical notch, between the hip and trochanter, are stitched together, and the splint is covered with wash-leather.

When extension of the hip is required (see page 80), it can be applied to the leg below the splint without lessening the support that affords.

The accompanying figure, 59, is drawn from a splint fitted by Mr. Heather Bigg on the plan just described.

_Gutta-Percha_ may always be substituted for leather in these splints, and the same plan of fitting is used, except that the notching requisite in leather is not necessary in using gutta-percha; for the directions to use this material see page 50.