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the arm should be flexed; for division of the internal popliteal nerve, the leg flexed on the thigh. In experiments performed on monkeys, there was evidence to point in favor of this method of treatment, since in those cases of division of the median nerve in which the monkey's limb was kept in extension, no union occurred; whereas when it was flexed perfect union of the nerve resulted. As yet, there is too little evidence

in human beings to confirm the correctness of this teaching, but on a priori grounds it appears to be reasonable, and provided there are no contraindications it would be

well to adopt it. C

Treatment of the Individual Nerves.-1. Musculospiral.-A light splint of plaster-ofParis or metal or leather so applied as to hold the hand and thumb fully extended and reaching to the first interphalangeal joint should be applied in every instance. The two distal phalanges need not be extended, since, owing to the action of the interossei, the patient has them under voluntary control. The little additional freedom given by leaving these two joints

free is a great convenience to the patient, Fig. 27.–A splint who would otherwise have a completely for musculospiral

helpless hand. I wish to emphasize the paralysis. (Spitzy.) Note the effective necessity of extending the thumb, the distal abduction of the phalanx as well as the proximal, since the thumb produced by

extensors of this finger are supplied by the wire spring. The bar “C” holds the the musculospiral alone. In using the proximal phalanges moulded plaster-of-Paris splint the lower extended. The dis

end should be made sufficiently broad to tal phalanges are left free.

hold the thumb in this extended position.

The leather or metal splints should have a little side arm, easily constructed of a strong piece of wire, to maintain the correct position (see Fig. 27).

2. Ulnar Nerve.—In the case of the ulnar nerve there is no tendency to overstretching of the paralyzed muscles. On the contrary, that portion of the flexor profundus muscle supplied

F

by the ulnar nerve frequently undergoes a shrinkage, producing contracture of the fourth and fifth fingers. The splint should be applied so as to prevent this contracture by keeping the fingers straight. It is easily made of either plaster, wood, or cardboard.

3. Paralysis of the Median Nerve.—Here there is little danger of overstretching the paralyzed muscles since they are much more powerful than the corresponding extensors. Unlike

[graphic]

Fig. 28.—Light plaster-of-Paris splint reinforced with iron band to hold arm in abducted position, applicable to injuries of the deltoid or in aftertreatment of contractures of the pectoralis major.

the ulnar nerve, however, there is little or no tendency to contracture, so that in the case of this nerve there is no necessity for a hand splint. If the injury lies near the elbow a splint, holding the forearm flexed, may, on Stoffel's hypothesis, promote union.

4. Musculocutaneous.—A light dorsal moulded plaster-ofParis splint or two pieces of metal held together at an angle of 70° should be applied to hold the forearm sharply flexed upon the upper arm, so as to relax the paralyzed flexors.

5. Circumflex.—The arm must be held abducted. In addition to the methods already given for injuries to the shoulder-joint, the simple splint shown in Fig. 28 gives excellent service. This is made in the following way:

[graphic]

Fig. 29.—An easily improvised plaster-of-Paris dorsal splint for paralysis of the anterior tibial nerve or for drop-foot due to any other cause. The bands running from the sole to the calf piece are made of strong webbing and are sewn tightly to the cotton flannel covering the plaster.

A piece of cotton flannel, reaching from the patient's iliac crest to the axilla and then forward to the elbow, is measured off. Its width should be twice that of the plaster-of-Paris bandages which are to be used to form the splint (the 6-inch size is the best). The bandages, after being immersed in water, are rolled backward and forward on the table so as to form two layers each about 116 inch thick and corresponding in length to the strip of cotton flannel already prepared. Meanwhile, the surgeon has bent a strip of malleable iron about 10 inches long to form a right angle. This is placed between the two layers of plaster-of-Paris and the whole is enveloped by the two layers of cotton flannel. The plaster splint is applied to the patient's body and arm and fastened in place securely by a gauze bandage. After it has hardened, additional strips of webbing can be sewed to the cotton flannel so as to obviate the necessity of gauze bandages.

6. Brachial Plexus.—The arm should be kept abducted, the elbow flexed, and the hand extended. This is best done by a modification of the abduction splint shown in Fig. 28.

7. Sciatic Nerve.—The foot should be held at a right angle to the calf, since owing to the comparative weakness of the extensor muscles, pes equinus will rapidly result unless measures are taken to prevent it (see Fig. 29).

8. External Popliteal and Anterior Tibial.The same splint is used as in the case of injury to the sciatic nerve.

9. Musculocutaneous.—The splint should be applied so as to hold the foot in moderate eversion (about 5° beyond the neutral position). Although the peronei are plantar flexors, it is not advisable to splint in the position of equinus for fear of developing a contracture of the Achilles tendon.

10. Internal Poplietal.The foot should be splinted in moderate equinus position (about 110o) with downward pressure over the dorsum and upward against the ball of the foot so as to prevent cavus deformity.

11. Posterior Tibial.—Owing to the preservation of the nerves to the gastrocnemius and soleus, a splint is of no particular assistance in this type of injury.

In addition to splinting the extremity in the approved position, massage of the paralyzed muscles and electrical stimulation should be begun as soon as feasible.

CHAPTER III

INJURIES TO THE MUSCLES, TENDONS AND

CUTANEOUS TISSUES

In the orthopedic treatment of injuries to these structures, it is impossible to formulate any rule of thumb. Two principles must be followed: (1) prevent contractures; (2) seek to maintain the function of the injured muscle and tendon. Frequently these two principles seem to run counter to one another and the only way to decide how to apply the splint with maximum benefit to the patient is by an intimate knowledge of the comparative strength of opposing groups of muscles. It is therefore advisable to consider the various types of injuries to the soft parts and to state what in my opinion is the position giving the best end result. In general it may be stated that the flexors and adductors tend to produce contractures when injured; therefore the limb should be so splinted as to keep them on the stretch. The extensors and abductors, on the contrary, tend to become overstretched; therefore subsequent to their injury the part should be splinted so as to give the maximal muscular relaxation.

Injuries to the Sternocleidomastoid or Muscles of the Neck (Fig. 30).—If untreated, these result in a torticollis, owing to the formation of scar tissue in the wounded muscles. The head is drawn toward the affected side and the chin tilts up toward the opposite side. It is therefore necessary to splint the head in just the opposite direction (see Fig. 31).

Injuries to the Trapezius or Shoulder Muscles.—These frequently result in a raising of the shoulder on the affected side (see Fig. 32), with a resultant scoliosis. A plaster-of-Paris dressing should at once be applied holding the two shoulders on the same level.

Injuries to the Deltoid.In these there is no danger whatever of scar tissue contracture. On the contrary, the difficulty to

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