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by Sergeant-Major Tapson. This is a spring clip which can be fastened directly to the boot of the patient in cases of fracture of the leg and when attached to the Thomas knee splint gives a most effective traction (see Fig. 33).
Fig. 34.—Richard's device for suspending fractured limbs during transport.
To prevent jarring of the limb during transport, Capt. Owen Richards has devised a frame illustrated in Fig. 34 by means of which the fractured limb can be lifted off the stretcher. PART II
AT THE BASE HOSPITAL
THE TREATMENT OF BONE INJURIES
If the work at the front has been properly done the orthopedic problem which confronts the surgeon at the base hospital is much simpler than if ineffective methods have been followed. In all instances his first duty is to take a roentgenogram of the fracture, to determine the position of the fragments. If there is a reasonably good alignment, with little shoretning, there is no necessity to change the immobilizing splint. If, however, interference with function is threatened, either by shortening or by angulation, the position of the fragments must be corrected.
In the fresh cases, this correction can almost always be accomplished by non-operative procedures; in later cases, when the bone fragments have already become firmly united, open operation is frequently necessary to correct the deformity.
Non-operative Correction.—Much of what has already been stated of the treatment of fractures at the front (see p. 18) is applicable here. In the base hospital, however, the surgeon has a somewhat wider choice of methods, since he is not hampered by the necessity of transporting the patient.
To overcome shortening, an anæsthesia is frequently necessary in the later cases. By mean of block and pulley, or one of the numerous extension tables, the muscular contraction is overcome, the bones disengaged by lateral motion and an appropriate splint then applied. In recent cases, an anæsthetic is seldom necessary, since 30 to 40 pounds extension will overcome the shortening even in cases of several inches overriding in a muscular individual. The essential is effective application of the traction. Adhesive plaster does not suffice in cases of marked shortening. The bone itself must be gripped, either by the nail-method, or better by the bone-tongs. If the fracture is near the ankle and the shortening is not readily overcome, tenotomy of the Achilles tendon will aid materially.
Fig. 350.—Compound fracture of both bones of the calf with 2 inches overriding. The usual extension methods failed to overcome the deformity. For effect of fracture with bone-tongs, see p. 63.
Fig. 35 (a and b) illustrates the effect of the bone-tongs traction combined with tenotomy in a stubborn case of overriding which had been treated for over a week without effect by other methods of extension. The final anatomic and functional result in this case was excellent.
The longitudinal extension should be supplemented in suitable cases by lateral traction to overcome lateral deviation or by a rotating pull to correct a torsion of the fragments. A comparatively slight weight—2 to 5 pounds—is usually sufficient. The rotating traction is applied by a strip of adhesive passing about the limb in the desired direction as indicated in the diagram (Fig. 36). Every lateral pull requires countertraction. The cords to which the weights are attached pass over pulleys fixed to the sides of the bed. A convenient addition to the equipment for extension is the “Balkan" frame, serving for the attachment of pulleys at any desired point.
Fig. 356.—Compound fracture of both bones of the calf with 2 inches overriding, five days after inserting the “bone-tongs." The original traction of 40 lb. was decreased to 20, allowing the bone ends to come into contact, with final excellent anatomical and functional result.
One of the most perplexing difficulties in the traction treatment of extensive compound fractures of the femur is the prevention of adhesions to the quadriceps femoris, and consequent stiffness of the knee. The problem has been solved by Ansinn, who has devised a method of extending the thigh and at the same time mobilizing the knee. By reference to Fig. 37 the essential principle is made plain. The apparatus
1 Buckner (see Surgery, Gynecology and Obstetrics, April, 1917) has also devised an apparatus closely resembling in principle that of Ansinn.
Fig. 36.—Diagram (Bardenheuer) illustrating the attachment of adhesive strapping for extension, lateral traction, rotation, etc. a, Longitudinal traction; b, traction to prevent drop foot and to lift heel from bed; c, pull toward ceiling to correct backward displacement; d, transverse traction to correct lateral displacement; e, rotatory pull to correct external rotation.
Fig. 37.-Photograph illustrating the Ansinn method of traction in cases of fracture of the femur, combined with mobilization of the knee joint. For a detailed description see page 65.