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consists of a jointed inclined plane. The joint corresponds to the knee. The upper end of the plane supports the injured thigh, which is extended by adhesive plaster, or in severe cases by the bone-tongs affixed to the condyles of the femur. To the calf, a separate adhesive plaster extension is applied. This is fastened to the lower end of the inclined plane, whereas the thigh is fastened to an immovable upright or to a bar affixed to the lower end of the bed. It is clear

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Fig. 38.—Modification of the abduction splint (Fig. 4) to encourage motion of the elbow. The patient is bending forward so as to show the transverse bar applied near the wrist which supports the hand during flexion and extension of the elbow.

that the calf can now be flexed or extended without in any way interfering with the constant traction exerted upon the thigh. By a simple pulley arrangement, the patient can alter the position of the leg himself. Ansinn has modified the system by attaching his apparatus to a motor which very slowly raises and lowers the calf; a movement of 90° requires about six hours. The results from this method are excellent in cases where any other system of extension would tend to result in disastrous adhesions. A similar idea is applicable to fractures of the humerus, by modifying the abduction splint so as to allow motion at the elbow (see Fig. 38).

The Ansinn method of extension has a further advantage to which Zuppinger's recent studies in muscle physiology have attracted attention. Zuppinger demonstrated that by flexion at the thigh and at the knee, sufficient muscular relaxation

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FIG. 39a.

FIG. 396. Fig. 390.-Fracture of the upper third of femur, showing characteristic angulation. 396. The same subsequent to correction by the abduction method described on p. 67. could be secured to permit correction of shortening by about half the traction necessary when the joints are fully extended. This fact can be utilized not only for the Ansinn method, but for other cases in which this is not indicated, by bending the Thomas splint at the knee and suspending it from the Balkan frame (Besley in J. A. M. A., Jan. 12, 1918, Silver, Lower leg fracture splint, Blake and Bulkley, Surg., Gyn. and Obst., March, 1918). The principle is of course the same as that utilized in the Hodgen's splint, with the added advantage of a more effective method of traction.

Correction of Angulation.-Not only in the recent cases, but even in those which are six or eight weeks old, the angulation can usually be corrected by simple manipulation. In one patient, even after three months I was able to correct the angular deformity without incision (Fig. 39). This is probably due to the fact that the healing of gunshot injuries to the bone is distinctly slower than of fractures produced by indirect violence. The method of correction is simple. Take, for instance, an angulation of a fracture in the upper third of the femur. The characteristic deformity is an angle pointing outward, due to the adduction of the lower fragment. The patient is placed upon a hip rest, a stout strip of webbing, 4 inches in width, is passed about the upper fragment and fastened firmly to any fixed point on the opposite side of the patient's body. The operator then grasps the lower fragment above the knee, and while the assistant exerts strong traction in the longitudinal direction, he slowly forces the lower fragment outward until its longitudinal axis lies in the same line as that of the upper fragment. While it is held in this position by an assistant, a plaster spica, extending from the nipple to the toes, is applied; or the Jones abduction splint can be used.

In fractures of the mid-third of the femur, a backward angulation is frequently present, owing to a sag of the bones through the improper application of straps or to improper technic in putting on the plaster splint. This should be corrected by traction toward the ceiling at the point of angulation. For this purpose it is convenient to have a block and pulley attached to the ceiling of the operating room; a broad webbing band is passed around the femur and attached to the rope which passes over the pulley. By depressing the lower fragment, the angulation is overcome. The webbing band is left in place during the application of the plaster.

Angular deviation of fractures of the humerus can usually be corrected simply by changing the angle of the abduction splint; when the angle of deviation points outward, increase the abduction; when the angle points inward, decrease the abduction, until the fragments are properly aligned.

Operative Correction.—In the later cases when the bones are firmly united by callus, recourse must be had to osteotomy. This operation should not be performed until all signs of infection have subsided, since otherwise disastrous results may ensue. The principle of the operation is removal of a wedge of such a shape and size that by abduction or adduction of the lower fragment the proper alignment can be secured. I I have found it of assistance in these cases to make an accurate tracing of the anteroposterior roentgenogram and operate first upon this tracing with a pair of scissors to determine the exact size of the wedge to be removed.

When the angulation is combined with marked shortening, this method does not give as good results as an oblique division of the bone in the line of callus, followed up by energetic traction. This form of treatment, however, is more timeconsuming and should therefore not be applied when the wedge-shaped osteotomy suffices to correct the deformity.

The Duration of Immobilization.—No specific time can be given for any one type of fracture, but each case must be judged on its own merits. The x-ray is the most important guide in determining when immobilization may be discontinued. As a rule, the healing does not occur as rapidly as in fractures due to indirect violence, and even when the x-ray shows a distinct callus formation and palpation indicates an apparent union the bone must be carefully protected against all undue strain, since it is readily refractured or, in the case of the lower extremity, bent by the superimposed body weight. It is therefore wise, after removing the immobilizing splint, to apply some protective apparatus to the injured bone. This should be as light as possible and allow as much freedom of motion of the adjacent joints as is consistent with the necessary protection of the fracture. Fig. 40 illustrates a light plaster-of-Paris dressing applicable to a healing fracture of the upper third of the humerus. The plaster is applied, without any padding, over a piece of stockinette and is held in place by the strip of flannel passing around the patient's chest.

In fractures of the radius, with extensive shattering of the bone, the patient must be warned against too early pronation. I have found it advisable, whenever possible, to apply a leather splint so constructed as to allow full extension and flexion at the elbow and wrist, but to prevent pro- and supination. This consists of two leather cuffs, one attached to the upper arm and one to the forearm, held together by two lateral steel supports which are jointed at the elbow.

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Fig. 40.—Anterior and posterior views of a simple plaster dressing applicable to the after-treatment of extensive fractures of the upper end of the humerus. The splint allows a moderate range of motion and at the same time guards the bone against refracture.

For fractures of the femur, it is not advisable to allow full weight-bearing when the patient first gets out of bed. The Thomas splint can be modified effectively to remove the body weight from the bone; this is done by running the lower transverse bar through a slot in the heel of the boot. The uprights must be a trifle longer than the length of the patient's leg so as to prevent his heel from quite touching the ground.

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