VOL. X.

PRIMARY AND PERMANENT DRESSINGS OF FRACTURES.*

BY W. RUML, M. D., OF CEDAR RAPIDS. IOWA, SURGEON C. & N. W. RY.

The important consideration in the First Aid given an injured person, is to move him to a place of safety, his home or hospital, with the least possible exposure to further pain and shock. In cases of fractures it will be necessary to make such provision as will prevent further damage by the movements of the broken bones, such as is produced by muscular contractions and gravity.

The character of the dressing will depend somewhat, upon the distance the patient is to be transported for the permanent treatment. If, for instance, the trip is only a short one as in the city, the patient is to be taken from the shops or street in an ambulance to the hospital, and there is no hemorrhage, it will only be necessary in case of fractures of the bones of the extremities, to firmly tie or bandage to the trunk in case of arm, or its fellow in case it is the lower extremity. The least possible handling of the parts, until all is in readiness for the permanent retention of the bones, is essential, thus saving the patient's pain and strength as well as lessening the injury to tissues likely to occur in attempting to correct the deformity of broken bone. If, however, the distance is considerable or it be necessary to wait for some time for trains, as in cases of wrecks, it will then be necessary to provide a dressing of a more permanent nature.

In case of fracture of the leg below the knee, the clothing is removed sufficiently, so that the leg can be bandaged with a roller of gauze (this is to be described later) and placed in a quilt or a blanket splint. The blanket or quilt is folded in such a way that it will be long enough to extend beyond the foot. It is then rolled firmly from either end towards the center, in such a manner as to make the two rolls firm and as nearly as possible, of the same size. This is held firmly by an assistant and the leg placed on top of the smooth surface and then allowed to drop between the folds as they are slowly unrolled but kept firm, until it is deep enough for the rolls to grasp it along its entire extent. Then strips of bandage, which have been placed so as to be under the blanket splint, are tied firmly. Sufficient extension is kept up until the strips of bandage are tied, thus the leg will be held in position firmly and the patient will be able to travel a long distance if necessary without much discomfort.

It is essen

tial to have this splint extend well beyond the foot so that the ends can be tied or pinned, thus supporting the foot.

Read before the ninth annual meeting of the American Academy of Railway Surgeons, heid at Kansas City, October 2-3, 1902.

No. 1

The tying or pinning of the ends of the splint should be left until the last, that is, until the strips about the leg are tied. This is to prevent the pushing up or overlapping of the fragments. It is well to place a small compress inside the splint under the heel tendon, to keep the lower fragment from sagging. If blanket or quilt cannot be obtained a pillow will do very nicely, or clothing can be so arranged to carry out this principle. However, frequently these are not at hand, so after wrapping with the gauze, sufficient cotton wadding is applied to pad well, then plaster of Paris rollers can be put on. This is very easily carried out, as water and a pail can always be found about a station or engine.

I will now describe the permanent dressings as adopted by Dr. Ristine and myself in our hospital service, as well as in our private practice outside. It is one that we have found satisfactory in the majority of the cases of fractures of the extremities, both upper and lower, and simple as well as compound. I do not believe in the so-called temporary dressing of broken bones (except First Aid) waiting for the limb to swell and then for the swelling to go down, before a permanent splint is applied. It is my opinion that the proper application of a plastic splint early prevents the swelling and filling up of the tissues with serum, damaging the cellular structure which undoubtedly has an effect in delaying repair. It is true that occasionally a fracture cannot be permanently dressed at once, but in the majority of instances this can be done. However, the plastic splint can be put on as a temporary dressing and readjusted readily when necessary.

We will take for example again, the fracture of the leg below the knee. The leg is thoroughly washed with formalin soap I per cent and scrubbed with gauze (I have discarded brushes). If the fracture is compound, the opening in the skin is protected while the other part of the leg and foot are being cleansed, then the wound area is treated likewise. This is to prevent washing any infected matter into the wound. The foot is wrapped in a sterile towel, the leg is covered with sterile towels except in the region of the break. If the fracture is compound, from now on I work with gloves. It is of great importance not to handle the exposed bone with the bare hand, as it is impossible to disinfect the hands. The bones are reduced; minimum amount of extension is resorted to. The pulling increases the rigidity of the muscles, and perhaps binds the fragments of bone in their displaced condition. By manipulation and slight extension in the axis of displacement until the distal fragment is freed from the upper, then returning to the normal axis we are able to correct a deformity easily that could not