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ORTHOPEDIC TREATMENT OF
AT THE FRONT
Here two principles predominate in the treatment of all gunshot wounds of the extremities: surgical cleanliness and adequate fixation. It is with the latter that we are concerned.
FRACTURES AND INJURIES TO JOINTS
The method of fixation must comply with the following requirements:
1. It must prevent shortening and hold the fragments properly aligned.
2. It must be adapted to the transfer of the patient from the front to the base hospital.
3. It must allow free access to the wound not only for dressing but for incision in case of abscess formation.
4. The materials used must be such as to allow their ready transport.
It is self-evident that no one splint can meet the requirements of the many types of fractures and also that in many instances a variety of methods can be employed with equal effectiveness. In all cases, however, it is essential that the surgeon have sufficient mechanical skill to appreciate the nature of the problem confronting him, and sufficient ingenuity to adapt the method to meet the demands of the individual patient.
Splints are distinctly more advantageous than plaster-ofParis dressings, because the application of the latter demands more time and also more experience on the part of the surgeon. Since, however, the splints are not always to be had, whereas
Fig. 1.—The Leyva splint for the abduction treatment of fractures of the upper end of the humerus. Traction is secured by the adhesive straps fastened to a hook attached to the end of the splint.
plaster-of-Paris is almost always obtainable, every surgeon should be able to use it effectively. It is a mistaken notion that all the work at the front must be done in a hurry; this happens only after extensive engagements when there is a sudden inpouring of wounded. In the usual type of trench warfare, there is excellent opportunity for careful work and accurate adjustment of the dressings.
Fractures in the Neighborhood of the Shoulder, either of the Humerus or of the Scapula.--In the majority of cases, the abducted position of the arm (50%) is indicated for three
reasons: First, because in the event of ankylosis of the shoulder the abducted position gives the patient 90° free play through the action of the scapula; second, because the fragments are usually best reduced by this position; third, because it relaxes the most important muscles of the shoulder, thus lessening the tendency to overriding and preventing unnecessary strain of the muscle fibres. There are, however, cases of fracture of the humerus in which the bony fragments are best aligned by less abduction, or even by bandaging the arm at the side of the body.
Fig. 2.-Severe comminuted fracture of the scapula and of the humerus. The line of fracture extends into the glenoid fossa. Treatment by the abduction method.
Abduction must not be accompanied by internal rotation of the arm, as in the case of the Mitteldorf triangle, but the arm must be kept in the neutral position—that is, one corresponding to its position when hanging at the side of the body with the thumb against the seam of the trousers. As the lower arm when fully extended would be too great a drag on any ambulant splint, it is bent at a right angle and therefore points forward in the same direction as the patient's toes (see Fig. 1). The upper arm lies slightly anterior to the mid-coronal plane of the body, since this position enables the patient to bring the hand to the mouth even if the shoulder is completely ankylosed.