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Methods of Securing this position.—The surgeon must have several at his command. If he is fortunate enough to be equipped with the abduction splint shown in Fig. 1 he need only apply this. The little splint of Sir Robert Jones (see
Fig. 3.-Photograph of the patient whose roentgenogram is given in Fig. 2 four months after the injury. Primary immobilization in the abducted position was followed by exercise treatment which resulted in almost the normal range of motion.
“Notes on Military Orthopedics,” p. 123), though useful in paralytic cases, does not, I find, give sufficient fixation for fractures. An effective splint can be improvised rapidly in the following way:
Bend a wire splint or bar of malleable iron to form a triangle whose one leg corresponds in length to the patient's body from the axilla to the crest of the ilium; whose second leg measures from the axilla to the elbow; the third leg reaches from the elbow to the iliac crest. To the angle supporting the elbow, a second splint is attached by a rivet or a
Fig. 4.–The fenestrated abduction plaster dressing for injuries in the neighborhood of the shoulder and fractures of the upper portion of the hume
Extension is secured by means of the adhesive straps and a strong piece of rubber tubing attached to the hook-like prolongation of the splint beyond the elbow.
few turns of wire, so as to support the 'forearm which has been bent at right angles to the upper arm. This frame is then heavily padded with sheet wadding and fastened to the patient's side by plaster-of-Paris bandages, passing around the torso and over both shoulders. In case traction is necessary because of overriding, the splint is easily modified by prolonging the second leg of the triangle (corresponding to the upper arm) several inches further for the attachment of adhesive strips fastened to the arm (see Fig. 4).
In all plaster-of-Paris dressings for compound fractures, provision must be made to prevent soiling by the wound secretions. A primary essential is to have the window sufficiently large to expose at least two inches of healthy skin on all sides of the wound. Further protection of the plaster is given either by cuffs of oiled skin (Osgood) or by strips of cotton
soaked in paraffin, so placed as to close in the slight gap between plaster and skin and to cover the free ends of the plaster.
Fractures of the Shaft of the Humerus. These must be considered in two groups; those above the insertion of the deltoid, and those below this point. In those above, owing to the pull of the powerful abductor, the lower fragment must be abducted to secure the proper alignment; in those below
Traction bandage Fig. 6.—A plaster fenestrated dressing applicable to gunshot injuries of the lower end of the humerus and of the elbow. Traction is exerted either by adhesive strips fastened to the upper arm or in case the wound prevents their application, by a bandage running over the forearm, just below the bend of the elbow.
Traction bandage Fig. 7.—Diagram illustrating the iron bands incorporated into the plaster dressing shown in Fig. 6. a, The outer iron band. b, The inner band which runs along the patient's chest and partly encircles the arm.
the insertion of the deltoid, abduction is usually not necessary. For the first type, the abduction splints already described are applicable; for the second (those of the lower half of the shaft), the modified Thomas elbow splint is well adapted (see Fig. 5). If this is not to be had, an excellent fixation is secured by the fenestrated plaster splint reinforced by iron bands, as shown in Fig. 6. The technic of application is as follows:
Two malleable iron bands are necessary, 18 inches thick, about 172 inches wide and 1 yard long. The surgeon should provide himself with a small vise, triangle file and hammer, so as to cut off the band at the point desired. The first is bent corresponding in form to that marked A in Fig. 7; it follows the outline of the shoulder and the upper arm to a point several inches above the wound, then bends sharply at a right angle outward, then downward, then corresponding to the bend of the elbow, forward parallel to the lower arm, and then again at a right angle, so as to bring it once more against the surface of the patient's extremity. The