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The modified Thomas humerus splint, when supplemented by a traction bandage above the elbow and adhesive straps to the lower arm, pulling the wrist forward can also be applied in fractures of this type.
Injuries at the Wrist.-In these cases it is essential to fix in hyperextension so as to preserve the strength of the grip in case of ankylosis. The position is easily secured by a moulded plaster-of-Paris splint or by the hand splint of Sir Robert Jones. In case the injury happens to be on the anterior surface of the arm, the splinting method must be modified by using lateral braces instead of anterior ones.
Injuries to the Hand.—One or more of the metacarpal bones are usually hopelessly shattered and the tendons injured. Methods of traction are of little avail in these cases and there is practically nothing to be done at the front except to fix the hand in a position of moderate extension by one of the methods outlined for injuries to the wrist. Whether the splint be of wood, plaster-of-Paris, or metal, it should always be so adjusted as to leave the wound free for the dressing or for irrigation methods.
Injuries to the Fingers.—These offer great opportunity for the surgeon's ingenuity, since fingers which seem hopelessly damaged can, by the appropriate treatment, be rendered useful members. The best splint is either a rounded bit of metal corresponding in length to the finger or a wooden tongue depressor. These are applied to the finger by adhesive strips in such a way as to correct the deformity by traction, pressure or torsion. In Fig. 15 I have indicated how in case of lateral angulation the adhesive bands are applied so as to overcome the deformity of the fractured phalanx.
Injuries to the Spine.—These require rigid fixation not only of the vertebral column but also of the head and thigh. The Jones splint and the Bradford frame, both commonly used in the treatment of Pott's disease, are excellent for the purpose. If they cannot be had, a plaster-of-Paris bed which meets the requirements can be made rapidly and cheaply in the following way:
The necessary materials are (1) ten 8-inch plaster bandages; (2) eighty strips of common burlap, such as is used for making bags, each strip about 8 inches wide by half a yard long; (3) a pail of plaster-ofParis. The patient is placed, face downward, on a narrow table. The back and thighs are greased with a little oil or petrolatum, and a piece of stockinette is laid over the head, to keep the plaster from the hair. One assistant is necessary to help apply the bandages; a second assistant to mix the plaster-of-Paris and pass the bandages. The work is begun by the second assistant, who begins mixing a plaster cream. This is done by shaking the plaster-of-Paris slowly into half a pail of cold water, and stirring gently until the correct consistency has been reached. Meanwhile the operator and the first assistant'apply the plaster-of-Paris gauze bandages from the thigh to the head in a series of overlapping turns which entirely cover the patient's back. A single layer suffices.
When the plaster cream is ready, the burlap strips are dipped into it one by one, and when thoroughly saturated with the plaster are handed to the operator who applies a series of strips first in the vertical direction, then in the transverse direction; and a final series in the vertical. At the neck, an extra series of strips should be applied because the tendency to break is greater at this point than at any other; it is even a wise plan to strengthen this portion of the bandage by two small pieces of malleable iron, bent at the appropriate angle. When the burlap strips are all in place, the remaining plaster cream is poured over the patient and rubbed into the burlap. The splint is completed by a series of plaster bandages corresponding to the layer first applied to the skin. Usually, the plaster has hardened a few minutes after its application, and with a little care
it can be removed from the patient's body, the edges trimmed, with a strong knife, and a suitable opening cut over the wound. Near the anus the plaster is cut away, allowing ample room for defecation. It requires 20 to 30 minutes to make such a plaster bed. Despite the absence of padding, it will be found that if the technic has been accurate, the patient will be comfortable and that there is comparatively little tendency to decubitus formation. If possible, the splint should be allowed to dry for three days, before using it as a permanent dressing.
Injuries to the Hip.-In lesions to the hip, the position to be given the limb depends upon the pathological condition. If the femoral head or the acetabulum has been extensively injured with consequent danger of ankylosis, it is best to abduct about 10°, and flex about 5. This is the position which most patients find of greatest advantage in ankylosis occurs. If, however, the danger of infection seems comparatively slight, and the bullet has produced a simple fracture of the neck, corresponding to that seen in the ordinary traumatic cases, then the position of marked abduction, as advocated by Bardenheuer and by Whitman, is to be preferred. Of course, it is not easy for the surgeon at the front without aid of the x-ray, to differentiate between these two conditions; yet by careful palpation and inspection of the wound enough can be learned in many instances to enable him to apply the method of choice.
There are at least two good methods of fixing the hip. In both, the essential factor of the fixation is a firm grasp, not merely of the lower extremity, but also of the trunk to the level of the nipples. The Jones abduction splint (Fig. 16) and the plaster-of-Paris spica are the two best means. In applying the plaster-of-Paris, the patient's buttocks and shoulders must rest on some support, and the legs must be held in the line of the body, either by assistants or by an appropriate suspension apparatus. In case a hip rest is not at hand, one can readily be improvised by nailing two discs of wood, each about 4 inches in diameter, to a 6-inch length of broom-stick. The upper disc is padded with felt or cotton wool. In applying the plaster, no peculiar technic is necessary except in those instances where the wound is very extensive. Then it is impossible to give access to the wound without endangering the solidity of the splint. In these cases, it is necessary to reinforce the plaster by strong bands of malleable iron, so bent that they bridge the area of the wound, leaving ample space between them and the skin for the surgeon's instruments. They are applied in the same way as the fenestrated splints already described for the arm (p. 24).
In the treatment of injuries to the hip, as well as in all other cases of injuries to the leg, it is always necessary to prevent
drop-foot. It is therefore well to prolong the spica to the toes, cutting out on the dorsum of the foot so as to give the patient the maximum amount of freedom.
Fractures of the Upper Third of the Femur.-In these, the common deformity is due to an abduction of the upper fragment, and an adduction of the lower, producing an angulation, as shown in Fig. 17. In my own experience in the base hospital, I found that practically all of the fractures in this portion of the femur, despite the fixation at the front, showed this typical lack of alignment. In all of them this was due to insufficient traction and to the lack of a proper countertraction. Far and away the most efficient method of treating these fractures is by means of the Thomas knee-splint. The pelvic ring furnishes excellent counter-traction, and ample traction can usually be secured by means of adhesive plaster bands attached to the lower end of the splint. A modification
of the splint which allows of further traction by means of a simple ratchet and screw, adds to its effectiveness (see Fig. 18). In case the adhesive plaster does not hold, or if much shortening has already occurred, it is advisable to get a direct grip on the bone by some other method. Driving a nail through the condyle of the femur, as advocated by Codivilla and Steinmann, is an effective method but not entirely safe, owing to the danger of infection. I prefer what may be termed the "ice-tongs"