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method. A strong pair of hooks (Fig. 19) resembling the ordinary ice-tongs, can, while the patient inhales a few whiffs of chloroform, be made to grasp the condyles of the femur, and when the handles of the tongs are approximated a traction of 40 or 50 pounds can be exercised without danger of slipping. Extreme asepsis must of course be practised, and not only the wound produced by the tips of the tongs, but the entire instrument, should be swathed in sterile gauze.
Fig. 18.—The modified Thomas knee splint. This model differs from the original in the attachment of a foot piece preventing the drop-foot and in the addition of a ratchet and screw, facilitating the method of applying traction.
If the Thomas splint is not procurable, recourse must be had to plaster. I know of no splint that is more difficult to apply correctly than this. The great difficulty lies in the proper construction of the counter-traction against the patient's pelvis. The patient is placed on a hip rest, the shoulders and legs are supported as already outlined, and the parts are appropriately padded. A strip of felt, about 3 inches wide by 8 inches long, is held firmly against the spine of the ischium and the ascending ramus by means of a piece of cotton flannel 2 yards long and 3 inches wide, the ends of which are grasped by an assistant and pulled taut in the direction of the patient's head. When applying the plaster, particular care must be taken to mould it firmly against this piece of felt, since otherwise the close fit required for effective counter-traction is not furnished. Some means of traction must now be devised. That which consists in applying strips of adhesive to the leg and then turning these adhesive strips backward over the plaster so as to incorporate them in the bandage, has never proven effectual my hands, nor have I seen good results even from the men who most enthusiastically advocate its it must be such that the slack can be taken up from day to day. An excellent method is the incorporation of a stout iron band into the lower end of the plaster, which forms a projecting loop some 6 or 8 inches below the level of the sole (see Fig. 20) serving for the attachment of the adhesive plaster strips. Of course, when this method is adopted, the foot is not to be included in the plaster bandage.
The adhesive tends to give, and within a few days all semblance of effectual traction has been lost. Whatever traction method is adopted,
Fig. 19.—The bone-tongs for the direct method of applying traction. The sharp prongs penetrate the cortex easily and are held in place by the traction of the cord which passes through the handles.
In the severe cases with extensive overriding of the fragments, sufficient traction by means of the adhesive plaster may be impossible. Then the bone-tongs should be used or a stout piece of wire can be passed directly through the os calcis by means of the ordinary bone-borer, and direct traction applied to the bones by this means.
In some instances it is impossible to secure alignment of the ends of the bone by these methods, owing to the marked abduction of the upper fragment. Then the lower fragment must also be abducted until the corresponding angle is reached, and fixed in this position, either by the Jones abduction splint or by
Fig. 20.-Fenestrated plaster dressing with stirrup extension enabling the patient to walk without bringing his weight upon the fractured limb. The plaster must be carefully moulded about the tuberosity of the ischium, which is protected by a suitable pad of felt. A similar splint can be applied to a patient in the recumbent position; then the stirrup extension serves for the attachment of the adhesive straps which exert traction upon the fractured limb.
the plaster abduction spica. Traction is necessary in this
. position as well as in the non-abducted to prevent shortening.
Injuries in the Middle Third of the Femur. In these there is no deformity that can be spoken of as typical. In many cases the fragments have interlocked in such a way as to prevent shortening, and the surgeon need merely apply two lateral moulded splints or two of the rounded metal splints used by Jones to hold the fragments properly aligned. In other instances, there may be very marked overriding with deviation of the lower fragment, usually to the inner side or with backward angulation. When this occurs, the traction methods
outlined for fracture of the upper one-third must again be applied.
Injuries to the Lower Third of the Femur.-As a rule, the lower fragment is displaced backward by the powerful pull of the gastrocnemius. The Thomas splint is a most effective agent in overcoming this backward displacement. Sir Robert Jones relates in one of his essays how in a case of this kind his house surgeon who had adopted an exceedingly skeptical attitude toward his "Attending's" methods of treatment, prepared all his instruments ready to ligate the popliteal artery because he was sure the fragment would penetrate the vessel if no other traction were employed than that given by the Thomas splint. The house surgeon was much surprised when he found his preparations unnecessary, since within 2 days after the injury a perfect alignment had occurred.
The plaster-of-Paris method is also applicable although more difficult in technic and much more time-consuming.
Injuries to the Knee.—Rigid immobilization is particularly essential in these cases to prevent spread of an infectious process. Although some authors favor a position of flexion to about 30°, maintaining that this position is more convenient to the patient in case of ankylosis, I have found it more advantageous not to flex the leg more than 5°, since even if ankylosis does occur, the patient prefers a good walking leg, even if this be in the way when sitting, to one good neither for walking nor for sitting. The latter I find to be the case when the knee is ankylosed at 30° of flexion. The surgeon must be particularly careful to avoid hyper-extension at the knee, such as is almost certain to occur when a perfectly straight splint is applied. To avoid this unsightly and crippling deformity, the leg should always be slightly flexed.
The methods of splinting are again (1) the plaster spica, including the pelvis and the foot; (2) the Thomas splint. As a last resort, if neither can be applied, the Volkmann leg splint can be used. This consists of a metal trough extending from the heel to the hip, with a right-angled foot piece to prevent drop-foot. Its disadvantage lies in the fact that owing to its failure to include the pelvis, the fixation is not secure.
Injuries to the Bones of the Calf.-Fractures of the fibula alone are exceedingly simple to splint, since the tibia holds the fragments in place. Frequently fractures of the tibia alone are splinted by the action of the uninjured fibula. In both these events, an effective external splint is readily made either by two mou.ded plasters or by two lateral metal splints. The