Continuous and anterior traction was devised by Nathan R. Smith, in the use of a so-called anterior splint, which was later modified and improved in device by Hodgen. The method of its use is shown in Fig. 322. Adhesive strips are used in this method as well, permitting the leg and foot to be attached to the lower bar of the wire frame. The position of the frame which contains the limb, swung within it upon turns or strips of bandage, is then controlled by a suspension apparatus, as shown, which tends to constantly pull the frame and its attached lower part of the limb away from the patient, the effect being to make a constant but gentle traction. If the point of suspension were placed directly above the limb there would be no traction whatever. The essential feature of the method, then, consists in arranging it as shown, so that the pull shall be oblique, and that, according to the obliquity of the suspension cords, the amount of traction shall be regulated.

In this method of treatment there is no violent attempt made at reduction or overcoming displacement, but dependence is placed, at least for two or three days, on the effect of the constant pull and its overcoming muscular activity. After this such added splints or expedients may be adopted as the case may require. The knee is usually flexed at a comfortable angle, the intent being not to lift the foot too high, so as to avoid being compelled to overcome this added weight, but to regulate the tension by the obliquity of the suspending cord.

This method has found favor in the West under the enduring influence of Hodgen’s teaching. In the East it is not so generally practised. It has, however, several advantages, as follows: (1) Equably perfect and comfortable extension; (2) easy adjustment; (3) easy exposure for inspection; (4) when a fracture is compound it permits of easy application of dressings; (5) adaptability to nearly all fractures of the femur. It is peculiarly serviceable for feeble and aged patients who chafe at restraint. If it be desirable to flex the knee to a considerable degree this can be done, e. g., in fractures near the lesser trochanter.

In fractures of the thigh, patients are frequently disturbed by muscle spasms occurring during sleep. This can usually be obviated or minimized by suitable doses of sulphonal, given early in the evening.

Fractures of the femur in children are not uncommon. In those who still wear diapers, and perhaps in those a little older, these injuries may be best treated by vertical suspension, with sufficient weight to overcome all shortening. Here the adhesive strips and the suspending cords should be attached to both limbs alike, in order to have sufficient access to the perineum, and in order to judge of the effect which we are obtaining. Figs. 323 and 324 illustrate this method.

Plaster-of-Paris dressings for fractures of the thigh appeal especially to those who are most familiar with the use of the material. Some patients with fracture of the neck of the femur may be early put in the erect posture, upon an elevated surface, allowing the injured limb to hang down while the patient rests upon crutches. In this upright position, with the down-hanging leg, to which traction can be made by an assistant, a plaster-of-Paris spica may be applied, extending from the waist-line down to or below the knee. As a limb is thus dressed so it will heal, and it is of importance that complete reduction be effected as a part of the procedure.

FRACTURES OF THE PATELLA.

During the active period of middle life the patella is the bone most frequently broken by muscular violence. In many cases it is practically cracked over the condyles, as one would crack a piece of wood over the knee. If direct force be applied, as by a fall, in connection with the above, the effect is even more marked. In such cases the fracture is sometimes comminuted (Fig. 325), or the line of fracture may run more or less perpendicularly rather than horizontally. Ordinarily, however, these fractures are transverse, while the upper fragment is pulled upward, sometimes to a considerable distance, by the powerful extensors of the leg. When the fracture runs vertically the displacement is very slight. Occasionally these fractures are compound, a most undesirable complication, since the knee-joint is thus exposed to infection, from which it suffers unless first attention be prompt and scientific. There is usually sufficient hemorrhage to distend the joint cavity, and it may at first be quite impossible to bring the fragments near enough to each other to get crepitus, but the loss of the power of extension and the evident gap between the fragments will serve to make diagnosis positive, at least in all transverse fractures. A vertical fracture without much separation is a milder form of injury which may be regarded in a much more favorable light (Figs. 326, 327 and 328).

In these transverse fractures it is rare that bony union can be secured by non-operative methods. This is not only because of the difficulty in maintaining parts in apposition, but because it is notably the case that fragments of periosteum or other tissue drop in between bony surfaces and tend to prevent their actual contact, no matter how firmly they may be pressed toward each other. Osseous union then may occur without operation, but is rare. The best that can be expected is fibrous union, the intervening fibrous band being short or long, according to the success met with in treatment and to the amount of strain later put upon it by too early use of the limb. Even with two inches of fibrous tissue intervening patients are not completely disabled. The usefulness of a limb under these conditions, however, is seriously impaired. Something will depend, also, on the extent to which the joint capsule and the aponeurosis terminating the vasti muscles may have suffered.

Treatment.

—The non-operative treatment consists in placing such a limb upon a single inclined plane, for the purpose of relaxing the quadriceps extensor group. In this position the limb should be maintained for at least from ten to fourteen days. Some expedient should be added, so soon as swelling has subsided, by which the upper fragment can be coaxed downward toward its fellow. A neatly molded splint, formed out of gutta-percha or of plaster of Paris, may be fitted to the thigh above the fragment, held in position, and then drawn downward by elastic traction on either side of the leg, the principle of traction being thus given a special application. Something of this kind should be done if the fragments are to be approximated to each other.

The more completely mechanical method, partaking of the operative, is afforded by the use of certain hooks, whose points are permitted to pass through the skin above and below the fragments and to engage in the bone. By a screw mechanism these points are drawn toward each other, and thus approximation is effected. This method was first devised by Malgaigne and is usually known under his name, although his device has been much improved. This is far from ideal, and yet has given good results in some cases. The surgeon should constantly guard against infection through the punctures.

By far the most ideal method, when it can be suitably carried out, is the open operation, a transverse incision being made across the front of the joint, which is completely opened; this affords an opportunity to empty out clots and to thoroughly cleanse it, which of itself is a great advantage, since these clots often produce subsequent adhesions. The exposed surfaces may now be freed from clot and all soft tissue, or they may be neatly sawed as near to the fractured surfaces as possible, the intent being to permit them to come into absolute and complete contact, and to hold them there by wire or other sutures, for a length of time sufficient for absolute bony union. When properly performed this operation gives ideal results; it, of course, exposes to great danger if improperly done.

Treatment by non-operative method rarely affords a useful member under an average period of from thirteen to fourteen weeks, while the operative method permits a reduction of this time to less than half. It, therefore, has obvious advantages for those (e. g., laboring men) to whom time is of great importance. The operation, however, is not to be practised as a rude emergency affair, but only when we may be absolutely certain of everything pertaining to aseptic technique. After operation it is rarely necessary to use a drain, and such a limb can usually be dressed in a plaster-of-Paris splint. Compound fractures, however, will probably need drainage at least for a day or two, and because of this need may as well be operated at once. In comminuted fractures the method is desirable, since by a loop or by some other expedient fragments can be held together as in no other way (Figs. 329 and 330).

Injuries to the patellar region, equivalent to fractures, are separations, either of the tendon from the bone, or of the bone from the ligament which holds it to the tibia. Such injuries can be recognized by the fact that the contour of the bone itself is preserved; in the former case it is not drawn up, although the extensor muscles have lost their power while in the latter it is drawn up, leaving a well-marked gap below it.

Remarks concerning the treatment of fractures apply equally here. Choice can be made between the operative and the non-operative treatment. In well-selected cases the former seems much the more desirable, the fibrous end of the tendon or ligament being held to the bone by strong sutures of silk or wire.

THE LEG; FRACTURES OF THE TIBIA.

The head of the tibia is occasionally broken as the result of extreme violence, the fragment being usually held reasonably in place by one or other of the lateral ligaments. Hemorrhage into the joint will be profuse, with swelling extreme, while disability will be complete. Not a few of these cases justify operation, directed toward opening the joint, removing all clot, and fastening the fragment in place with suitable sutures (Figs. 331 and 332).

Transverse fracture below the tubercle is less rare. The insertion of the terminal ligament of the quadriceps extensor group will, in all of these injuries to the upper portion of the tibia, tend to pull up the upper fragment and make it project beneath, even protrude through the skin. Fractures of the lower part of the tibia are freer from such distorting influences. Fig. 333 illustrates the distortion produced as above, while Fig. 335 shows one of the tendencies in fracture of the lower end of the tibial shaft, which has to be overcome by correct emplacement of the foot within the dressing. Fig. 334 illustrates synostosis as the result of fracture of both bones at about the same level. Torsion is a factor of no small importance in the production of most of the fractures of the leg, to such an extent as sometimes to make a completely spiral fracture, a condition generally held to be more serious than fracture of the ordinary type. The line of fracture often extends in such a direction as to leave a sharp spicule of bone close beneath the skin; here rough handling, or carelessly made pressure in the dressing, may cause a perforation within a few hours or days after the injury, by which a simple is converted into a compound fracture. Such a complication should always be avoided.

FRACTURES OF THE FIBULA.

The lower end of this bone is much more often fractured than the upper, although it may be broken at any point. Into its upper termination is inserted the external lateral ligament, and this insertion may be torn off from the bone in cases of violent sprain of the knee, damage occurring which is similar to that which happens in injuries about the ankle. The upper portion of the bone lies well buried beneath muscles, and fractures here are not so easily recognized. A good maneuver for their recognition is to seize the bones at the lower portion of the leg and press them together; if such pressure gives severe pain above, or if it be shown that the fibula is more movable than natural, fracture may be practically diagnosticated, even though crepitus be not detected. A skiagram would, of course, clear up such a diagnosis.

Fractures of both bones of the leg occur almost as frequently as of either alone, usually as the result of direct violence, with or without more or less torsion; as, for instance, when the foot is more or less entangled, and, at the same time, twisted at the time of injury. These double fractures are by no means necessarily placed upon the same level; thus the tibia may be broken low down and the fibula high up, so high indeed that the latter fracture may escape observation. With fracture of both bones disability becomes complete, while shortening is very likely to occur, all the muscles passing from the leg to the foot conspiring to this effect. These fractures, moreover, are often comminuted and compound, sometimes to an extent necessitating exsection of fragments or of an inch or more from the shaft of each bone. In exsection of the tibia an equivalent amount should for obvious reasons be taken from the fibula. Displacements are extremely likely to occur, and in every compound fracture the presence of the opening may be utilized for the emplacement of sutures or suitable means for enforcing approximation. Indeed, other means failing, resort may be had to this measure in order to secure an ultimately good result.

While wire sutures may be used as freely as may be indicated it will be well, at least in the majority of cases, to leave the ends protruding in such a way that they can later be untwisted and removed. The presence of wire after a certain length of time rather interferes with the process of ossification than helps it.

Fractures of the lower end of the leg nearly always involve the joint, to some extent at least, in respect of being accompanied by sprain if nothing else. They are accompanied by displacement of the foot, and are produced by violence, which first involves the foot. The term “Pott’s fracture” is meant to include the injury originally described by Pott himself. In the typical Pott’s fracture, as shown in Figs. 336 and 337, there are a chipping off of the internal malleolus, of the outer portion of the articular end of the tibia, and fracture of the fibula a little above the joint. In spite of the classical description which Pott gave fractures of the fibula alone, those accompanied by tearing of the internal lateral ligament, or chipping off of the malleolus, are frequently referred to under the same term. The more complete the injury the greater the possibility for displacement. Eversion and outward displacement, of course, are conspicuous. Lesser degrees of injury are accompanied by less displacement, but all of these injuries will be followed by extreme swelling of the ankle-joint, which may at first make diagnosis somewhat difficult, because of the extreme tenderness which prevents the handling necessary for careful determination. It is not always easy to so completely replace the bones, when we have the combination of three fractures as above, as to get an ideal result. Nevertheless with suitable treatment usually very useful limbs are secured. When the injury has been made compound the difficulties are increased. Such a result will not be obtained, however, unless the tendency to backward and lateral displacement be overcome, when the limb is placed in its permanent plaster-of-Paris splint, as it should be after a few days. Great care should be given to this point in the management.

Treatment of Fractures of the Leg.

—Nearly all these fractures are likely to be followed by swelling, even to a degree which makes it impracticable to put them up in permanent dressing until the swelling has subsided. This means a period of two to several days, during which the limb should be kept absolutely at rest, and the bones maintained in apposition by side splints, while the limb is restrained within a folded pillow or other comfortable cushion. More frequently here than in any other part of the body there will form blebs or large blisters, which are most liable to occur in alcoholic subjects. The leg should be scrubbed and shaved before putting on dressings, in order that the skin may be reasonably clean before its surface epithelium is raised. Ecchymosis, infiltration, and sometimes general edema may become somewhat pronounced, and the splint which would be required to fit a limb under these circumstances would soon be too large when this disturbance has subsided. The limb should not, therefore, be placed in a fixed or permanent dressing until it is in every respect ready.

While these disturbances are subsiding, or perhaps being encouraged to subside by the use of an ice-bag or of cold wet applications, extreme care should be taken that proper position and apposition are maintained. This will at times need considerable ingenuity. A delirious or maniacal patient would need restraint far beyond that required for one who is rational and docile. Moreover in all of these fracture cases which entail confinement to bed there is a tendency to deficiency of elimination which will require judicious use of laxatives and other eliminatives.

The writer prefers a well-molded set of side splints, properly padded, to any other first dressing for fractures of the leg. A limb thus dressed may be supported on a pillow and even made adaptable for transportation should it be necessary to remove the patient from one place to another. The fracture box can be well superseded by this method.

So soon as swelling has subsided, plaster of Paris should be used for a fixed dressing. The limb should be enveloped in a layer of cotton, by which the skin is protected, within which swelling may occur without much strangulation. Over this and down the front of the leg a strip of thick pasteboard should be placed, which can be moistened and made to adapt itself, or a strip of sheet tin, an inch wide, which can be made to fit the part, and upon which one may cut down later in removing the splint. This refers especially to the use of the roller bandage saturated with plaster of Paris. Molded splints can be made, as recommended for the upper extremity, out of surgeons’ lint, canton flannel, or old blanketing, while at the lower end of these splints may be incorporated, with the plaster, a strip of bandage or other material, by which a loop is formed beneath the foot, which may be utilized for the purpose of traction.

The foot should always be placed at a right angle to the leg. If there be too much muscle spasm to permit this, or make it too uncomfortable, the tendo Achillis may be divided. This position should be maintained during the period of repair, in order that so soon as one resumes the use of the limb the foot may be planted naturally upon the ground. In addition to this precaution it must be noted that backward displacement is completely overcome, and that eversion is perhaps a trifle overcorrected.

In all fractures of the lower end of the leg the foot and entire leg should be enclosed in a bandage. In fractures near or above the middle not only the leg but the lower part of the thigh should be immobilized if the promptest and most satisfactory results are to be obtained.

The limb being immobilized it soon becomes a question as to how quickly the patient can leave the bed and begin to move about on crutches. This will depend to some extent on the patient’s temperament. Timid women are less desirous of getting out of bed than are active men and children. Some patients acquire facility with crutches very slowly. Others are so tenderly built that crutches give pain and even produce crutch paralysis. It is advisable to get patients at least into the sitting posture so soon as the immobilization has been secured, while those inclined may be encouraged to use the uninjured limb and move about with crutches. A foot and leg too long kept off the ground will swell when again lowered. The later this dependent position is attained the greater the liability to edema. Patients should be cautioned about this.

The so-called ambulatory method of treatment has found favor with some surgeons. This implies something more than merely permitting motion with crutches; it means really such dressing as to permit use of the injured limb in locomotion. The various forms of splints used for immobilizing the limb in hip-joint disease may be used in this way. A useful splint is made with body and perineal bands, or an inside steel bar with ischiatic crutch and a cross-bar below the sole of the foot, on which the weight of the body may be supported. This is to be combined with a plaster-of-Paris support.

The ambulatory treatment is occasionally of value, but the advantages claimed for it have not been generally sustained.

FRACTURES OF THE FOOT.

The astragalus and the calcis suffer more often than the other tarsal bones, partly because of their size and partly because they are in the line of transmission of force as usually directed after accident. When the posterior end of the calcis is broken off there remains a fragment which is easily palpated, and which would be displaced backward and upward by the tendo Achillis were it not for the plantar fascial fibers which are inserted into it. The bone may also be comminuted, in which case that part of the foot will lose much of its shape and distinctive peculiarities. The sole will be flattened, but swelling and hemorrhage will at first be so great that there will be much difficulty in recognizing the exact nature of the injury.

The astragalus is usually broken by being caught between the calcis and the lower end of the leg. It is generally broken through the line of its so-called neck. Not infrequently one or more of the fragments is forced out of place, usually beneath the anterior tendons. When such extensive displacement occurs the fragments should be removed if the fracture is compound. In both of these bones results are generally satisfactory when displacement is not marked, also after removal of the entire astragalus. The foot and leg should be immobilized in the best possible position, and this can be best accomplished within a plaster-of-Paris dressing.

In regard to the tarsal bones, diagnosis can now be made accurately by the use of the x-rays. These bones, according to Eisendrath, may be fractured in any one of the following ways: (1) Compression, as when the weight of the body is violently thrown upon the feet; (2) sudden dorsal flexion, often with fracture of the inner malleolus; (3) forced supination or pronation, the interosseous ligaments being stronger, the bones forcibly pulling the latter apart; (4) violent traction upon the heel through the calf muscles, by which the tuberosity of the calcis may be torn from the rest of the bone; (5) extensive crushing injuries, in which several tarsal bones may be involved; (6) gunshot fractures. Some assistance in diagnosis may be obtained by computing the distance from the malleoli to the bottom of the heel, which will be shortened when the bones are compressed; or shortening of the length of the foot, or by fixed abnormal positions.

The metatarsal bones are broken by direct violence, the first and fifth being most exposed. As in other fractures of the foot contusion will be a serious feature, and swelling and laceration will frequently seriously complicate, while the fractures themselves may be compound. The same is true, also, of fractures of the phalanges, crushing and comminution being common. The matter of treatment often includes an estimation of the blood supply and of the vitality of the distal portion. The operator may sometimes temporize with an antiseptic dressing until this matter is settled. Simple fractures require only immobilization in good position.