Illustrating the more common types of talipes. A combination of any may be present.
Talipes Equinovarus is usually congenital and is the most common type. It is characterized by inversion and torsion of the foot with elevation of the heel. The weight is borne on the outer side of the foot and in extreme cases upon the dorsum as well. Calluses are always present which are red and painful upon the point where the greatest weight is borne. The most common method of treating this condition is to divide the tendo Achilles at a level with the malleoli. The operation should be done aseptically and under complete anesthesia. As an assistant raises the end of the foot so as to stretch the tendo Achilles the surgeon enters the knife parallel to the border of the tendon through the skin and tendon sheath into the tendon itself. Next with a tenotome inserted into the incision and turned at right angles to the tendon, the tendon is divided first on one-half then on the other. Care should be taken to disturb the tendon sheath as little as possible for it serves an important purpose in repair. When the division is complete as indicated by the separation of the divided ends, the tenotome is withdrawn and the minute opening in the skin, from which there is only slight bleeding, is covered with aseptic gauze. The foot is forced into dorsal flexion and if in severe cases the deformity is not then corrected, the tendons on the outer side of the foot may be shortened, while those on the inner side may be lengthened in the same manner as the tendo Achilles. A plaster of Paris cast is then applied well up to the knee with the foot in the over corrected position, care being taken that no undue pressure is brought upon the seat of operation, as this might interfere with the effusion of plastic material. Personally I believe that functional use of the limb and foot stimulate repair, and I always encourage the patient to stand and walk after the discomfort of the operation has passed. At the end of four weeks the space between the two cut ends will be filled with new material and the cast can be removed, and in another month the splice, which is somewhat larger and thicker than normal, should be strong enough for use. In the course of a year the lengthened tendon is perfectly normal.
Talipes Equinus.—In this type the patient walks on his toes with the heel highly elevated, in the same position as the horse, and it will be noticed that the foot has no dorsal flexion whatsoever. Infantile paralysis affecting the anterior muscles of the leg is usually the cause of this condition, though sometimes shortening of the leg following knee joint disease, or fracture may lead to an adaptive equinus which serves to make the limb of equal length for walking. This type is by far the easiest to remedy, and the results following operations are perfect. A simple division of the tendo Achilles is made under anesthesia and a cast applied as above, in a position of exaggerated dorsal flexion. Functional use of the limb after the cast has been removed overcomes any stiffness that might occur and perfect results are obtained in a short time, compared with the other types.
Talipes Calcaneous.—This is a condition in which the foot is held in a position of dorsal flexion. The patient walks on the heel with an inelastic gait because the spring of the foot is absent and the whole weight is borne upon the os calcis. The best procedure in this type is manipulative treatment into a position of plantar flexion to overcome the contraction of the anterior muscles of the foot and leg, and bring about contraction and shortening of the posterior muscles. A tenotomy of the anterior tendons or an anesthetic is rarely indicated, though in severe cases, a series of casts holding the foot in position of plantar flexion may be necessary to secure good results. I have found it a help to have a shoe with a heel prolongated backward, or a steel splint laced to the leg to prevent the foot from upward motion.
Talipes Valgus.—This is a very uncommon type of deformity, characterized by eversion of the foot. The patient walks on the inside of the foot and, as a rule, experiences very little trouble. I find a manipulative treatment is best for this condition, aided by braces.
Talipes Cavus.—This form is sometimes called “hollow foot” and is very uncommon in this country. It is characterized by a markedly high arch sometimes as in Chinese women to the extent that the anterior part of the foot is approximated to the heel. The plantar fascia is badly contracted and one can distinctly palpate the bands beneath the skin. This condition is practically the same as the ordinary so-called “contracted foot” except that it is much more exaggerated. The ordinary high arch of today is usually the result of wearing too short a shoe, and if painful, long last shoes, aided by manipulations, will usually correct the trouble. In severe cases of contracted foot the plantar fascia may be divided, under anesthesia and the arch brought down and put in a cast, though this procedure is not very successful. In case it is done the patient should be made to walk in two or three weeks, as this helps materially to overcome the deformity and hasten repair of the fascia.
Talipes Planus.—This condition is commonly known as “flat foot” and is taken up in another part of this text. However, it is one of the classifications of “club foot” and is far the most common type.
Prognosis.—These conditions never correct themselves and if uncorrected usually get worse and the more severe types certainly become obstinate malformations. In general the tendency to relapse is strong, though if properly treated the results are excellent. In infantile cases the time required for correction is relatively short, but retentive appliances are needed for a longer time. The older the cases and larger the foot the more difficult, of course, the correction, but usually there is less danger of relapse. A perfect correction, that is when the gait and attitude are normal, will never relapse. I find it better to leave the fixation appliance on too long than not long enough. Never remove a cast under four weeks except in the cavus type, then apply a brace such as can be obtained from any supply house for any type of case, for from one to three months longer. The tendons involved in these conditions are so apparent that it is almost impossible to make a mistake in the division of them. About the only precaution necessary is to be assured that the tendon itself is completely divided, but that the tendon sheath is only slightly disturbed.
Perhaps no bony lesion has caused so much difference of opinion in this profession as tubercular conditions of the spine, bones and joints and I wish it understood that in the following discussion, it is not my desire to reopen the argument. My observations have been of cases treated both osteopathically and by fixation, in private practice and institutional work. And I have come to the conclusion that the fixation method of treatment is absolutely always indicated. In general the pathology and etiology of all tubercular bone conditions is the same. It begins as a tubercular infection of the spongy tissue of the epiphysis, the first change being a local hyperemia of the portion involved, followed by one of three courses: the diseased focus being absorbed and a spontaneous cure resulting; it may extend to the periphery of the bone and break through the periositum and empty itself there by abscess formation; or most commonly it may extend to the joint, which becomes involved through attendant injury. Repair is brought about by the formation of fibrous tissue probably arising from the layer of non-tuberculous granulation tissue which grows in and replaces the tuberculous tissue. Also the replacing material may become calcified and encapsulated. A fibrous or bony ankylosis may result from this process of repair.
The vulnerability of growing bone accounts for the frequency of tubercular bone disease in children as compared with adult life. Injury not only causes a local predisposition to the disease, but it favors its progress when it is once established. About seven-eighths of the cases of this trouble occur under fourteen years of age, more especially when the vertebræ or hip-joint are involved. The knee and ankle joints as well as the elbow and shoulder joints are more often diseased in later life. While the inherited predisposition is very direct and positive in twenty-five percent of the cases, the acquired predisposition is of most importance since it includes lessened vitality due to poor food and imperfect hygienic surroundings. As to the distribution of the disease the vertebræ are most commonly affected, followed closely by the hip and knee joints, and then in the order of frequency the ankle, elbow, shoulder and wrist joints.
This condition is commonly called Pott’s Disease or Caries. It is a chronic destructive process of the bodies of the vertebræ. The spine bends at the weakest point and the compression and collapse of the affected parts cause the characteristic posterior angular projection at the seat of the disease. If one vertebral body is destroyed, the projection will be sharp; if several are involved it will be less angular and if one side breaks down before the other, there may be a lateral as well as posterior distortion. The size of the deformity and its effect upon the patient depend upon its situation; that is, if either end of the spine is involved the angular projection is slight because the area of the spine directly involved in the deformity is small compared with that which is free from the disease. If the middle of the spine is affected, the deformity is great, because the entire spinal column may enter into the angular projection. In the latter area the internal organs are compressed and, of course, the effect upon the vital organisms of the body is disastrous.
Pathology.—The first indication of tubercular disease of the spine is usually found in the anterior part of a vertebral body just beneath the fibro-periosteal layer of the anterior longitudinal ligament. From this point the foci may advance along the front of the spine following the course of the blood vessels and invading the adjacent vertebral bodies. The destruction may begin in the interior of the body itself, more often in several minute foci near the upper or lower epiphysis, which coalesce, gradually enlarge and form a cavity surrounded, for a time, by unbroken cortical substances which finally collapse under the pressure of the weight above. The intervertebral discs seem to offer some resistance to the extension of the disease from one vertebra to another but once the bone is destroyed on either side, they too quickly disintegrate and disappear. Pedicles and articulations which come into direct contact with the disease may become involved. Originally the disease is confined to one or two adjacent vertebræ and may extend in either direction, and the final area of deformity and rigidity shows that from three to six bodies may be involved before a cure is established. The infected granulations advance rapidly with the usual retrograde change of shape and structure to a cheesy degeneration and frequently liquefaction and abscess formation may follow.
Symptoms of Pott’s Disease.—There are three main symptoms of Pott’s disease, namely the peculiarity of attitude and gait, limitation of motion or muscular stiffness and the pain and referred pains. In the cervical region, the chin is held somewhat raised and the patient may have somewhat the same appearance as in wry-neck. In the mid-dorsal region one will always find an elevation of the shoulder besides the deformity. In the lumbar region, the patient nearly always leans backward and has a sort of sidling gait or waddle due to the contraction of the psoas and iliacus muscles. The patient in walking, stooping, or lying down most carefully guards the spine against any jar or motion, and always assumes attitudes which will relieve the strain on the involved vertebræ. There is always present an unnatural mode of standing or walking, especially when the dorsal and lumbar regions are involved, as the patient walks more on his toes and with the knees slightly bent, because in this posture all possible strain of the step may be brought into play to diminish jarring of the spine. The child becomes tired very easily and lies down or rests on the arms of a chair or seat. The pain rarely occurs in the back, but is usually referred to the peripheral end of the nerves and is thus felt in the chest, abdomen or limbs. The abdominal pain passes sometimes as a stomach ache and often times in the limbs, as rheumatism or “growing pains”. I have noticed also a peculiar grunting respiration and sometimes cough especially when the mid-dorsal region is involved. Muscular stiffness is always present, all mobility being lost. The temperature is not at all diagnostic, though sometimes in the afternoon it will be one or two degrees higher than normal and does occur independently of abscesses. About the only complication that occurs is paralysis or abscess formations. Paralysis is given as a frequent complication, though I have never seen it. It is usually flaccid and bilateral and may exist from a mere muscular weakness to a complete loss of power. It is certainly uncommon under proper treatment, and the prognosis is favorable. Abscesses, though a very distressing complication, are very uncommon in my experience and are certainly an evidence of improper or incomplete treatment. They may subside in any region and be absorbed without detriment to the patient, though if they increase in size there is no tendency towards absorption. It is best to incise them and secure complete drainage. It is hard, of course, to do this on account of the depth. Abscesses occur always in close proximity to the disease.
Treatment.—Some authors recommend a brace for the treatment of this condition, while others recommend a frame to which the patient is strapped, and rest in bed. I have found nothing that gets results like a plaster of Paris jacket applied with the patient suspended by the neck and shoulders. I make no attempt at correction of the deformity present other than the traction of the weight of the body at the time the cast is applied. The spine is, of course, fully extended by this and any undue pressure on the cord relieved. The cast should extend over the shoulders and well down over the pelvis and sacrum. If the disease is in the neck the cast should include the head as well. A large window is cut in front and one must be cut over the involved area of the spine behind. Ordinary absorbent cotton is used for padding with, of course, extra padding over all bony prominences. From two to five years’ time is required for a complete recovery. The X-ray is invaluable in diagnosing this trouble, and each time a cast is removed to see how much progress has been made. The casts should be changed as often as they become soiled.
This is a chronic tubercular condition of the head of the femur or of the acetabulum commonly known as hip-joint disease.
Pathology.—Primarily the head of the femur is the seat of the disease, the epiphysis being attacked in seventy-five per cent of the cases and the acetabulum in twenty-five per cent. The irritated pelvic femoral muscles which are in a state of chronic contraction crowd the head of the femur against the upper and back border of the acetabulum. Under this continual pressure, absorption of that portion of the rim takes place with actual enlargement of the acetabulum from below upwards. This is spoken of “migration of the acetabulum” and is one cause for the shortening of the limb. Changes in the head of the femur are the result of inflammation and pressure. Partial destruction of the head also helps shortening of the limb and elevation of the trochanter above its proper level the same as the wearing away of the acetabulum. The synovial membrane is found to be reddened and thickened and granulation tissue is present, and usually the cartilage is gone from the head of the femur. Rarely does perforation of the floor of the acetabulum take place, but if such is the case a dense wall of fibrous tissue and thickened periosteum shuts off the head of the femur from the pelvic cavity. A natural cure results in two ways,—by absorption or calcification of the tubercular tissue, or by the evacuation and discharge by an external opening. This latter suppuration seems to be nature’s effort to eliminate the disease, and when a cure is established this way it is usually characterized by malpositions and shortening of the limb, and, of course, an ankylosed joint.
Early Symptoms.—The most characteristic symptoms of the disease are the ‘night cries’, stiffness and limping, shortening of the leg, atrophy of the muscles of the hip, leg, and thigh, and the unconscious protection of the joint. A referred pain is usually present to the inside and front of the thigh near the knee or directly at the knee joint itself, due to the intimate relations and anastamosis of sciatic, obturator, and anterior crural nerves.
Diagnosis.—The chief diagnostic sign is muscular spasms or the presence of stiffness of the joints and limitations of its proper arc of motion, due to the tonic contraction of the muscles controlling the joint. If there is no limitation of motion it is almost safe to say there is no hip-joint disease. The lameness may be intermittent. The attitudes or abnormal positions of the diseased limb are caused by the action of muscles holding the limb stiffly in a distorted position. The pelvis is usually tilted and always one will find the patient assuming attitudes which will favor the diseased limb. Atrophy is very significant and a comparison of the two limbs should be made by measuring at the middle of the thigh and the middle of the calf. Nearly always one will find a deep thickening over the front of the hip joint and behind the trochanter.
Physical Examination.—1. Observe the general condition of the patient.
2. Note the attitude in standing.
3. Note character of the limp.
4. Note shortening of the limb.
5. Remove the clothing and lay patient on the back.
6. Test the function of the groin. Always begin on the sound side for comparison in order that the patient may become accustomed to the manipulation before the limb suspected of disease is tested. Tuberculosis in a joint is always accompanied by muscular spasms that positively limit motion in every direction, while in other affections only one or more limitations are observed, but never in all directions. Compare closely the motions of the sound and affected limbs while the patient is on the back. Turn patient on face and test for extension by holding pelvis flat on table with one hand and gently elevating thigh with the other. The normal range in a child is about twenty degrees backward from the line of the body and limitation of this range is perhaps the earliest indication of hip-joint disease. It is due to psoas contraction. If this range of motion is unrestricted hip disease can be practically excluded.
The X-ray completes the diagnosis when used with a thorough knowledge of the physical signs. It must be remembered that in early life a larger part of the extremity of the femur is cartilaginous and does not show well in a radiograph. The X-ray picture shows clearly the destructive effect of the disease on the femur and acetabulum and gives a clear conception of the actual condition of the joint.
Treatment.—The object of treatment of this condition is threefold: first, to relieve the pain that depresses the vitality of the patient; second, to relieve the muscular spasms that induce distortion of the limb and which stimulates the destructive process by increasing pressure and friction of the diseased surfaces of the opposing bones; third, to correct and prevent deformity by lessening pressure and by restraining motion, thereby keeping the femur from upward displacement.
Rest and protection are the two cardinal features of treatment of this condition. Sunshine, fresh air and good nutritious diet are very important.
Complete rest of the joint offers the most favorable opportunity for nature to repair this disease. The recumbent period of the treatment necessitates rest in bed for the reduction of the deformity and subsidence of acute symptoms. By the aid of traction, which is applied to the length of the legs by means of a Buck’s extension. As much weight should be applied as can be borne without discomfort to the patient.
As soon as the deformity and acute symptoms have subsided, the ambulatory treatment should be substituted to keep up the general health of the patient. This merely consists of the application of a long plaster of Paris spica of the hip which should reach well up to the thorax and extend down and include the foot. All bony prominences should be well padded, and a moderate amount of traction with about twenty degrees abduction should be used while applying the plaster bandage. Though various forms of apparatus have been devised for fixation and traction, I believe that the plaster of Paris spica is far the most effective and should always be used, changing the cast as often as it becomes soiled. Locomotion is possible with crutches providing the shoe on the well side is stilted by an iron patten which is high enough to allow the casted limb to clear the floor.
The earlier treatment is begun, the better the outlook. Recovery with perfect motion occurs in about twenty-five percent of hospital cases; fifty per cent will obtain useful motion and the other twenty-five per cent will obtain practical fixation, but it must be remembered that results will range entirely according to the thoroughness of treatment, the severity of the disease in the individual case, and the natural resistance of the child. In general, the hip should be fixed as long as it is sensitive, it should be protected and distracted as long as there is muscular spasm, and protected until the congested and inflamed bone of the epiphysis is replaced by firm healthy bone.
Tuberculous disease of the knee is next to the hip in frequency. It is a chronic destructive process of the epiphysis of the femur or tibia, or it may start in the patella, head of the fibula, or primarily in the synovial membrane of the knee joint. The condition presents two distinct types; one, the adult type beginning as a chronic synovitis, of which the early symptoms are subacute; and the other, the childhood or most common class, in which the symptoms of pain, muscular spasms and deformity seem to indicate clearly a primary disease of the bone.
Symptoms.—This disease is commonly known as “white swelling” and the symptoms as a rule are quite characteristic. The affection begins with a limp and limitation of motion, and is usually slow in progress with periods of severe pain. There is usually much swelling and this together with the distortion of the limb by muscular spasm and atrophy of the muscles both above and below the joint, gives a most characteristic knock-kneed appearance. The affected limb is usually longer at first, owing to the congestion of the epiphysis of the knee. Local heat is always present in the more acute stages and the lameness is usually a constant symptom. The differential diagnosis from other joint troubles is easy because of the slow insidious onset.
Treatment.—Like other tubercular bone conditions the fixation treatment is best. Rest in bed with a Buck’s extension to overcome the deformity and the local application of hot packs until the acute symptoms have subsided, is the best preliminary treatment of this condition. Five- to ten-second exposures to the X-ray each day for ten days seems to relieve the pain and in most instances causes less marked infiltration of tissues.
When the acute stage has subsided, the ambulatory treatment by fixation in a plaster of Paris cast extending from the groin to the ankle, with about 10 degrees flexion, is most efficient.
The patient is allowed to walk about with the aid of crutches, having the shoe on the sound side stilted enough so that the diseased limb clears the floor. The functional results after conservative treatment are in the average case excellent, that is providing proper treatment is begun at an early stage. Useful motion is obtained in fifty per cent of these cases, perfect motion is restored in twenty-five per cent, and complete rigidity results in the other twenty-five per cent of cases.
Any chronic, painful inflammation confined to a single joint, in which motion is limited by muscular spasm, and in which there is a tendency towards deformity, is almost always tubercular in character.
The plaster of Paris bandage was perhaps first applied by Kluge of Berlin in 1829, but to the Dutch physicians Mathysen and Vander Loo belongs the credit of the modern bandage.
It is imperative to give, in this chapter, a detailed and complete description of what constitutes a properly made plaster of Paris bandage and the application of it, in order that the general practitioner may become familiar with its use. Even though one cares not to treat the conditions heretofore enumerated, I have found that for fractures of almost every bone in the body requiring immobilization, the plaster bandage properly applied is far superior and rather to be preferred to any other form of splints.
It has been used very little in the past in private practice because the ordinary commercial bandage found in any supply house does not come up to requirements, in that it is usually air slaked or the plaster has been shaken from it by the time it is received. Then too the mesh is too closely woven and the plaster lies on the bandage instead of in the meshes and there is, in consequence, an excess of plaster; also as a rule the bandages are rolled so tightly that the water does not reach the deeper layers.
The ordinary plaster of Paris bandage made in your own office can always be successfully applied because the right quantity of plaster can be incorporated in the bandage and it can readily be made into the desired widths. The plaster of Paris to be used should be of the superior quality used by dentists and should be of the quick setting kind. It can be procured at almost any drug store but the surest place for quality will be your dentist.
Absolutely, the only kind of gauze to be successfully used is white crinoline of the ordinary variety used by dressmakers and obtainable at any dry goods store in twenty-four yard bolts. It is especially desirable to get a kind not too rich in starch or dextrin and of a mesh running about one hundred holes to the square inch.
The bandages should be made in six yard lengths, and of widths ranging from three to five inches according to the part that is to be cast; for instance the three inch widths are most suitable for casts for the extremities, while the larger ones serve best for conditions of the spine. After the length had been measured and cut the desired widths can be torn the full length without trouble. The edge of the crinoline nearly always frays out and naturally will become so entangled as to prevent rolling in the plaster or as to hinder the free unrolling of the bandage when applying it. To prevent this, three threads should be plucked from each side of each strip before starting to roll in the plaster.
A hard surface of, at least, two feet in width should be used on which to roll in the plaster. Starting at one end, a handful of plaster of Paris is rubbed into the crinoline with the palmar surface of the hand, bearing down hard, so that all excessive plaster passes to either edge of the bandage. No more plaster should be rubbed into the crinoline than the meshes will hold, and as each successive yard is incorporated with the necessary amount of plaster, it is loosely rolled in such manner that in the center of the bandage there is a hollow cylinder of the thickness of the index finger, and the concentric layers are easily movable on one another. This manner of rolling permits of the rapid and uniform spread of water through the bandage when it is to be applied, and prevents parts of the bandage from being insufficiently moistened.
The general practitioner should always keep on hand about two dozen completed bandages that he is most accustomed to using in his daily practice. These should be corded as it were, to prevent unrolling, in an air tight container, either of glass or tin in the bottom of which is placed a small quantity of plaster of Paris, and should always be kept in a dry place. I have never found either a nurse or an office girl who could not make these bandages successfully so that in the future there is no excuse for a practitioner not using this superior form of splints.
While plaster of Paris is in no way harmful to either garments or surroundings, both the operator and the assistants should be properly gowned and the floor covered with newspapers to prevent unnecessary soiling. It should be borne in mind that if a properly made bandage is used, which is squeezed to the extent of ridding it of an excess of water, very few drippings will be scattered and the whole procedure of the application of the plaster differs in no way from simple roller bandaging.
The number of bandages intended for use should be taken from the container and placed in a pan near the pail holding the water, in which they are to be immersed, in a position in relation to the pail that will guard against water being splashed upon the dry bandages, which would render them unfit for subsequent use. Water as hot as the hand will tolerate, as opposed to cold, facilitates setting. I do not recommend any chemicals to hasten setting, because a properly made bandage, prepared as above, of quick setting plaster sets in remarkably fast time.
The area to be cast should be encased in ordinary absorbent cotton of the thickness in which it comes rolled, putting an extra pad over all marked bony prominences, and a roller gauze bandage applied to hold it in place and snug to the part. Under no consideration do I advise the use of flannel bandage or the ordinary sheet wadding cotton that are recommended by some authors, because padding with these materials is always conducive to applying a cast far too tightly, especially in fractures where the swelling increases after application thereby causing constriction of the limb and interference with circulation. The regular absorbent cotton as padding beneath a cast is always best for it is almost impossible to apply a cast too tightly when it is used.
The bandage should be completely submerged on its side, and should remain so until the bubbles cease to come off, which time takes place most readily in the properly rolled dressing. When the bubbling has ceased, the bandage is lifted out of the pail and squeezed with the hands merely to free it of the excessive water, the end is found and handed to the operator ready to apply. No undue traction should be made in applying the successive turns of the bandage, though it must be remembered the cast should fit snugly to the part, and the ordinary rules of simple roller bandaging followed, except that the reverse spirals are unnecessary. The assistant should constantly rub the layers as they are applied by the operator, as this not only helps the cast to fit more snugly, but also makes the rough edges of the bandage adhere more firmly to the layer beneath, thereby making a smoother cast.
As a rule there need be no dread of an increased swelling beneath the bandage because usually several hours have elapsed after the injury before the physician has arrived and made preparations to apply the plaster. Indeed, one of the best means of limiting swelling after a fracture is the prompt application of a plaster of Paris bandage. If there is any concern that the cast is too tight, while the plaster is still soft it can be easily cut through the entire length with a knife, and thus relieve the pressure existing. Also it is a good plan to cut a window or opening over the sight of injury, which would in no way harm the object of the cast and would allow a gentle massage to the part. A neat finish may be given to the edges of a plaster cast by turning over the ends of the cotton, in cuff-like fashion and held in the grasp of the last few turns of the plaster at either end.
On clothing you will find it best to allow the plaster to dry before removing, while on furniture or the hands it is readily removed by washing off in warm water. The water in which the bandages were immersed contains, of course, considerable plaster, and under no circumstances should this be emptied into a sink or waste pipe for it will certainly demand the services of a plumber. The water may be poured out on the ground and the paste shaken into a refuse barrel or ash pile. The best way to remove a cast is to moisten it with water or vinegar along the path of the knife. I might add that all patients are in constant fear of being cut either while you are trimming, cutting windows, or removing the cast, but because of the cotton padding underneath you will find that it is almost an impossibility. Care, of course, should be taken that the knife does not slip in any of these procedures and come in contact with the unprotected parts.
In general, for fractures of the extremities it is best to apply the plaster with the patient in the recumbent position to secure complete muscular relaxation, and the part to be cast should be supported by an assistant. It is also a general rule that in fractures of the shaft of the long bones, especially of the lower extremities, the plaster bandage should be applied to include the adjacent articulation and extend well beyond the joints.