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IMPROVED APPARATUS AND METHODS IN THEIR TREATMENT.
By E. YOUNKIN, M. D.
Every physician with a reasonable share of practice, will meet with fractures, whose results, to a greater or lesser degree, will affect the function of the joints. Fractures of the humerus, of the condyles, at the base of the condyles, either with or without splitting into the joint, are specially frequent, and the consequences, generally, are: great inflammation, permanent deformity and bony ancholysis. The opposite result in such cases is usually regarded as a fortunate exception to the rule. From the frequent occurrence of such accidents, and from the embarassments experienced in the use of the different appliances in vogue, in overcoming those results, I have been led to attempt the use of certain devices, whereby I am enabled more readily to execute that which is acknowledged to be the more rational methods of treatment.
In 1876, I was called to see Mary Niel, a girl aged twelve years, who had fallen upon the sidewalk, striking the right elbow. I saw her a few minutes after the accident, but the parts about the joint were considerably swollen. The forearm was slightly flexed and proned. Upon seizing the forearm firmly with one hand and grasping the condyles of the humerus with the other, and moving, I discovered motion above the condyles, and crepitus. I could likewise feel the point of the upper fragment. There was lateral widening of the condyles, and upon extension I could press them together, when it became apparent that they were separated by a splitting between them into the joint. On removing the pressure and
extension the condyles again separated and the olecranon drew up between them. I set forth to the patient and friends, as I always do in like cases, the liability of a stiff elbow-joint; and promised to do the best I could, if my services were desired. I set the arm in Day's rectangle splint and went home. At my leisure musings I raised in my mind the essential principles in the treatment of my patient's arm. These occurred to me about as follows:
1. The proper adjustment of the fragments. 2. The arm and elbow-joint must be immobilised. 3. The imflammation must be guarded. 4. The anchylosis should be prevented. I thought of the gratification which would be experienced if these ends should all be obtained.
Upon examining the literature of such cases I came to this expression of Hamilton: "In no case, ought more than seven or fourteen days to elapse before all bandaging and splinting should be abandoned, and careful, but frequent flexion and extension be substituted."
The object that Hamilton has before him in this suggestion is, doubtless, the restoration of the function of the joint. Every one can see, however, that if the bandages and splints are abandoned at the end of seven or fourteen days, it will be at the risk of deformity and misplacement of the fragments. Why not retain and support the fragments, and at the same time employ passive motion? It would seem to me that this would be the most rational course. The splints formerly in use were not capable of accomplishing this end, and hence Hamilton chose to abandon them altogether at this juncture, and take the chances of permanent deformity. Here was a difficulty that I had often met and I determined to rectify the evil.
ARTIFICIAL HINGE-JOINT FOR BROKEN ARMS.
With my "jack-knife" and pine stick I carved my idea into shape and hastened to my instrument-maker and had it made of metal (Fig. 1). It is a hinge-joint that turns by a key to any angle. Any degree of power can be used, and it is reversible, so that it may be used either anteriorly (C) or posteriorly (D). To this hinge I fitted two pieces of thin board and applied it to the posterior portion of the arm of my
patient. After seven days,
when the period of inflammation had passed, I turned my hinge backward and forward every day; and to my great satisfaction the arm grew as supple and useful as before. This joint is made to be adjusted to any ordinary material that is sufficiently strong for a splint. The splint itself is cut from anything at the surgeon's FIG. 1.-A HINGE-SPLINT. command, and the joint applied. So highly pleased was I with my first instrument that I immediately ordered another. Before I obtained it from the shop, Charles Jay, a boy aged fifteen years, fell upon his knee and broke the internal condyle of the femur. I obtained my hinge and, fastening it to a couple of boards, I turned the hinge to nearly a straight splint, and applied it to the posterior part of the leg. In ten days I began the use of passive motion by turning my splint into a double inclined-plane and then back to a straight position, thus supporting the fragments and at the same time moving the joint.
In fractures of the condyles of the knee, Hamilton says: "As soon as union is consummated, the joint-surface should be submitted to passive motion, in order to prevent anchylosis; and it would be better to commence this so early as to hazard somewhat a displacement of the fragments than to wait too long. It may not in some cases be improper as early as the fourteenth day, and in nearly all cases it should be practiced as early as the twenty-eighth."
The reader will see that my treatment suggests a much earlier movement of the limb; and by retaining the support, having the fragments well secured, the hazard of displacement is avoided. In my second case I had the satisfaction of seeing my patient walk without a limp.
From that year to the present (seven years) I have had
numerous cases of like character, and with this plan of treatment I have had the most gratifying results. I have just now dismissed a patient who six weeks ago fell from a high boardfence, breaking the external condyle of the humerus, and thrusting the internal condyle through the skin upon the inside of the arm. A physician was sent for, who decided upon amputation. Two hours and a half after the accident, and before the physician could get his associate operator, I saw the patient and proposed to try and save the arm. I reduced the dislocation and put on my angular splint. The arm was treated antiseptically with boracic acid. Not a sign of inflammation occurred, and the motion of the arm is almost perfect. Do such results follow the use of the fixed rectangle splint, or can we hope to prevent deformity by the too early abandonment of splints and bandaging?
One more point, however, was to be obtained. I desired in certain cases to have a hinge in which motion could be made in the joint by the will of the patient, while at the same time the bones of the arm were fixed. For this purpose the above hinge could not be used.
Fig. 2 represents a lateral hinge that may be used with free motion at the joint. The thumb-bolt, A, may be turned to tighten or loosen; it may be fastened at any angle desired. At B the hinge is applied to
splints made of shingles or bookbinders' board. This splint, it will be seen, may be applied either inside or on the outer side of the arm, so that with the two hinges, Fig. 1 and Fig. 2, the surgeon is supplied with all the necessary apparatus for the treatment of fractures of the arm.
With Fig. I a pistol-shaped
splint can be made also to fit FIG. 2.-LATERAL HINGE. over the shoulder, and Fig. 2 is applicable at the wrist, where such apparel is required.
In August, 1882, the author's own arm was broken near the elbow. The lateral hinge was applied, which gave me freedom of motion; and during its application I was permitted, by the liberty it gave me of the elbow-joint, to set for other patients-two fractures of the tibia, one of the femur, one of the ulna and radius, and one of the humerus.
FRACTURES OF THE LEG.
This is all that I had hoped to do with my apparatus, but as matters went on I perceived no reason why I should not seek to perfect a plan for the treatment of fractures of the leg.
The methods usually adopted by our country surgeons have some serious objections. In attempting to confine the bones of the legs, the body itself is kept so much in one position that the patient is oftentimes worn out by the close confinement. In old people suffering with fractures, especially about the neck of the femur, the decubiture is long and devitalising. Surgeons have acted like the Yankee, who had placed the yoke upon his oxen in front of the horns. Upon enquiry into his reason for this strange method, he replied that he "proposed to get labor from the whole ox and not from half, as you fellows do down in the States."
A little change of position in the body, and in the limb of a patient suffering with fracture, affords a wonderful amount of comfort. If, therefore, this can be done without hazard to the fractured part, it is the duty of the surgeon to afford it. Some surgeons prefer one position of the limb, where others prefer another. Some desire to set upon a straight splint, others upon an inclined or double-inclined plane.
In fractures about the neck of the femur, I believe the straight position, or at most a slightly-inclined plane, is the best, and is the one usually recognised. Fractures just below the minor trochanter should first be set in the double-inclined plane, owing to the lower end of the upper fragment being drawn up by the contraction of the iliacus and psoas muscles. Fractures near the middle of the shaft of the femur may have a lesser degree of double inclination. As the base of the condyles is approached the greater double inclination is again