HEAD AND TRUNK.
Fracture of the lower Jaw.—The External Splint and Bandage.—A method requiring the lower jaw to be firmly fixed against the upper one while the broken bone knits.
Apparatus.—1. One and a half yards of bandage four inches wide.
2. A piece of gutta-percha, sole leather, or binder’s millboard.
3. Dentists’ silk or wire.
4. Boiling hot, and cold water.
Step 1. The fracture is first reduced. While the apparatus is being fitted, the recurrence of the displacement is prevented by the hands of an assistant, or by lacing the teeth together with stout silk or wire. It is well also to wet the patient’s chin with a sponge and cold water, to prevent the gutta-percha from sticking to his beard while it is soft.
Step 2. A piece of gutta-percha is prepared 2½ inches wide and long enough to reach from one angle of the jaw to the other when passing in front of the chin. This is softened thoroughly by immersion in boiling water, and when quite pliable should be quickly removed from the hot and plunged for a moment into cold water: if a towel be previously laid in the hot basin, the gutta-percha can be lifted on it without stretching. It should be laid on a table, and its surface sponged with cold water to prevent it sticking to the skin, it is then slit from each end into tails 1 inch and 1½ inch wide, leaving 2 inches uncut at the centre. So prepared, the splint is applied to the jaw with the middle pressing against the chin, the narrower ends being carried horizontally backwards to the angles of the jaw; the broader part is next bent up beneath the chin, its ends overlapping the horizontal ones. While the splint is still soft, the surgeon presses it firmly upwards that the gutta-percha may mould itself accurately to the chin. When set, the splint is removed, trimmed, and punched with holes here and there for evaporation. A covering of wash-leather may be added, if desired. When the splint is finished, it is replaced on the chin. If sole leather or pasteboard be used instead of gutta-percha, they must be prepared in the same way, but allowed to remain on the chin twenty-four hours that they may set before the final trimming and adjustment.
Step 3. A bandage, 4 inches wide and 1½ yard long, and slit from each end to about 2 inches from the centre, is then applied to the splint, and a small pad of folded flannel should be placed at the nape of the neck to protect the skin from the crossed bandage. When all is ready, the two upper ends are carried behind the neck, crossed, drawn tight, and tied or pinned on the forehead; the lower ends are carried upwards, taking a turn round the first pair at the temples, and fastened at the vertex (see fig. 23).
Fig. 23.—Outside splint for fracture of the lower jaw.
The ligatures that may have been used on the teeth can now be removed, or if they cause no pain, they may be left for a week or two.
It is a useful precaution to place a piece of soap plaster spread on soft leather, under the chin and along the throat, to protect the skin from the chafing of the splint while it is worn.
Sometimes the jaws close too nearly to allow food to be taken between them. It is then necessary to place a thin wedge of softened gutta-percha, 1½ inch long, ½ inch wide, and about ⅓ inch thick, between the molars on each side. The gutta-percha must not be softened much, or when the bite is taken the teeth will pass through it. These plugs should be omitted unless absolutely required, as the fragments keep a better position without them.
On emergency, when gutta-percha, leather, or pasteboard are not at hand, the jaw may be set, and then kept in position by a four-tail bandage, made from a pocket-handkerchief, until more complicated apparatus can be prepared.
The apparatus must be worn five weeks before it is laid aside and mastication permitted.
Interdental Splints.—In cases of unusual difficulty, interdental splints may be employed. To fashion some of these, the mechanical skill of a dentist is requisite, unless Morel Lavallée’s plan is resorted to. He applied a mould or socket to the line of the teeth, and kept it in place by pressure underneath the jaw. He first brought the fragments into apposition by means of threads and wire. Then he took a piece of gutta-percha, about ⅓ inch thick and ½ inch broad, and long enough to extend, when bent along the lower jaw, from one wisdom molar to the other. This was softened in water, and pressed on the teeth; next a well-padded horse-shoe plate was placed under the chin, reaching from one angle of the jaw to the other, and two wires were passed through the side of this plate opposite the angle of the mouth; these were drawn through the plate by a screw nut; their upper ends being curved into hooks with sharpened points. The points catch into the gutta-percha; by screwing up the nuts, the chinplate was raised, and the teeth driven up and bedded into the splint.
This method, however, has its disadvantages. If the fracture take place behind the first molar, the bearing on the upper fragment is too slight to keep it down in its place.
In the New York Medical Journal for September and October, 1866, Mr. Gunning, of that city, has published a mode of applying caps fitted to the teeth for fracture of the jaw-bone. External support is abandoned wherever it is possible. In simple fractures, the caps or interdental splints, being accurately fitted, require no fastening to the teeth.
The jaw should be adjusted in its splint as quickly as possible after the accident. The fragments are first brought into their true position. Gaps through loss of teeth at the line of fracture, are filled by plugs of hard wood, and the fragments kept in place by wiring the teeth together tightly. Continued strain on the teeth causes much pain; hence all means for keeping the fragments in place while the splint is being fitted should be removed when that is accomplished, though ligatures used solely to support loosened teeth may be left, as there is no traction upon them. Stumps, and teeth loose before the accident are best taken out, if they interfere with the arrangement of the splint.
Fig. 24.—Vulcanite Interdental Splint to fit the arch of the teeth of the lower jaw, seen upside down. The holes marked a pass through to the upper surface, to allow water to be injected between the splint and the teeth, while it is worn, for cleaning.
The next thing is to take a mould of the lower jaw in wax softened by heat, holding the wax in an ordinary dentist’s tray. From this mould a plaster cast of the jaw is made. If the line of teeth be uneven in the cast, it is to be sawn through, the pieces raised to the right level, and cast again. In this cast a vulcanite plate is made exactly fitting the teeth (see fig. 24). The margins of the mould or splint should be carried down below the line of the gums, to grasp the jaw beyond the alveolar border; and when the fracture takes place behind the teeth, its outer side should be prolonged backwards as far as the muscles will allow, to prevent the displacement of the anterior fragment outwards which muscular action produces in these fractures. Holes should be made in the top of the splint, to permit a stream of water to be sent between the splint and the teeth daily, for cleanliness. Also, in difficult cases, a hole should be cut opposite a tooth in each fragment, for ascertaining from time to time that each part continues in its proper position while the splint is worn.
Metal is used for the plate by English dentists, instead of vulcanite. It can be made thinner, and is less brittle than the latter.
The perfect fit thus secured suffices, in simple fracture, to keep the parts in close apposition; while the movements of eating and speaking are very little interfered with.
Fig. 25.—Showing the method for supporting externally the jaws in the splint, when the teeth are not fastened to it by screws, E. Upper wing; G. Lower wing; H. Mental band to keep the jaw up in the splint; I. Neck-strap to keep the band back; K. Balance-strap to hold skull-cap in place. The upper wings are of course dispensed with, when a single splint only is used.
When the displacement is considerable the fragments are held in place by riveting one or more teeth to the cap, or, when circumstances prevent support being obtained in this way, external support is supplied to the splint by steel wings, fixed into the splint at the angles of the mouth (see fig. 25), and carried outside the cheek to the angles of the jaw. A piece of stout jean or canvas, cut to fit under the chin, is then connected with these wings, and also fastened by a tape behind the neck.
If the case require that a bearing be made on the upper jaw as well as the lower one, as in fracture of both jaws in edentulous persons, the two splints are articulated behind, so that they may open and shut with the lower jaw. Each piece then carries a wing, the lower one supporting a chin-piece, and the upper one being connected by strings attached at the temples to a close-fitting skull-cap. The skull-cap is prevented from slipping forward by connexion with a strap fastened to both shoulders.
A fractured Rib is very well treated by strapping the injured side alone, without enrolling the chest in a tight bandage, which harasses the patient by impeding respiration.
Apparatus.—1. Diachylon plaster.
2. Can of boiling water.
Fig. 26.—Strapping a broken Rib.
Strips of plaster long enough to reach from the spinal column to the sternum, and 2 inches wide, are to be firmly drawn round the injured side. The first strip should be carried as high as can be managed under the arm-pit. The next strip overlaps it about an inch (fig. 26), each succeeding strip overlapping and fixing the preceding one until the lower ribs are covered in. The arm should then be bandaged to the side, and supported in a sling.
A second mode of treating fractured ribs, is to take a flannel roller 6 inches wide, and 8 yards long, and carry it firmly round the chest in successive spirals, beginning at the armpits, and passing down till the waist is reached. The turns of the roller may be kept from slipping down by throwing across the shoulders two strips of bandage like a pair of braces, and stitching each turn to the brace in front and behind. The arm should be confined to the side as in the other method. This plan has the inconvenience before mentioned of interfering with respiration.
In Fracture of the Pelvis, the fragments are kept in position by a broad roller carried several times round the pelvis and fastened.