Fig. 91.—Box Splint for Fractures of Leg.
The limb is placed in this box, the sides of which have been carefully padded. Ring pads are applied to take pressure off the condyles, the head of the fibula, the malleoli, and the prominence of the heel, and a large supporting pad is placed behind the tendo calcaneus. A folded towel is laid over the front of the leg, forming a lid to the box, and the whole is bound to the limb by three slip-knots. Finally, the foot is fixed at right angles to the leg and slightly abducted by a figure-of-eight bandage or a piece of elastic webbing. Sand-bags placed alongside serve to steady the limb. In fractures of the lower third of the leg, the box splint may stop short of the knee and the limb may then be suspended in a Salter's cradle, which allows the patient to move about more freely in bed.
Fig. 92.—Box Splint (applied).
To prevent shortening in oblique fractures and in those near the ankle-joint, where it is often difficult to control the lower fragment, extension, applied by weight and pulley, or through a Thomas' knee splint, may be of service. The strapping may be applied only to the distal fragment, but we prefer to carry it to the upper third of the leg. If the overriding of the fragments persists, extension may be taken directly from the bone, the ice-tong callipers gripping the malleoli or the calcaneus.
When the skin is damaged, as it so frequently is on the medial aspect of the tibia, means must be taken to prevent infection.
Massage is carried out daily, and, to prevent stiffness, the ankle is moved from the first. In the course of three weeks, lateral poroplastic splints retained by an elastic bandage may be substituted, and the patient allowed up on crutches. In simple fractures without displacement, union is usually complete in from six to eight weeks, but when the fracture is oblique, comminuted, or compound, union is often delayed, and the functions of the limb may not be fully regained for three or even four months after the accident.
Operative Treatment.—When overriding cannot otherwise be corrected, it is advisable to replace the fragments by operation. A curved incision with its convexity backward is made over the medial side of the tibia, exposing the fragments, which are then levered into position and if necessary plated or otherwise fixed according to circumstances. It is seldom necessary to deal separately with the fibula. A box splint is applied till the wound has healed, after which a poroplastic splint is substituted and massage commenced.