Step 5. The limb is lastly put into position by elevating the heel and by raising the body with pillows till it is in a half-sitting position.
The patient wears this splint four weeks, during the first fortnight of which the bandage should be perseveringly re-applied every three or four days until the upper fragment is brought into apposition with the lower one. After this the splint may be changed for a light starch or gutta-percha case, to be worn for six weeks more, and then replaced by a back splint of leather and knee-cap, that must not be laid aside for another period of three or four weeks. If the patient can be persuaded not to bend his knee for four months, the union of the fragments will be less likely to yield afterwards. He should be also warned that much stiffness will result from the long fixed position necessary to procure good union between the fragments; but the stiffness will all subside in time, notwithstanding the long-enforced rigidity.
Strap and Spiral Bandage.
E. K. Samborne’s Plan of drawing Patella Fragments together.—A strip of diachylon plaster 4 feet long and 2½ in. wide is applied to the front of the limb from 2 in. below the groin to the small of the leg, leaving a free loop or doubling opposite the patella. Beneath this loop a firm compress or horseshoe pad is placed above the upper fragment. A roller is then carried round the limb to keep the strap in place, but leaving the loop at the knee exposed. This done, the body is propped up in a half-sitting position, and the limb elevated on an incline. A stick, 6 inches long and ½ inch thick, is inserted into the loop of plaster, and then twisted round and round till, by shortening the loop, the loose tissues of the thigh, and with them the upper fragment of the patella, are drawn down to the knee. The stick is prevented from untwisting by a roller lightly carried round the knee. As the plaster slackens, the stick may be tightened from time to time and the fragment brought in a few days into its proper place.
Fig. 47.—Malgaigne’s Hooks.
Malgaigne’s Hooks (fig. 47), for drawing closely and holding together the fragments in transverse fracture of the patella, or of the olecranon, often procure a closer union than any other method. They should not be inserted until effusion is absorbed and the soreness has subsided. To insert them, one pair of hooks should be bedded in the ligamentum patellæ, and catch against the lower edge of the bone; the skin is then drawn up the limb, while the upper pair of hooks is passed through it and behind the upper fragment; the two ends are then approximated by turning the screw. The fragments usually do not come quite close the first day, but the next they can be drawn so firmly together that if one is moved the other goes with it. In applying the hooks care should be taken that the upper pair go well through the skin and fascia behind the bone, or when they are screwed up the upper fragment is apt to ride unevenly over the other, and exact junction is lost. The pain of the insertion soon passes off, and the hooks can commonly be worn without annoyance for five or six weeks, until union is secured.
Fracture of the Shaft of the Thigh-bone.—The long Splint.
Apparatus.—1. A wooden splint.
2. Rollers, 3 inches wide.