A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

37. The second means, not less efficacious than the first, consist in the forms of apparatus, in which the limb is placed, and which, being differently modified according to the fancies of their different authors, present us with an assemblage of various splints, compresses, &c. To appreciate, with accuracy and correctness, the advantage and disadvantage of these, let us first unfold the curative indications which they ought to fulfil; we will then compare their mode of action with these indications, from whence will result, as necessary inferences, the object of our research.

38. The intention of every form of apparatus being, to prevent the displacement of the fragments, the causes of this displacement ought to be the basis or foundation of its mechanism and construction. But these causes in the present case are, 1st, the muscular action drawing the inferior fragment upwards (10); 2dly, the weight of the body pushing the superior fragment downwards (14); whence every form of apparatus intended to keep the os femoris in place when fractured obliquely, ought, 1st, to draw the lower fragment downward and retain it there; 2dly, to draw and retain upwards the superior fragment, and the trunk which bears on its upper end. This principle is applicable generally, and subject only to a few exceptions which I shall notice when treating of transverse fractures, where the displacement is lateral, or in the direction of the cross-diameter of the bone, or where no displacement at all exists. 3dly, The apparatus must also be so constructed as to prevent the rotatory motions of the lower fragment (18), and secure the immobility of the limb, lest by means of some motion being communicated to it, the fragments might be deranged.

§ VII.

OF THE MANNER IN WHICH THE DIFFERENT PIECES OF THE APPARATUS ACT.

39. If to these indications we compare the mode of action of the different pieces that unite in composing our common forms of apparatus which do not make permanent extension, such as common bandages, splints, compresses, bolsters, &c. we will perceive that they are but ill calculated to fulfil them: and first of bandages. Whether the common roller, or the eighteen-tailed bandage be employed, their mode of operation is the same: their only action is, to add a second exterior and artificial covering to the natural cutaneous and aponeurotic covering of the thigh; to press against the fragments the muscles which form for them a kind of natural case intended to keep them in apposition; and to augment, by this pressure, the lateral resistance of the soft parts. By this contrivance, lateral displacements will, in part, be well guarded against, and, in this respect, these bandages are useful in transverse fractures. But what is there in them to prevent the two inclined plains of an oblique fracture from sliding on each other? What provision is there in them to secure the limb from the effects of motions and shocks which may be accidentally impressed on it from without? Will the pelvis be kept steady by them? or will muscular action be sufficiently checked and kept under by them? The force of the muscles will indeed be slightly diminished by means of compression; and to make this compression is the principal use of these bandages in oblique fractures. But will mere compression be sufficient to prevent a displacement in the longitudinal direction of the bone, particularly if the rollers be slack, as certain practitioners recommend, on the ground of the fallacious theory of Duhamel, who conceived, that a constriction too tight, would injure the action of the periosteum, which, according to him, is the sole agent in the formation of callus? So much, then, for bandages, whose only use is to prevent, by compression, the swelling of the limb, and to diminish, in some degree, the contraction of the muscles, which they press against the fractured bone.

40. These remarks apply equally well to the use of compresses; which make but a very feeble resistance against a powerful cause, and cannot be considered as any obstacle whatever to displacement. What can be said of those surgeons who, from servile attachment to a particular form of apparatus, do not consider a fracture as reduced, unless a certain quantity of compress secured by a given quantity of roller, be applied on the limb. Servile imitators in an art which calls for genius in its votaries, they are only capable of following, without reflection or judgment, the steps of their predecessors.

41. Bandages will do nearly as much harm as good in fractures of the os femoris, if, as was practised by the ancients, they be formed by a single roller surrounding the limb: in such a case, the limb being necessarily raised up at each time of their reapplication, will be exposed to continual displacements. Hence the ingenious idea of applying to simple fractures of the lower extremities the eighteen-tailed bandage, invented for compound fractures, and by means of which the thigh may be suffered to remain at rest. But to this bandage belongs also an inconvenience. The pieces which compose it, being stitched together, cannot be separated, and if one of them be soiled they must all be changed. Hence the superiority of the bandage of slips, known in former times, and engraved by Scultel, but long since forgotten, till Desault revived the use of it, and adopted it exclusively, both in simple and in compound fractures.

42. Splints of different kinds, which form the second division of the pieces of apparatus, used for fractures of the os femoris, have the advantage of fixing the limb in a solid and firm manner, and securing it from any displacement that might result from jolts, or muscular contraction, arising from the inattention of patients: these prevent, more effectually than bandages, any displacement laterally, and, on this account, their use is sufficient, even without extension, in transverse fractures: they also prevent, particularly if they be made of wood, the rotatory motion of the thigh either outwards or inwards (18). But if the division be oblique, will they prevent the gliding of the fragments over one another, and the consequent shortening of the limb? They can evidently produce this effect in no other way, than by the forcible pressure made by the pieces of apparatus, particularly by the straps or bandages that secure the splints, and then, to make effectual resistance, it would be necessary to apply them with such a degree of tightness as would endanger the life of the limb. Will splints prevent the trunk from sinking downwards, and pushing the superior fragment before it? Will they prevent the muscles from acting on the lower fragment? Can they, in a word, fulfil all the indications formerly pointed out (28)? Certainly they cannot. Splints, then, are calculated only to prevent displacement in the lateral or cross direction of the bone, and to secure, better than bandages, the immobility of the limb. Whence it follows, that they ought not, in this case, to be confined to the thigh alone, but should extend to the leg, whose movements, if communicated to the os femoris, may derange the contact of the ends of the bone. The neglect of this precaution, contributed formerly not a little to displacement and deformity.

43. In former times a kind of splints was in use, which were made by securing bundles of straw round sticks proportioned in length to the length of the limb to which they were to be applied. But as these, from being of a round or cylindrical form, touched the limb with but a narrow surface, they did not retain the fracture with sufficient firmness. They were, therefore, very properly exchanged for flat and strong wooden splints, (such as Desault used) which retain the fracture much better, in consequence of presenting to the limb a broad surface, and thereby rendering it in some measure immoveable.