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

by P.-J. Desault

9. The two ends of the bandage (L) previously made to cross each other on the sole of the foot, are passed the one through the mortise, and the other through the hollow or notch in the lower end of the same splint, and then, being drawn forcibly, are tied in a firm knot, so as to act as a substitute for the hands of the assistant, who now lets go the patient’s foot.

10. If the roller (g g) become relaxed, it is tightened again, and the patient being laid in a suitable position, the limb is protected from the pressure of the bed clothes, by a kind of basket placed over it.

11. A roller (K k) laid first on the sole of the foot, and then brought across over its upper side, and fastened laterally to each splint, serves to secure that part from turning outward or inward, and thus prevents the rotation of the limb.

63. If the mode of operation of this bandage be compared with the general indications formerly established (38) for all oblique fractures of the os femoris, it will be easy to perceive that, conformably to those indications, it tends, 1st, to draw the inferior fragment downward; 2dly, to retain the superior one up; 3dly, and to prevent the rotation of the lower fragment, and secure the immobility of the limb.

64. It is evident that the bandage or roller (g g) so unites the pelvis to the external splint (AA), that the latter cannot be pushed upwards, without drawing the former in the same direction, as well as the superior fragment which adheres to it. But if, after this roller is fixed, the lower one (L) be tightened, the first effect produced is, to push the external splint forcibly upwards; the second, to draw the leg, and with it the inferior fragment downwards; so that, by fixing the roller (L) in the notch and mortise of the splint with the necessary degree of tightness, extension and counter-extension are made permanent. By this means the muscles, being kept on a stretch, lose by degrees their power of contraction, which is still further diminished, by the immoveable state in which they are kept, and by the compression made on them by the bandage of strips. So that, on the one hand, the inferior fragment will have no tendency to rise upwards, and even if it had, it will meet with a sufficient resistance to prevent it; while, on the other hand, the superior fragment will not be pushed downwards by the pelvis.

65. To this advantage is added that of a state of perfect immobility. The pelvis, the leg, the thigh, and the foot being firmly fixed on the external splint, constitute one entire whole, all the parts of which must retain, with respect to each other, the same relative position. Should even a stroke be accidentally given to this assemblage of parts now converted into a solid whole, each portion of it will move at the same time, there will be no partial motion, and the relative position of the parts will not be changed. Hence the advantage of being able to raise the patient without apprehension; a most desirable circumstance indeed, in a position so painful and so long continued (26). The external splint, being extended beyond the sole of the foot, prevents the lower fragment from obeying a tendency, which it sometimes has, to displace itself by a rotation on its axis. Should this tendency be towards the internal side, an occurrence much more rare, the lengthening of the internal splint will effectually prevent it.

66. These considerations induced Desault to renounce his ancient mode of making permanent extension, and employ this exclusively, in the latter years of his practice. Like all other kinds of apparatus, formed principally of rollers, this is very subject to become relaxed; and requires, therefore, great attention on the part of the surgeon. It ought to be examined attentively every day, particularly the two extending bandages (L and g g). As soon as they become relaxed, they must be immediately tightened again: without this precaution, the effect of the apparatus will be lost. Be vigilant also, with respect to the compress placed between the roller (g g) and the tuberosity of the ischium. Should this slip, the roller being frequently tightened, and pressing immediately on the skin, may produce excoriations and ulcers difficult to be healed, particularly in females. The roller itself may slip, and then, having no longer a solid point of support and action on the tuberosity of the ischium, it makes extension in but an imperfect manner.

67. One of the charges brought against this apparatus is, the facility with which the upper roller becomes displaced, a facility that imposes a degree of care and attention, of which few surgeons are capable, and which, when bestowed even by Desault himself, did not always prevent the shortening of the limb.

68. Further, the extension made on the fold of the thigh, partakes, a little, of the inconvenience that accompanied the ancient mode of reduction, namely, that of compressing and irritating the muscles of the upper and internal part of the thigh (30). This inconvenience would be still more sensible, if, for want of extending to a sufficient distance up the pelvis, the upper splint should allow the roller to cross the muscles at an angle somewhat acute, as it would then enclose and press on the greater part of them.