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

by P.-J. Desault

OF PERMANENT EXTENSION IN OLD FRACTURES.

74. I will close this article by a few remarks on the advantages of permanent extension in old fractures. Nature reunites fractures differently, according to the relation of the divided surfaces to each other. Are those surfaces in perfect contact? If so, they are chiefly instrumental in the formation of callus, which then probably acts in a manner similar to the reunion of wounds. On the other hand, does an overlapping of the fragments separate the divided surfaces from each other; the reunion takes place then principally on the sides, by a kind of enlargement of the bones, produced no doubt by the periosteum. Such is the mode of consolidation, which, on opening dead bodies, is found in most oblique fractures of the os femoris, succeeded by a shortening of the limb.

75. Hence it follows, that this shortening, which would readily yield to extension, at the time of the fracture, becomes obstinate in its resistance, in proportion to the age of the accident. In such a case, indeed, the substances destined to reunite the overlapping fragments, acquiring daily more and more solidity, oppose to the reduction obstacles constantly increasing. Hence, most practitioners regard this reduction as beyond the resources of art, after the expiration of the twelfth or fifteenth day. Nor is this opinion entertained without some foundation, for at a later period, almost all efforts at reduction, however powerful, have proved unavailing. But that which cannot be performed by a very powerful effort, acting momentarily, is, notwithstanding, oftentimes easily attainable by a much weaker one, provided it be long continued. The following cases are in proof of this.

Case III. Ann Gallot, of Melun, aged sixty-nine, having fractured her right thigh, by falling down the steps of a cellar, remained twenty-two days without assistance, and without even knowing the nature of the accident, when, on consulting a surgeon, she was sent to the hospital at Versailles. From the long standing of the disease, a reduction being despaired of, and no one being willing even to undertake it, the patient was sent to the Hotel-Dieu, on the 27th of February, 1791.

A shortening of four inches distinguished the diseased thigh from the sound one. The overlapping was sensible to the touch: in the mean time, a slight mobility at the place of fracture, inspired a hope of being able, if not to restore to the limb its natural form, at least to diminish the contraction. Several efforts were made at first, but without success, as Desault foresaw. The apparatus for permanent extension was applied: on the day following, the extending rollers being a little relaxed, were again tightened. Fourth day, a sensible increase in the length of the limb; apparatus renewed. Ninth day, the left thigh but an inch longer than the other: eleventh day, equality in length almost re-established. After this, the apparatus was kept constantly applied and renewed from time to time.

Fortieth day, consolidation already perceptible: forty-sixth day, symptoms of a putrid fever have made their appearance: fiftieth day, symptoms worse; fifty-second, something better: fifty-fifth, worse again: fifty-seventh, dead. On opening the body, an oblique fracture was found, its surfaces very nearly in apposition, and already united by a very solid callus.

Case IV. Joseph Maugrin, a saddler, broke his thigh in the month of July, 1793. A surgeon being called to him, placed his limb in an old form of apparatus, which did not prevent a shortening, to the extent of an inch and a half, from showing itself on the following day: hence a new reduction, and a new application of the apparatus: but soon afterwards, another shortening; the same means to remove it; the same failure of means. Weary of such trials, the surgeon abandoned the limb to its fate, contenting himself with merely keeping it in the apparatus.

On the twenty-ninth day, Desault being called in consultation, and finding the thigh shorter by three inches than that on the opposite side, proposed permanent extension, persuaded that this expedient alone would soon be sufficient to re-establish the contact of the fragments. The proposal was acceded to. On the day following, the effects were already perceptible; the thigh was lengthened by almost an inch. By the sixth day, it was equal in length to the other: during this period, the extending rollers were tightened twice a day.

At the end of two months the consolidation was complete, and the patient walked perfectly well, except that there was a little shortening of the limb, trifling though indeed, compared to what would have been the consequence, had the original treatment been continued.