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

by P.-J. Desault

§ V.

OF THE REDUCTION AND THE MEANS OF MAINTAINING IT.

15. I have already observed (7), that the causes of the separation of the fragments are, as far as respects the upper one, the contraction of the extensor muscles; and, in relation to the lower one, the flexion of the leg; whence it follows, that the means of preserving contact between these fragments are 1st, all those that are calculated for the prevention of muscular action; 2dly, such as may keep the limb in a state of permanent extension. Hence two leading curative indications must be fulfilled by the bandage constructed for fractures of the rotula: the last of these indications presents in general but little difficulty; but, with regard to the other, the case is different. To fulfil the latter, it is necessary first, to weaken the contractile force of the muscles, and by that means diminish the effort which they make to draw the superior fragment upwards; and then, to oppose to them a proper mechanical resistance, which, by acting in a direction the very reverse of that in which they act, may countervail their efforts.

16. But the force of contraction is diminished, 1st, by throwing the muscular fibres into a state of relaxation; this end is best attained by bending the thigh on the pelvis: 2dly, by making compression over the whole limb, by means of a circular bandage, which, by confining the muscles, tends to restrain and weaken their action. Thus it is known that the advantage of the bandage employed to unite transverse wounds, consists chiefly in that compression which, by diminishing muscular action, prevents the retraction of their edges. Another advantage resulting from the bandage in this case is, that it prevents the swelling of the limb.

17. As to the mechanical resistance, which must act in a direction opposite to that of the contraction of the muscles, and, by that means, prevent the displacement of the superior fragment, it cannot, in the present case, be of the same nature as in fractures of the thigh, the clavicle, &c. where permanent extension is practised. The superior fragment offers too small a purchase for any extending forces to act on. This resistance must be made, then, by placing some body above this fragment, and retaining it in that situation with a force sufficient to hinder the fragment from rising upwards: such as a few turns of a roller drawn tight, a bit of leather, some hollow compresses, &c.

18. It is evident from the foregoing principles, that every bandage intended to retain a transverse fracture of the rotula, ought to be calculated to maintain the following state of things: 1st, the extension of the leg on the thigh; 2dly, the flexion of the thigh on the pelvis; 3dly, a uniform compression over the whole limb; and, 4thly, some mechanical resistance properly secured above the superior fragment: the three last expedients relate to the displacement of that fragment alone; while the first has a relation to that of the lower one. Let us examine whether or not the bandages, hitherto employed by different authors, be calculated for these purposes.

19. M. Valentin, believing that position alone was sufficient to retain the fragments in contact, neglected the application of apparatus entirely, which he even considered as hurtful, in consequence of the swelling it produced; but experience soon proved the insufficiency of this method. The slightest movement, or the least effort on the part of the patient, made the extensor muscles contract, which, drawing the superior fragment upwards, separated it from the lower one; and, as the time of reunion is in direct proportion to the distance of the fragments from each other, it must, under such treatment, have been necessarily tedious, and sometimes must have even failed altogether.

20. As to a swelling being produced by the bandage, this never occurs, unless when some openings are left, through which the integuments protruding become tumefied: but, when the pressure is uniform throughout, when the fluids find throughout an equal resistance, this accident is not to be apprehended, as is proved by the practice of Desault, who never met with it; on the contrary, a bandage properly constructed and applied, is calculated to prevent swelling (16).

Mere position, then, though always of service in this affection, is not alone sufficient, because it fulfils only the first of the indications or principles laid down with respect to every form of apparatus for transverse fractures (18), namely, that which relates only to the lower fragment; while those that relate to the upper one, remain still to be fulfilled.