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

by P.-J. Desault

12. The fore-arm being thus placed, an assistant makes extension, by taking hold of the four fingers; a mode to be adopted in preference to that of Petit, who directs us to make extension at the wrist; for the real momentum or force of a power is in the inverse ratio of its distance from the place of resistance. At the same time, another assistant makes counter-extension on the humerus, which he grasps with both his hands, in such a manner, that his thumbs correspond to the back part of it, while his fingers cross each other anteriorly.

13. It further follows, from what was said (8 and 9), that the process of conformation, so often useless and even injurious, in other fractures of bones, is necessary here, to restore to the fragments that exact contact which they have lost, in a transverse direction. If the displacement be forward, the surgeon pushes both fragments backward, while the assistants maintain the extension. If the bones project backwards, they must be pushed in the contrary direction. As to a lateral displacement (8) in which the broken ends approach each other, it is not altogether useless, as Petit observes, to endeavour to remove it, by forcing the muscles into the space between the bones. This is done by making a moderate pressure on the anterior and posterior surfaces of the fore-arm, in order that the bones, being thus removed from each other, may come in contact with their broken ends. If this be done, when the apparatus is first applied, the reduction is attended with but little difficulty, and the ends of the fragments are easily retained in apposition.

§ VI.

OF THE MEANS OF MAINTAINING THE REDUCTION.

14. Our forms of apparatus are nothing but means of continuing, for a long time, that state of things, which extension and the process of conformation temporarily produce at the time of reduction. This principle, though generally acknowledged, was particularly neglected in such fractures, as that now under consideration, till the time of Petit, who made it the basis of his practice. Before him, there was a common inconvenience attached to every kind of bandage. The two bones being pressed against each other, by circular rollers applied externally, were thus drawn in that very direction, in which the action of the pronator muscles already tended to displace them; because, the form of the fore-arm being irregular, made these rollers act more powerfully on its lateral parts, where it is very convex, than either behind or before, where it is very flat. It is well known that bandages will make the greatest pressure on the most projecting parts of the limbs round which they are applied; so that, if the fore-arm be bound or pressed on behind and before with a force equal to one, it will sustain laterally, that is, on its sides or edges, a pressure equal to two. Hence results, not only a tendency in the radius to approach the ulna, but also, a want of resistance in the muscles situated on the posterior and anterior sides of the fore-arm. For these muscles being, from their flatness, less compressed than the bones, give way, and do not, by forcing themselves between them, oppose the approach of the bones to each other.

15. Such was the disadvantage of the apparatus of Hippocrates, consisting of one roller applied immediately on the skin, of a many-tailed bandage intended to retain this, and of four splints, applied on the seventh day, and secured by another roller. Such was also the inconvenience of several bandages, proposed after the time of Hippocrates, by different authors, who modified his without improving it, and who, in attempting to alter it, even added to its imperfections. Thus, the compresses with which the limb was first covered, previously to the application of the rollers, served only, by becoming wrinkled, to render the compression unequal, fatiguing, and even painful to the patient. In like manner the pasteboard, which many authors, particularly Duverney, have substituted for splints, and which a majority of practitioners employ, even at the present day, soon becoming softened by moisture, bends without resistance, becomes incapable of preventing a displacement, and has at least the inconvenience of being useless.[18]

16. Is it to be wondered at then that a perfect cure of fractures of the fore-arm has been regarded as a thing of so much difficulty, and that most authors should have advised practitioners, as a thing of prudence, to warn the patient of its being impracticable to cure him, without the loss of the motions of pronation and supination? Thus, in like manner, it was formerly declared, that a constant deformity was the necessary consequence of fractures of the clavicle.

17. Petit first conceived, that he discovered, in the very means destined to prevent the displacement, the cause of its being continued, and that, in order to be effective, the bandage ought to do constantly what the hands of the surgeon do at the time of reduction (13); that is, it ought to oppose to the unremitting action of the pronators, a resistance equally unremitting, by pressing the muscles into the interstice between the bones. But, after having discovered the end to be attained, he accomplished it only in an imperfect manner. For by first applying a roller immediately round the fore-arm, he reproduced, in part, the very inconveniences and disadvantages he wished to prevent, by placing anteriorly and posteriorly two long and thick graduated compresses, intended to keep the bones asunder, by forcing the muscles between them.

18. Duverney, more judicious, proposed to place the graduated compresses of Petit on two circular compresses, previously applied round the fore-arm. But what availed these circular compresses? If they be drawn tight, will they not produce that approximation of the bones which the surgeon wishes to avoid? And if they be not tight, they will, in consequence of their loose and pliable state, form troublesome and inconvenient wrinkles, without being productive of any good to counterbalance this inconvenience.