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

by P.-J. Desault

57. To the bandage which we have just described, Desault added formerly a strip of linen, to be placed all along the posterior part of the arm, secured first at its upper end by circular casts, which began above; this strip was secured afterwards by oblique casts, as far as to the place where it met the olecranon, separated from the ulna. Here, the surgeon quitting the roller, took hold of the bit of linen, and drew it downwards, and along with it the circular casts of the roller, together with the muscles on which these casts were applied, and also the fragment which the muscles drew upwards. An assistant then secured it here, while the surgeon, after having made some casts in form of the figure of 8, descended to the inferior part of the fore-arm, where the end of the strip was made fast by tight circular turns. (See [fracture of the rotula].)

58. The intention of this additional piece of apparatus, was to draw down the superior fragment, to prevent the circular casts of the roller from separating by their relaxation, and, by that means, to retain the fragments in apposition. But, on the one hand, may not the superior fragment be drawn by the hand, as well as by a roller employed for the purpose? And, on the other, if the circular casts of the roller be liable to become relaxed, why not the strip of linen also? These considerations induced Desault to lay it aside, and use the bandage in the form just described.

59. The advantages it offers are far from being equivocal. 1st, The limb is kept in a state of invariable extension by the anterior splint, and, on this account, there can be no displacement on the part of the inferior fragment. 2dly, The bandage, which accurately envelopes the whole limb, restrains the action of the muscles by compressing them, and prevents in part the contractions of the triceps; while the casts in the form of the figure of 8, applied with skill and precision, hold down the superior fragment, and render it difficult for it to be displaced. 3dly, Without the application of a roller over the whole limb, a swelling, more or less considerable, would probably be the effect of the constriction at the elbow, which must necessarily be somewhat tight, because, as the turns of the roller, in form of the figure of 8, act on the olecranon obliquely, if they be too loose, they will slip and not perform the office of retention.

60. Like all kinds of apparatus composed of rollers, this ought to be frequently examined, lest, by becoming relaxed, it should not make sufficient resistance to the triceps, which is always disposed to draw itself upwards. There can be no period fixed on for the reapplication of the apparatus; the moment it begins to become slack, it ought to be renewed: three or four times during the course of the treatment are generally sufficient. Should a considerable swelling give reason to suspect that the constriction is too great, it will be necessary to remove the bandage in order to apply it anew.

61. The period necessary for the reunion of fractures of the olecranon varies, according as the bandage is more or less exactly kept in its place. Among ten cases of this kind, collected in the Hotel-Dieu, four united in twenty-four days, three in twenty-eight, and three in thirty-two. Hence, taking the mean term, all other circumstances being alike, the process of cure requires about twenty-six days.

62. When this is completed, it is necessary to impress on the limb motions of flexion and extension, gradually increased every day. This is, as David properly observes, the most certain method of avoiding a stiffness, and even an anchylosis, too often the consequence of this fracture.

63. But that illustrious practitioner, in recommending this salutary remedy, has erred with regard to the mode in which it operates. To consume, by degrees, a superabundant callus in the interior of the articulation, and thus reduce it to a level with the articulating surfaces, is not, as he conceives, the effect which these motions produce. This opinion, founded on the ancient doctrine of an osseous juice, is refuted by the dissection of many bodies of patients that died during the treatment, and in which Desault discovered no trace, either of an effusion of osseous juice, during the reunion, or of its superabundance after this reunion had been completed.

The exercise communicated to the limb, appears to act principally by removing the congestion of the tendons and membranes surrounding the joint, which, being at first irritated by the fracture, are thrown into a state of engorgement; and further by dissipating a kind of numbness which affects the muscles after they have remained too long in a state of rest.

64. But whatever may be its mode of action, it ought to be gradually increased, according to the state of the parts, and continued for at least twenty days, a period sufficiently long to restore to the limb, in general, its natural motions.

65. It is seldom that after this methodical treatment, the patient is exposed to an anchylosis, a thing inevitable in such cases, according to most authors, A celebrated surgeon, believing the long continued extension of the fore-arm to be the cause of this accident, has advised here to abandon every kind of bandage, and to commit the cure entirely to nature. But this doctrine, contrary to the general principles of the reunion of divided parts, has not in its favour the result of experience, which proves that, under such neglect, the stiffness in the parts near to the joint is always as great as in other cases, that the reunion is more tedious and more deformed, and that sometimes it cannot be accomplished at all. The analogy of the inconveniences and disadvantages attributed to the method of Foubert, in fractures of the neck of the os femoris, constitutes another argument against this method, which is now almost entirely abandoned.