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

by P.-J. Desault

23. Pott imagined, on the contrary, that if the lower extremity were kept in a half-bent position, the muscles, being more relaxed, would offer less resistance to the efforts of the extension: he, therefore, proposed to bend the leg on the thigh, and the thigh on the pelvis, and to lay the patient on his side, a position, which, when first employed in reduction, was to be continued throughout the treatment, during which it would render the causes of displacement less active (10...15). Bell adopted this method, which indeed appears to be generally in use in England.

24. But the difficulty of making extension and counter-extension, with the limb thus situated, the necessity of making them on the fractured bone itself, and not on a part distant from the fracture, such as the lower part of the leg; the impossibility of comparing the diseased thigh with the sound one, to judge of the regularity of the conformation; the uneasiness occasioned by this position, if long continued, though it may at first appear the most natural; the troublesome and painful pressure of the body on the great trochanter of the affected side; the derangements to which the fragments are exposed when the patient goes to stool; the difficulty of fixing the leg with sufficient steadiness, to prevent it from affecting the os femoris by its motions; the evident impracticability of this method, when both thighs are broken; and, finally, experience, which, in France, has been by no means favourable to the position recommended by Pott: such were the considerations, which determined Desault to have recourse to it no more, after having tried it on two patients, in one of whom the limb was considerably shortened, notwithstanding the most scrupulous attentions.

25. Besides, all that is gained by the relaxation of some muscles, is lost, by the tension of several others. The knee cannot be bent without the triceps flexor being brought into action; an inconvenience the more serious, as this muscle acts immediately on both fragments. The rectus anterior, though relaxed by the flexion of the thigh, will be thrown into a state of tension by the flexion of the leg. The muscles attached posteriorly to the upper fragment, and even to the superior part of the lower one, will also in certain positions of the limb be rendered tense.

26. Hence it follows, that there can be no just comparison instituted as to the position proper for the limb, between fractures of the upper and those of the lower extremities; that, in the latter, the method pursued by the English surgeons presents an aggregate or general amount of inconveniences so great as to overbalance that of its advantages; and, that the position directed by Hippocrates and the other Greek physicians (22) ought to be adopted.

27. Having determined on the position, the operator proceeds to extension and counter-extension, which are to be made first in the direction of the limb as deformed or altered by the fracture, but must be changed afterwards according to the natural direction of the thigh. I need not here repeat the directions for this double operation: common to all fractures, they contain nothing particular, in relation to that of the thigh. But, on what part should extension be made? Petit, Heister, Duverney, and all their predecessors, recommend to apply the means or powers for making extension above the knee; a precept which is still to be found in the surgical department of the Encyclopedia. A strap surrounding the lower part of the thigh, aided by another placed at the ancle, serves, in this respect, to draw the inferior fragment downward.

28. Dupouy was the first to remark, that this practice rendered it necessary to employ great force, and that it would be better to make extension only on the foot. To this consideration Fabre added that of the inconvenience of the pressure made on the muscles, a pressure which, by irritating them and making them contract, multiplies the obstacles to the reduction.

Desault adopted their doctrine, from nearly the same views of the subject, introduced it into the Hotel-Dieu, and the success which attended it, in his practice, contributed not a little to bring it into general use.

29. For the purpose of making extension, he used the foot as a lever of the first kind. The two hands of an assistant, grasping it in such a manner, as to make the fingers cross on the back of it, while the thumbs, also crossing each other, corresponded to the sole, represented the power; the articulation represented the centre of motion, or fulcrum, and the leg together with the lower fragment, the resistance. The requisite motion was then communicated to the foot, and in that way was the extension effected. This mode is more advantageous than that usually employed, where the hands are applied to the lower extremity of the leg; for the force of the extending power is generally in the inverse ratio of its distance from the resistance intended to be overcome.