The standard “Buck’s extension” (for which latter word I prefer to substitute the term “traction”), by weight and pulley, with the limb in the extended position, is still the resort of the majority of surgeons, but combined with other support by long side splints or coaptation splints as may be needed. [Fig. 321] illustrates the method of its use, except that the ends of the adhesive strips should be extended upward to a point nearly opposite the site of the fracture. The amount of weight to be used should be graduated to the effect produced. From ten to forty pounds, or even more, may be needed. After the muscles are thoroughly tired the amount of weight may be somewhat reduced[41] ([Figs. 319], [320] and [321]).
[41] Before applying the strips of adhesive, the best for the purpose being that made of moleskin spread with material with which zinc oxide is incorporated, the limb should be carefully washed and shaved and then completely dried. A little cotton should be placed over each malleolus, in order to avoid pressure-sores, while the strip of wood beneath the foot should be sufficiently wide to prevent or minimize this pressure. The heel should be kept off the mattress.
Fig. 321
Mode of applying adhesive plaster. (When the dressings are completed the limb should not be allowed to rest on the bed.)
Continuous and anterior traction was devised by Nathan R. Smith, in the use of a so-called anterior splint, which was later modified and improved in device by Hodgen. The method of its use is shown in [Fig. 322]. Adhesive strips are used in this method as well, permitting the leg and foot to be attached to the lower bar of the wire frame. The position of the frame which contains the limb, swung within it upon turns or strips of bandage, is then controlled by a suspension apparatus, as shown, which tends to constantly pull the frame and its attached lower part of the limb away from the patient, the effect being to make a constant but gentle traction. If the point of suspension were placed directly above the limb there would be no traction whatever. The essential feature of the method, then, consists in arranging it as shown, so that the pull shall be oblique, and that, according to the obliquity of the suspension cords, the amount of traction shall be regulated.
Fig. 322
The Hodgen suspension splint.
In this method of treatment there is no violent attempt made at reduction or overcoming displacement, but dependence is placed, at least for two or three days, on the effect of the constant pull and its overcoming muscular activity. After this such added splints or expedients may be adopted as the case may require. The knee is usually flexed at a comfortable angle, the intent being not to lift the foot too high, so as to avoid being compelled to overcome this added weight, but to regulate the tension by the obliquity of the suspending cord.