COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64055051 RD101D441915 Simple, comfortable RECAP .J Columbia ®nttJf «ftp CoHese of $f)psician£( anb ^urgeonsf Hibrarp Digitized by tine Internet Arcinive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/simplecomfortablOOdepu SIMPLE, COMFORTABLE AND HUMANE TREATMENT OF FRACTURES Copyright, 1915 BY R. DE PUY I PRICE $1.00 'RDloi THE primary treatment of practically all frac- tures is rest, and the rest applied to the parts immediately involved consists in immobiliza- tion. Repair processes in bones are slow because of the density and poor blood supply of osseous tissue and the necessity of complete anatomical union with calcified material before functional use can become normal. To meet this indication of rest necessary for repair, splints of many types have been used suc- cessfully since history recorded injuries. Wood, iron, leather, stiff cardboard, and more especially plaster of Paris, have met the demands of the medical profes- sion until recently. Side excursions have been made into silicates and other quickly hardening substances which can be applied to fit the contour of different parts of the human body, and they have all fallen into disuse on account of expense or trouble of application. There remained to be devised material which would be pliable enough to permit moulding to fit different contours and sizes of limbs, and which would also possess sufficient property of stiffness and firmness to furnish support for fractured extremities. Plaster of Paris used as circular casts has the disadvantage of being dangerous from the standpoint of swelling of FRACTURES the parts within, of absorbing discharges, and of be- coming dirty and foul in a short time. When used as moulded splints some of these objections fail. However, moulded splints can be used on but one patient; they crack and become worn out in. a short time and, in common with all plaster of Paris dress- ings, need assistance for application. This applica- tion must be performed within a limited time — it is mussy and expensive, and plaster is not always to be obtained in fresh condition which permits a solid, non-crumbling setting. The De Puy Adjustable Wire Splints have been manufactured to avoid many of these drawbacks. They are light, pliable enough to permit moulding, can be used over and over again, and allow ready inspection of the limb without removal. There is no fear of compression or of interference with circulation and subsequent malpractice suits. Ambulatory pa- tients find them comfortable and not a burden. Compound fractures can be held in position easily, and discharges cause no damage to the splint, which is covered with a non-oxidizable and non-rusting mixture. These splints can be attached by adhesive or bandag- ing, as the surface is rough enough to prevent slipping. Their advantages are summed up as — 1. Lighter, cooler, and cleaner, with better wear- ing qualities than any other type of splint. 2. They will last for years and care for many cases, being especially valuable for hospital use. 3. They are adaptable to all fractures of the extremities. FRACTURES OF THE CLAVICLE 5 4. They are not entirely "ready made" splints, but are applied by moulding and bending and in com- bination to fit each patient. 5. They are cheaper than any other satisfactory splint and are used by the most advanced teachers of fracture treatment. 6. They permit X-ray exposure and picture-tak- ing without removal and consequent pain and distress to the patient. FRACTURES OF THE CLAVICLE The usual site is the junction of the middle and outer thirds, and the bracing or stay-like action of the bone holding the shoulder out is lost. The shoulder Fig. 1 Hawes' Clavicle Splint in 2 Sizes, Nos. 47 and 48 Shoulder Cap Not Shown tends to fall forward, downward, and inward when this support is lacking, and the clavicle itself takes on an apparent deformity. As it lies just beneath the skin, crepitus and deformity are easily ascertained. FRACTURES The clavicular portion of the insertion of the sterno- cleidomastoid muscle, meeting with no opposition when the continuity of the bone is lost, tends to pull upward the inner fragment, the outer fragment falling downward, dragged bv the shoulder weight. (See Fig. 1.) Fig. 2 Front View Showing Hawes' Clavicle Splint Applied Reduction consists in replacing the fragments in their normal position. This is aided by pressure on the fragments and by raising the shoulder upward, outward, and backward from its deformed position overcorrecting until the injured shoulder is held on a higher level than the sound side. (See Fig. 2.) Hawes' clavicle splints Nos. 47 and 48 fulfill these requirements FRx\CTURES OF THE CLAVICLE and hold the forearm and hand in a comfortable posi- tion, which is instantly adjusted, without removing the whole dressing, simply by tightening or loosening the straps. The arm on the injured side is bandaged with one layer of cotton sheet wadding, and the shoulder cap with the strap retainer is placed on the sound shoulder over light padding. (See Fig. 3.) Fig. 3 Back View Showing Hawes' Clavicle Splint Applied Beneath the arm on the injured side is placed angular elbow splint No. 17 or 18, lightly padded, which acts as an axillary support to hold the shoulder out from the chest. Free circulation of air is permitted through the wire meshes and there is no opportunity for skin FRACTURES maceration from sweating. (See Fig. 3.) This is fastened to the chest wall by a broad piece of adhesive tape passing through it onto the body. The arm portion of the splint is then slipped on after making sure that there is no pressure over the pointy of the Fig. 4 Angular Elbow Splints Nos. 17, 18, 70. Shaped to be Used as Wedge in Axilla Space elbow, and the straps are tightened to the desired position of overcorrection. If the splint is narrow for an unusually large forearm, it can be bent or moulded wider to fit. It should be noted that the elbow point is made very full to avoid pressure. Ad- FRACTURES OF THE HUMERUS justments of arm elevation can be made easily and quickly by the straps. After three weeks in the splint, when callus appears in the clavicle, the arm can be removed daily by light passive movements of the shoulder and elbow. General massage is also indicated. After the fourth week the splint is seldom used. This same dressing can be used after reduction of shoulder dislocations, being worn for from ten to fourteen days. Its advantages are obvious: the position obtained is highly satisfactory and easily readjusted; the site of the fracture is open for inspec- tion or manipulation; there is no adhesive plaster dressing to cut or macerate the skin on the arm, and the forearm and hand are held in a comfortable, steady position. FRACTURES OF THE HUMERUS For the sake of convenience these are divided into — a. Fractures of the head, tuberosity, and neck. b. Fractures of the shaft. c. Fractures of the condyles and at the elbow. a. Fractures of the head, tuberosity, and neck. Fractures of the head itself are rare and often accom- pany dislocation, as do also fractures of the tuberosity. Usually the injury of the head is a crack or split, and the indication for treatment consists in rest to permit the joint effusion to subside, followed by passive mo- tion when pain is not caused. After dislocation of the shoulder, fractures of the tuberosity are diagnosed by skiagram and, rarely, by palpation or loss of function. The broken-off 10 FRACTURES fragment is pulled backward and upward by the spinati muscles, and treatment must be directed toward bringing the shaft out into contact with the shell pulled off. This is accomplished by a position of ab- duction and outward rotation of the arm. Fig. 5 Shoulder Splints Nos. 24, 25, 26 Fractures of the surgical neck are common and may be impacted. The usual displacement is to find the head rotated outward and abducted, the shaft frag- ment being pulled inward and upward by the pectoral muscles. Reduction is made by extension on the arm, manipulation of the fragments into line, and their maintenance by splints (see Fig. 5) Nos. 24, 25, 26, applied over the lightly padded shoulder, FRACTURES OF THE IIIMERI S 11 aided by splints (see Fig. 6) Nos. 17, 18, in the axillary space, or (see Fig. 7) Nos. 21, 22, 23, on the inner side of the arm, high up. These splints are snugly bound on and the forearm supported by a sling, either in splint (see Fig. 8) No. 19, 20, or 42, or used in combination with the others. Abduction is furnished by the Fig. 6 Angular Elbow Splints Nos. 17, 18, 70 axillary splint No. 17 or 18. (See Fig. 4.) This treatment applies to all fractures in this area, including the rim of the glenoid and neck of the scapula. b. Fractures of the shaft are transverse, oblique, or 12 FRACTURES Fig. 7 Humerus Splints Nos. 21, 22, 23 spiral, the displacement varying with the location. When fracture is below the insertion of the deltoid mus- cle the upper fragment is pulled outward and upward; if the break is above this insertion, the lower frag- ment is pulled upward and outward. The position of fragments is usually apparent from the deformity, and treatment is indicated to bring them into align- ment and hold them there. The fragments are gently manipulated into place, the line of the longitudinal arm axis is straightened, and two large humerus splints, Nos. 21 and 22, are bandaged on over Fig. 8 Elbow Splints, Posterior, Nos. 19, 20, 42 FRAC^TURES OF THE HUMERUS 13 the padded arm. The forearm is supported in a sHng or, better, by combination with elbow spHnt No. 19, 20, or 42. (See Fig. 9.) If the overriding is trouble- some and difficult to correct, as in oblique and spiral fractures, splints Nos. 71 or 72, which have been devised to make extension on the humerus, should be used. The forearm piece of this splint, after being firmly Fig. 9 Showing Complete Immobilization of Arm with Splints Nos. 24, 21, 19, 1 strapped on, gives counter-extension from the saddle piece which goes into the padded axilla. (See Fig. 10.) Several inches of extension is provided for by the threaded bar or crutch which supports the axillary piece, 14 FRACTURES The nut is turned up until sufficient extension pressure is obtained and this is held bv the second lock-nut. The rod supporting the axillary band is fastened by a swivel so that the patient can rotate the arm out- ward at will without danger of disturbing the position Fig. 10 Humerus Extension Splints Nos. 71, 72 of the fragments. Adjustment of extension is easily made by the nuts without removing the splint, w^hich may be held on by the straps alone or by a light roller bandage applied over all. (See Fig. 10.) Sphnts Nos. 71 or 72 are also indicated in fractures low down on the shaft which do not extend into the elbow area FRACTURES OF THE HUMERUS 15 and which demand extension to hold proper position. Humerus spHnts Nos. 21, 22, 23, or posterior elbow splints Nos. 19, 20, 42, can be used in combination. (See Fig. 9.) For the -complete immobilization of the arm in a right-angled position a combination of splints Nos. 1, 73, 19, 21, and 24, by telescoping one part into the other, fulfills all requirements of arms of varying sizes. Fig. 11 Acute Angle Elbow Splints Nos. 76, 77, 78 c. Fractures of the condyles and at the elboiv. Supra- condylar fractures, or those which involve the elbow joint, including T fractures, usually have a posterior displacement of the lower fragments. When either condyle alone is broken off, it tends to be displaced laterally and upward. The indication for treatment is to replace the fragments in the best possible position 16 FRACTURES and to avoid a stiffness in the elbow joint. Author- ities now agree that the best position in many eases is one of acute flexion; that is, with the forearm flexed well onto the arm and held there until bony union is started. This flexion should be enough to make the angle between arm and forearm less than 60 de- grees. It is maintained for two weeks by splint No. 76, 77, or 78, which can be removed frequently for massage if the forearm is held in its flexed position and not allowed to move. (See Fig. 11.) After two weeks the elbow joint is moved a little and the splint can be bent to a greater angle to allow the forearm to extend gradually. After the third week the arm can be lowered to a right angle and splint No. 73, 74, or 75, or No. 19, 20, or 42, can be worn for a couple of weeks with daily massage and passive motion. This type of splint aims to maintain the carrying angle by holding the forearm and arm in the same axis, a most important factor in the treatment. (See Fig. 12.) Fig. 12 Right Angle Elbow Splints, Anterior, Nos. 73, 74, 75 FRACTURES OF THE FOREARM 17 FRACTURES OF THE FOREARM a. Fractures of the olecranon. The displacement is practically always a pulling upward of the proximal fragment by contraction of the triceps muscle. The indication for treatment is to reduce the swelling and to try to get the fragments in apposition. This can be done by full extension of the forearm, which brings the shaft of the ulna nearlv into contact with the Fig. 13 Angular Elbow Splints Nos. 17, 18, 70, Used Straight for Fracture of Forearm detached fragment, which can rise no higher than the limit allowed by the olecranon fossa of the humerus. Splint No. 17, 18, or 70, which permits adjustment, is the proper one to use. This is applied over the padded arm on the anterior side, with the arm at first in full extension. (See Fig. 13.) Every second day it is removed for massage and after two weeks light move- ments of passive flexion are started and the angle of the splint is gradually lessened. Four weeks should give good union. A long coaptation splint may be substituted for the elbow splint. 18 FRACTURES b. Fractures of the upper end and head of the radius are best treated with the forearm in flexion, after reckiction. The forearm should be held in supination, turned over on its back, in splints used for the elbow fracture, Xos. 76, 77, 78, and 19, ^20, or 42, ete. (See Figs. 11 and 8.) c. Fractures of the shaft of one or both bones. The shaft of the ulna is straight and palpable in its whole length. The radius is curved and rotates around the ulna. Consequently when the shaft of one or both Fig. 14 Radius Splints Nos. 1, 2, 3, 4, 5, 6. (Three Sizes in Rights and Leftsj bones is broken, the indication is to correct the deformity and displacement by manipulation and traction on the hand, and then hold the bones as far apart as they can be separated while heahng. The best position for this is supination. This separates the bones and, as experience shows that the restriction of use after forearm fractures is nearly always a restriction of supination, this position should be chosen. Splints Xos. 1, ^2, 3, 4, 5, 6, 7, 8, 43, and 44 can be used alone or in combination with the coapta- FRACTURES OF IIIF FC)RFAR:\I Fig. 15 Forearm and Hand Splints Nos. 7, 8, 43, 44. (Two Sizes in Rights and Lefts) tion splint No. 63, with the hand turned on its back. Sphnt No. 19, 20, or 42 can be used in connection. Sphnts Nos. 1, 2, 3, 4, 5, 6, 7, 8, 43, 44, or a coaptation splint on the palmar side of the forearm. (See Figs. 14, 15, 16.) d. Fractures of the lower end of one or both hones, and Colles' fracture. In Colles' fracture there is a typical displacement of the fragments. There is a Fig. 16 Coaptation Splints, 10 Pieces, 5 to 10 Inches in Length, Two of Each Size riding upward and backward of the lower fragment, which may also be impacted or displaced laterally. The usual appearance is a hump caused by this frag- 20 FRACTURES nieiit on the back of the wrist, the so-called "silver- fork deformity." The first indication is to reduce this deformity and displacement by unlocking the Fig. 17 Showing an Example of Radius Splints Nos. 1, 2, 3, 4, 5, 6, Applied fragments and shoving the lower one down into place. With the deformity overcome, the hand and the fore- arm rest very comfortably in splint Nos. 1, 2, 3, 4, 5, 6, FRACTURES OF THE FOREARM 21 T Fig. 18 Showing Colles' Splints Applied or Nos. 45, 46, which is strapped on. This leaves the fingers uncovered and free to move as they must from the first. (See Figs. 17, 18, and 19.) After ten days the sphnt is removed daily for massage and move- ments, and after the third week it can be dispensed with altogether. Both bone fractures near the wrist are treated similarly after reduction by traction and manipulation. Fractures of the wrist and metacarpal bones have little displacement and usually heal satis- factorily if given sufficient immobilization. If im- Fig. 19 Colles' Splints Nos. 45 and 46. (Posterior Part Not Shown) 22 FRACTURES paired wrist motion is feared, or an ankylosis threatens for any reason, the hand is best put in a position of shght extension, above the straight Hne of the forearm, because this preserves the gripping power. Sphnts Xos. 7, 8, 43, and 44 are used by the surgeon with padding to fit the angle of fixation he may desire. They are left on three or four w^eeks. Do not be in a hurry to start movement after carpal fractures. Fig. 20 Finger Splints Nos. 49 and 50 Fractures of the carpal bones are treated best by putting the hand in flexion. The Colles' splints Nos. 45 and 46, or Xos. 1, 2, 3, 4, 5, and 6, which permit the hand to be bandaged in flexion around the end, an- swer this purpose. They are left on about three weeks. Fractures of the fingers are treated by the finger splint adjusted to any degree of flexion (Nos. 49 and 50). This can be moulded to any degree of flexion by bending and fitting to the well hand before appli- cation. Any angulation desired can be secured, de- pending on the position which holds the reduced frag- ments best. The long forearm piece is bandaged or strapped on and the finger is then fixed to the distal FRACTURES OF THE FEMUR 23 portion of the splint. Two to three weeks' wear is snfficient for union. (See Figs. 20 and 21.) FRACTURES OF THE FEAIUR a. Fractures of the neck and head usually involve a shortening of the leg from one to three inches. The foot is rotated outward and cannot be lifted by the patient; and the trochanter, palpable beneath the skin, Fig. 21 Showing Finger Splint Applied is found elevated above Nealton's line, drawn from the anterior superior iliac spine to the ischial tuber- osity. The indication for treatment is to bring the broken shaft into line with the head fragment. This is done by extension, elevation, and abduction and is accomplished by splint No. 65 or 66. (See Fig. 22.) This is a strong, durable splint, which must be used on a fracture bed; i.e., one which is supported by boards placed across the bed beneath the mattress to prevent sagging. Both the thigh and leg segments of this 24 I RACTURES d in d a> N . 0) •—I Sh P4 C/3 0) a o "1-4 a o o FRACTrRK- OF TIIK KHMTR _'o Fig. 23 Showing CombinaTion Leg Splint Applied for Buck's Extension splint are adju>tcO)le for different sized individuals or t() all()w for padding. The gutter may he widened hy bending out the frame and the angle of inelination is ehanged easily l)y the setscrew. which locks firmly at the base. The heel of the footpiece is made large to avoid pressure, and through the slitlike openings at the foot the straps of a Buck's extension can l:)e passed to be attached to a Aveight at the foot oi the bed. See Fig. ^23.^ By means of the rings along the upper border of the splint the whole leg can be swung up by attach- Fig. 24 Showing Combination Leg Splint Applied for Hodgen's Suspension 26 FRACTURES Fig. 25 Showing One-Half of Femur Splints Nos. 67, 68, 69 Fig. 26 Showing Femur Splint Applied FRACTURES OF TIIF 1 KMIR Zi ment to a longitudinal bar built above the l)e(l. This gives an adjustable Hodgen's splint. (See Fig. 24.) For fracture of the neck of the femur this splint is used in slight angulation with or without Buck's extension and in a position of abduction. It is diffi- cult to obtain abduction unless two splints are used. Fig. 27 Anterior Patella Splints Nos. 34 and 35 One is applied to each leg, and both are fastened in place on the bed by a crossbar at the foot end, or held apart by a wooden bar notched at each extremity or with an adjustable rod which we can supply for that purpose. h. Fractures of the shaft, from just below the tro- chanters to near the knee are transverse, spiral, or com- minuted; and if the fracture is below the attachment of the psoas to the lesser trochanter, the upper frag- ment is usually flexed. Consequently the indication is to flex the thigh and apply some extension to over- come shortening. The reduction of fragments can be made and splints Nos. 67, 68, or 69 can be strapped on as coaptation splints (see Figs. 25 and 26), and then 28 FRACTURES HllflgHIII^""""''-'"^^^'^'^'^"^"^^^ Fig. 28 Posterior Patella Splints Nos. 36, 37, 38 the whole leg is placed in splint No. ^b or ^^ at the angle of elevation desired. The same modifications and use as a swinging Hodgen's splint can be used as described under ''Fractures of the Neck of the Femur." (See Fig. 24.) Large coaptation splints can also be used to help steady the leg. Femur splints Nos. 67, 68, or 69 may be used in combination with anterior patella splints Nos. 34 and 35, and posterior patella splints Nos. 36 and 38 to immobilize the thigh and knee joint. (See Figs. 27, 28, 29, and 30.) Fig. 29 Showing Anterior and Posterior Patella Splints Applied in Combination with Utility Splint No. 39, 40, or 41 FRACTURES OF THE FKMIR Splints Nos. 67, 68, or ()9 have also been used for immobilization of the chest in ril) fractures. (See Fig. 25.) The chest is lightly padded, and adhesive straps are passed around the outside of the splint, which is opened and laid on the padding. The ad- hesive should pass beyond the middle line both at the Fig. 30 Utility Splints Nos. 39, 40, 41 back and front and be anchored to the bare skin. The chest should not be completely encircled, of course. c. Fractures of the lotver end and condyles of the 30 FRACTURES femur, knee-joint fractures, and fractures of the upper end of the tibia. Those involving the lower end of the femur usually have a displacement of the lower frag- ment backward, pulled by the gastrocnemius muscle. The indication is to hold the leg in part flexion to bring the shaft and lower fragment in line. This is accom- Fig. 31 Showing Immobilization of Leg Using Splints Nos. 34, 36, and 31 plished by splints No. 65 or 66 elevated to the proper angle. Fractures into the knee-joint and the upper end of the tibia are treated in the same manner with the addition of Buck's extension to separate the joint surface, to avoid ankylosis, and correct shortening. If there is little displacement in fractures of the upper end of the tibia, they can be treated in flat extension with or without Buck's in this same splint. If desired, Nos. 34 and 35 can be used anteriorly to help main- tain position. FRACTURES OF THE HONKS OF IIIF FKO ;U FRACTURES OF THE PATEELA This bone is usually pulled apart by muscular action, which also tears the joint capsule. The upper frag- ment is pulled up by the quadriceps extensor and the lower fragment is held by the patellar ligament at- tached to the tibia. There is consequently separation of greater or less extent, and the indications are to cause the distention of the joint to subside and to bring the fragments into apposition. This can only be done by holding the leg in complete extension. Splints Nos. 34 and 35, combined with No. 36 or 38, do this, and act as a comfortable support until the patient is transported for operation. (See Fig. 29.) Fig. 32 Anterior Tibia and Fibula Splints Nos. 29, 30, 64 FRACTURES OF THE BONE OF THE LEG a. One or both bones in their shafts (knee-joint fractures are discussed under the femur). Shaft fractures are spiral, transverse, or comminuted, and the fibula is usually broken higher up than the tibia. 32 FRACTURES There is shortening and generally an angular dis- placement, especially in the spiral type. The indica- tion is to overcome the shortening by traction and reduce the angular displacement at the site of fracture by pressure under anaesthesia. Splint No. 31, 3'2, or 33 Fig. 33 Posterior Tibia and Fibula Splints Nos. 31, 32, 33. Used Indifferently Right or Left is used to hold the reduction, which may be used in combination with splint No. 29, 30, or 64. In some cases of nervous or alcoholic patients it is wise to combine also No. 34 or 35 and No. 36 or 38 with them. Coaptation splints over a badly displaced fibula or a persistent deformity in the tibia are also a good combination. (See Figs. 31 and 32.) b. Fractures at the loiver end, the two malleoli, and Pott's fracture. When both bones are broken above the ankle, the axis of the leg must be perfected and the foot held at a right angle to the leg and in alignment with its long axis regardless of the displacement after FRACTURES OF THE BONES OF THE LE(. :v.\ Fig. 34 Pott's Fracture Splints Nos. 79, 80, 81, 82. Used Indifferently Right or Left 34 FRACTURES Fig. 35 Showing Pott's Fracture Splint Applied (Notice Flexible Hinge at Ankle) the break. This is accomphshed by sphnt No. 31, 32, or 33, alone or in combination with anterior tibia and fibula splint No. 29, 30, or 64. (See Figs. 32 and 33.) The Pott's fracture splint, which is adjust- able, can also be used. For fractures of the malleoli, internal or external malleolus, both malleoli. Pott's fracture, the Pott's fracture splint No. 79, 80, 81, and 82 have been devised. (See Fig. 34.) FRACTURES OF THE BONES OF THE LE(i ')•) Fractures of the internal malleolus alone call for immobilization of the foot in a line with the long axis of the leg and at right angles. Posterior displacement should be guarded against by padding the heel well forward. These fractures are rare. Fig. 36 Showing Pott's Fracture Splint Applied Fractures of the external malleolus alone, with or without slight injury of the internal malleolus and rupture of the internal lateral ligaments, is what is understood by the term "Pott's fracture." In this the foot is usually displaced outward by the twist, and the astragalus is pushed outward. Posterior 36 FRACTURES displacement also may be present. The indication is to bring the foot well forward and swing it inward by pressing against the internal malleolus until the astrag- alus is shoved back into position beneath the tibia. (See Figs. 35 and 36.) The foot is thus inverted and Fig. 37 Pott's Fracture Splint Applied adducted; it must also be held at right angles to the long leg axis. This adjustable splint No. 79, 80, 81, or 8^2, fastened to the leg above, is swung into the position desired and the thumb-nuts, which main- tain the position of overcorrection in adduction, are tightened. This should be left on four weeks, with removal for massage. No weight is borne for from six to eight weeks. For fractures of both malleoli the indications for treatment depend on the displacement. If there is much posterior displacement, it must be corrected by padding the foot well forward. Lateral displace- ment of the foot is also corrected by manipulation. FRACTURES OF THE JAW HONE .>/ Fig. 38 Maxilla Splints Nos. 27 and 28 Fig. 39 Showing Maxilla Splint Applied 38 FRACTURES and the foot is usually placed in a position of slight abduction by tightening the thumb -nuts when the position is secured. If it is desired, the footpiece can be changed to hold the foot in slight plantar or dorsal extension. x\ bandage may be applied over all, or if the splint is left open there is room for the application of an ice bag. For ankle and foot fractures the Pott's splint No. 79, 80, 81, or 82 is the best, as it permits the foot to be held in any desired position of flexion, extension, abduction, or adduction after reduction is finished. (See Fig. 37.) The Pott's fracture splint for children is also avail- able for permanent dressing to hold club-foot in chil- dren after reduction by manipulation or tenotomy. The lightness and cleanliness of this splint, together with its durability and ease of adjustment to any desired angle, make it a favorite for club-foot. AS A POST-OPERATIVE DRESSING Any combination of the previously described splints can be used after open operation for the application of Lane plates or bone-splints. The wire mesh per- mits instantaneous inspection of the limb and short- ens and simplifies post-operative dressing. Stitches can be removed and massage administered with little trouble to the patient. DE PUY MANUFACTURING CO. CORNER MARKET AND COLUMBIA STREETS WARSAW, INDIANA R. R. DONNELLEY & SONS CO., CHICAGO COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DU^ . - C2e(n4i)Mioo D44 BDlOl ^^^U co«>forta.le and .u^-= f^DlDi t>44 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 101 D44 1915 C.1 Simple, comfortable and humane treatment 2002109646 ■i