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Fractures of the Thigh-bone.Fractures at the first-named part of the bone - which is called the neck of the thigh-bone - most frequently occur in old people, as a result of a fall upon the hip, though they may also result from a fall upon the feet. Fractures at the lower part of the bone are usually the consequence of direct violence, such as the passage of a wagon-wheel over the thigh or the fall of a heavy weight upon it. Fractures of the thigh-bone are usually oblique, so that one end of the broken bone rides over the other. The muscles attached to this bone are very powerful, and as a result of these two factors, the fracture is almost invariably accompanied with a great deal of shortening of the thigh. Signs. - The signs of a fracture of the thigh anywhere below the neck of the bone, are usually so clear that the conditon is recognized without difficulty. There is great pain and swelling in the thigh ; the limb is often bent at some point, and it may even be possible to execute such movements with the lower part of the thigh as would indicate the presence of a joint between the knee and the hip. We can also distinguish a grating between the ends of the bone ; the thigh is shortened sometimes one or two inches. A characteristic sign of a fracture of the thigh, is the position of the foot, the toes being turned outward away from the other leg. Fracture of the thigh is usually accompanied by severe and extensive injury to the flesh; this may have resulted from the violence which caused the fracture, or may be the result of laceration by the broken ends of the bone, which are usually sharp. Sometimes dangerous hemorrhage results from injury to large blood vessels ; in other cases the laceration of the flesh is so great as to require amputation. If a fracture be simple, that is, if there be no wound of the flesh communicating through the skin, the parts usually heal without difficulty ; the fracture involves no danger to life. In many cases the thigh never recovers its former strength, and sometimes breaks again at the same spot upon the infliction of much less violence than before. It is necessary to keep the dressing applied for two months after the injury, and the weight of the body should not be borne upon the limb for another month. A complication of fracture of the thigh is stiffness of the knee ; this results simply from the enforced inactivity of the knee during the time when the dressing was applied. This stiffness can usually be relieved to a great extent, though in some cases motion is never fully recovered in the joint. Treatment.-A fracture of the thigh is one of the most difficult to treat satisfactorily. There are several difficulties which are met with nowhere else in the body. First, the muscles of the thigh are so powerful that it is a matter of great difficulty to overcome their contraction sufficiently to keep the broken ends in position ; second, the limb is so large and heavy that especial dressings are required in order to hold it in place. The ends of the fragment are oblique, so that the broken surfaces are large and slow to heal. The dressing must therefore fulfill several conditions : First, it must be applied to the limb in such a position that the muscles are relaxed and do not pull the fragments out of place ; second, it must overcome the tendency of the fragments to override each other, a tendency occasioned by muscular contraction, as well as by the weight of the limb. In the treatment of fracture of the thigh a most important item is the effort to avoid shortening of the limb. This effort is rarely entirely successful, since the difficulties in the treatment are so great that they cannot be always overcome by any dressing at present employed. By careful treatment, however, we can diminish the amount of shortening to a minimum. In order to avoid shortening of the limb, it is necessary that the length of the leg be measured every few days after the dressing is applied. This is a delicate process, which must be done with much care and accuracy in order to avoid erroneous results. The length of the limb is to be ascertaine'd in the following way : The person should be bared as far as the waist, or at least the outside of the thighs and legs is to be uncovered. The patient lies upon a hard bed, care being taken that the legs lie parallel and exactly in a line with the body. A tape measure, which must be inelastic, is employed for the measurement; one end of this is to be pressed firmly against the sharp corner of the hip-bone at the front of the body. The tape is then unrolled down the leg and pressed firmly against the bony prominence of the ankle, either on the outside or on the inside. Extreme care must be taken, in securing the comparative length of the two limbs, that the tape is pressed upon exactly corresponding points on the two sides of the body. After measuring in this way, it will be well to repeat the measurement, starting from the navel as the upper point. The inaccuracy of these measurements will readily be shown if we repeat them a few times between the same points on the same individual; it will be found that no two measurements of the same distance will exactly coincide. The fractured limb should be so dressed that its length as it lies in the splint equals at least that of the sound limb. When healing occurs, there will usually be some shortening ; this will not matter if it do not exceed half or three-quarters of an inch, since the difference will not necessarily cause any limping. In fact the two legs of the same individual are rarely of the same length. The choice of a splint for dressing a fractured thigh depends upon circumstances as well as upon the individual preference of the surgeon. It would be out of place in this work even to enumerate all the different varieties of splints which have been recommended and are used for the treatment of this fracture. It will be sufficient to mention briefly three varieties, which will be found to answer the requirements of all cases and to afford the best results. The first of these consists essentially of a double inclined plane. This is made by joining two pieces of board at their ends at an angle of about 90 degrees. The pieces must be sufficiently broad to support the thigh and the leg. This is carefully padded with cotton, and the leg is placed upon it so that the angle formed by the two pieces rests under the knee. The patient's bed is raised at the foot so that the weight of the body cends to draw the upper fragment away from the rest of the limb. The leg is bound to this splint with bandages, and the splint itself should be fastened to the foot of the bed so that it will not follow the movement of the trunk. Another method consists essentially of the following appa ratus : Long adhesive straps are placed one on either side of the limb, from the point of the fracture down to the ankle ; they project then several inches beyond the sole of the foot. These adhesive straps are held in position by a bandage firmly applied about the limb from the ankle up to the seat of the fracture; a piece of wood the center of which is perforated by a single opening is then fastened to the ends of the straps projecting beyond the foot, so that the wood lies parallel with the sole of the foot. A piece of clothesline or stout cord is then ' knotted at one end and passed through the hole in the center of this block. This rope is then passed over a " standard," that is a block of wood fastened to the foot of the bed and supporting a small pulley which should be at the level of the ankle. To the end of the rope which is passed over the pulley and hangs at the foot of the bed a weight is attached sufficiently heavy to pull the lower fragment of the thigh-bone from the upper. If the patient be a robust adult, two bricks will usually be necessary to accomplish this ; if the patient be a child a year old, a weight of one pound will usually answer ; a half-pound should be added for each additional year of the child's age. In every case it will be better to regulate the weight by the effect produced upon the thigh than by any rule. In applying the strips of adhesive plaster along the side of the leg care should be taken to pad with cotton the bony prominences at the ankle ; otherwis'e the skin will become raw and sore. The bed upon which the patient lies should be inclined, the foot of the bed being raised ; in this way the weight of the body tends to keep the upper fragment of the thigh-bone pulled away from the lower fragment, which is meanwhile drawn in the opposite direction by the weights attached to the rope. A modification of the same principle consists in 'a so-called " side splint." This consists of a piece of board, siding or similar light stuff, long enough to reach from a point above the hip-bone to another point several inches below the sole of the foot. It should be about three inches wide, or may be made to taper so as to be broader above where it is to lie in contact with the thigh and trunk. This splint is well padded with cotton, especially at the edges. It is then to be applied to the outer side of the limb, the upper end extending above the hip-bone. It may be fastened to the limb either by a roller bandage, which is applied from the toes up to the body or by strips of adhesive plaster, which are placed around the leg and the splint at intervals of five or six inches. It is advisable to employ both of these measures, the strips of plaster being applied first and the bandage put on afterward. Some surgeons modify the procedure by using a weight in connection with this side splint. Two strips of adhesive plaster are applied one on the inside the other on the outside of the leg, as high as the knee. These strips are fastened to the leg by means of a bandage. A block is placed between the strips, below the sole of the foot, in the way already described. To this a weight is attached and carried over a pulley in a standard. The side splint is then applied in the way just described. In using this side splint care must be taken to " set" the bone before the bandages are applied, for the fragments are kept apart by the pressure of the bandage which holds the limb against the splint. The bone is set by two persons, one of whom grasps the thigh at the groin, so as to pull the body toward the head of the bed; the other, meanwhile, seizes the ankle or the knee and draws the lower fragment downward toward the foot of the bed. The splint should be bandaged to the leg wThile the limb is thus held. This dressing is not so satisfactory as the preceding, if the patient be robust and muscular, for it will be impossible to maintain the broken ends of the bone in their proper position, and considerable shortening will result. In dressing fractures of the thigh in children, a special splint is used. This consists of two pieces extending up the leg with a cross-piece between the ends below the foot. Strips of plaster are applied to the sides of the leg as before, and the rope which runs through the block under the sole of the foot is fastened to the cross-piece of the splint. This in turn is supplied with a piece of clothes-line and a weight, the latter being suspended over a pulley and standard. The object of this dressing' is to keep the limb perfectly quiet, an object which cannot be otherwise attained in treating restless children. Indeed, surgeons sometimes employ a splint of this kind in which the cross-piece is so long that both legs of the child lie between the side-splints, and can be attached to the dressing so that movement in the bed is impossible. The disadvantage in all these methods is, that the patient is compelled to keep his bed for five or six weeks, and is not permitted any freedom of movement even in the bed. The condition becomes extremely monotonous and even painful ; the result is that the dressing must be loosened and changed so often that the fragments of the broken bone are not retained in position and the limb heals with considerable shortening. Several splints have been devised which obviate, to a greater or fesser extent, the necessity for perfect quiet on the part of the patient. One of these, which is now in general use in our large hospitals, is the invention of Dr. Smith, of New York. It consists of an iron frame, which can be made either of small gas-pipe or of solid iron rod half an inch in diameter. This is bent so that one piece lies on either side of the limb, being joined to its fellow by a cross-piece just below the foot. The inner rod extends up to the body on the inside of the thigh, while the outer one is made long enough to reach the top of the hip-bone. The two side-pieces are bent at an angle of about 150 degrees at the point where the knee is to rest. Such a splint can readily be made by a blacksmith. Strips of bandage are then pinned across from side to side of this splint, in such a way as to allow the limb to rest easily upon them. Two broad strips of adhesive plaster are then applied to the sides of the leg, which is then bandaged in the usual way. The block of wood attached to the lower end of these strips is fastened tightly to the cross-piece of the iron splint. The splint is then to be suspended by a rope, which passes through a pulley in the ceiling, so that this rope shall pull the splint toward the foot of the bed. This part of the bed is elevated by placing bricks under the feet, and the rope, which passes over the pulley, is tightened so as to draw the limb toward the foot of the bed. In this way the broken ends of the bone are drawn apart and kept separate, since the weight of the body keeps a constant traction on the upper fragment. The advantages of this splint are several : the patient is permitted considerable movement in the bed and can thus avoid the monotony and annoyance inseparable from the other splints already described. The limb, moreover, is kept above the bed and can be more readily inspected and adjusted as occasion requires. It would be advantageous to make a splint which would permit the patient to be up instead of lying flat upon his back. An attempt has been made to secure such a dressing by the application of plaster of Paris bandages. Experience has shown, however, that such a bandage is inefficient in holding the fragments apart if the limbs be large and muscular ; since in this case the bandage does not secure sufficient hold upon the flesh to overcome the contraction of the powerful muscles of the thigh. Furthermore, the limb always decreases somewhat in size from disuse ; hence a bandage which fits perfectly when first applied soon becomes so large that it fails to grip the leg as tightly as the requirements of the case demand. A plaster of Paris bandage, therefore, cannot be recommended for the first dressing, but it is often useful after two weeks have elapsed, by which time the fragments have united firmly enough to retain their proper position if the limb be kept quiet. A plaster of Paris bandage answers the requirements, since when it is applied the patient is unable to exert the muscles of the thigh, and hence cannot displace the fragments ; yet he can rise from his bed and remain up the entire day, thus avoiding in part at least the dreariness of his enforced confinement. We can, therefore, in many cases remove the splint which has been originally applied, between two and three weeks after the accident, and replace it by a plaster of Paris dressing. The mode of application of this dressing is thus described by the late Dr. Hodgen, the eminent surgeon, of St. Louis : " The first point is to secure a thorough extension of the limb while the plaster is being put on and is hardening. If the lower fragment can in some way be drawn down and held there while the plaster sets, the limb will then be incased firmly, and the patient may sit up and move about upon crutches without disturbing it. To secure this extension, prepare an ordinary table by boring through its end a hole two inches in diameter, through which a bar may pass, extending two feet above the surface of the table, reaching the floor below and made fast to a cross-piece between the legs. From the top of this bar another one passes to the other end of the table and rests on a bar like the first, or upon a box or other support. One or two hours before the main dressing is applied, a plaster of Paris bandage should be put on the foot and leg up to the calf, the surface of the foot and leg being first covered with cotton batting or soft cotton cloth, making it thicker over the ankle than above or below. When this dressing is hard a bandage can be tied around it and attached below the sole of the foot to a rope which passes through pulleys. A very strong force can thus be applied to draw the limb down without cutting or improperly compressing it. Having now the table prepared, a hard plaster splint on the foot and lower part of the leg, and bandages filled with plaster in readiness, you are prepared to apply the dressing. Place the patient upon his back on the table under the horizontal bar, with the upright bar or stanchion between his thighs pressing up by the side of the injured limb. This upright should be well covered with soft cloth, and its object is to hold back the body and upper part of the thigh against the force drawing the limb downward. Raise the hips from the table by means of a broad bandage passing beneath them and tied to the bar above. Cover the whole limb with soft flannel or a piece of woolen blanket, and fit it as neatly as possible. Then give the patient ether to relax the muscles and apply the force to the rope attached to the lower part of the leg until the leg is as long as the sound one. Having soaked the bandages (already filled with dry plaster before rolling them) two or three minutes in water, wind them on the limb smoothly but not tightly, in small successive thicknesses, sprinkling dry plaster on the surface frequently and smoothing it with the hand. " When the limb is well encased, allow the patient to remain in the same position for twenty or thirty minutes, until the plaster sets, then put him in bed and keep him there three or four days. After that he can move about on crutches. " This dressing must be carefully watched, lest it be too tight. If there is much pain, and if the toes become dark and lose their feeling, it must be cut off. If it becomes too loose a fresh one must be put on." The fact that there is such a variety of dressings employed for the treatment of fractures of the thigh, indicates the difficulty which surgeons experience in securing a healing of the bone without shortening of the limb. Indeed, it must be repeated here that some shortening of the limb must be expected. No apparatus has been devised which can be relied upon to secure a perfect result, and no experienced surgeon will ever promise to treat the fracture so as to make the broken limb as long as it was before. 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