AMBULATORY SPLINTS.—We seem to have seen the crest of the wave of the "ambulatory" treatment of fractures, in which, as in all things else, there is some measure of virtue. In a certain sense every patient who walks on crutches is receiving an ambulatory treatment for his broken leg, but in that there is noth ing new, nor in the application of one of the many forms of hip-traction splints, so long used for the treatment of disease in that joint, to fractures of the femur. The novelty, the real "ambulatory" splint, is a heavy plaster-of-Paris band age splint reinforced with a ring of sev eral extra turns of the bandage just under the tuberosities of the tibia and usually strengthened by incorporated bands of iron or strips of wood in such fashion that the weight of the body is transmitted from the head of the tibia to the ground, not through the splint, the foot being elevated by a sole of cotton or wool at least two inches thick or by a steel "stir nip," which is incorporated into the plaster and upon which the patient walks. The advantages claimed for this method of treatment are that it avoids the risks of confinement in bed and shortens con valescence by lessening the atrophy of the muscles and the stiffness of the joints. On the other hand, such splints cannot be used with safety in every oblique fract ure or in fractures that allow any great mobility, and they certainly increase the danger of mobility within the splint. Moreover, some patients absolutely re fuse to "amble," and those who will walk are usually able to get as much comfort out of a light, comfortable plaster splint and a pair of crutches as they can from such a cumbersome appliance. That they cannot get out of bed sooner than with crutches is evident, and that the convalescence is shortened by walking on the ambulatory splint does not seem to have been absolutely proved; yet in some cases they may prove very satisfactory.
TRACTION.—Continuous traction must sometimes be combined with immobiliza tion, notably in fractures of the thigh. Elastic traction involving complicated apparatus and exercising an indefinite force has been superseded by the weight and pulley. As the various apparatus are designed only for fractures of the femur, they will be described under that title.
—Very rarely nec essary or advisable except in compound fractures, in fractures of the patella (and possibly of the olecranon), and in cases of delayed union. Of course, if, for any other reason, such as the removal of a fragment, it is desirable to cut down the seat of fracture, it is but discreet to throw a few supporting sutures about the bone ends to insure their more accurate appo sition. In so doing the one important
caution to be borne in mind is that any bone transfixed or constricted by a me tallic peg, plate, or suture is liable to become necrotic. Consequently some ab sorbable gut or silk is the only form of suture material that may be used with safety. And, as a matter of experience, it may be added that periosteal sutures of stout catgut seem to last long enough to fulfill every requirement. It is true, however, that wire sutures may be used if their ends are left long, so that they may be untwisted and extracted at the end of ten days or two weeks.
the first week massage hastens the disappearance of the swell ing, and if used during the whole con valescence notably lessens the subsequent stiffness and atrophy (Lucas-Champion niere), but the expense of such treatment as well as the danger of disturbing the fragments nullifies these slight advan tages in most cases.
—Dur ing the early stages of convalescence the joints should be immobilized and sub jected to massage and elastic compression if they show any marked inflammatory reaction. Later, when the acute stage has passed they may be subjected to sys tematic passive motion, the massage and pressure being continued. Passive mo tion should never be insisted on, how ever, as long as its use causes persistent pain or increases the stiffness. Indeed, ordinary use is the best form of exercise. Forced passive motion (brisement force), with or without anaesthesia, should never be attempted, for it is sure to be detri mental, unless the obstruction is a single slight band whose rupture would not be followed by any great reaction: a rela tively rare condition. If gentle passive motion prove ineffectual, the joint may be subjected to dry heat (300° F.); and, this means also failing, if greater mo bility is absolutely essential, recourse may be had to open arthrotomy tiaith systematic division of adhesions or the removal of any obstructing callus. In addition be it noted that in the larger joints stiffness rarely persists, but in the smaller ones it may be permanent. This is notably the case with the extended fingers. Fingers should always be im mobilized in the fixed position, and pas sive motion on them never postponed beyond the end of the second week.