When the body and sound leg are firmly bandaged to the side-splint and the back is flat upon the bed, the diseased limb will assume a position either of ab duction or adduction, combined with rated position by pillows or by two boards hinged at one end and supplied with a prop, so as to make an inclined plane which can be raised or depressed accord ing to the needs of the patient. If there is great tenderness behind the trochanter, a blister may be applied with great benefit.
In cases of ostitis of the trochanter with marked tenderness, relief can fre quently be obtained by plunging the sharp point of Paquelin's cautery deep into the bone, the skin over the tro flexion, and in this position, whatever it may be, the line of traction must be made, and it must be made sufficiently great to give the patient freedom from pain. If traction, so applied, fails to relieve pain, and the position is that of adduction, a second line of traction may be made by passing a well-padded band around the thigh, close to the groin, and making traction outward at right angles to the long axis of the femur, over a pulley fastened to the side of the bed. The leg must be supported in its ele chanter having been injected with a drop or two of a 4-per-cent. solution of co caine. In exceptional cases there may be an effusion in the joint of so great extent as to make aspiration advisable, but this is unusual. If the synovitis be comes purulent the joint must be incised and washed out with Thiersch or Labar raque solution. The line of traction is to be changed little by little every few days, as the spasm of the muscles sub sides, until the leg is gradually brought parallel to its fellow and flat in bed, without disturbing the position of the trunk and the sound leg. When the legs can be made parallel and rest on the bed without tilting the pelvis, a splint may be applied. In some cases the disease will have advanced so far at the time of first observation that adhesions will have formed around the joint too strong to permit reduction of the deformity in this manner. And in such cases, where faithful trial of this method of reducing the deformity fails to give results, the patient should be anesthetized and the joint forcibly straightened. If, at this time, it is found that there is so much contraction of the rectos muscle or the adductors as to prevent reduction of the deformity, except at the expense of vio lently crowding the head of the femur into the acetabulum, free section of the contractured tissues should be made.be fore reduction is attempted. The joint should then be immobilized either with a splint or with a plaster-of-Paris dress ing extending from the ankle to the thorax, while weight-and-pulley traction is again resumed. If plaster of Paris is employed, it should be reinforced at the groin by a strip of iron to prevent crack ling. When the deformity has been overcome and the joint is free from ac tive inflammation, the patient may be allowed to rise when supplied with a suit able apparatus.
The object of the hip-splints now in use is twofold: First, to enable the pa tient to walk about easily without bear ing weight upon the diseased joint, and, second, to prevent the joint from receiv ing the traumatism consequent upon or dinary motion. If the patient is very large and fat or the joint extremely sen sitive, it will be found wise to use a pair of crutches in addition to the hip-splint, as the joint in this manner will be better protected and the patient freed from the galling sometimes occasioned by the pressure of the perineal straps in very heavy and fat patients. In the great majority of cases the apparatus most suitable for protecting the joint consists of a pelvis-belt with a bar running down the outer side of the leg to a point a couple of inches below the sole of the foot, where it joins a cross-bar, to which are attached two straps which serve to fasten the instrument to the buckles on the adhesive plaster. By means of a
ratchet and key on the foot-piece which is attached to a notched bar sliding in side of the main bar, which is hollow, the splint may be made longer or shorter.
Just above the knee a metal horseshoe shaped collar holds the thigh in position. Two straps pass from the front of the pelvis-belt to the rear, between the legs, and serve to hold the pelvis-belt in posi tion. The buckles to which these straps are attached should be near together in the front, to avoid pressure on the fem oral vessels, and widely separated at the back in order that the pressure may come under the tuberosity of each ischium. An elastic strap runs from the middle of the back bar of the pelvis-belt to the side-rod to prevent the pelvis-belt from tipping up too far in the back. When applied the pelvis-belt is to be fastened sufficiently firm by the perineal straps to prevent it from rising higher than the anterior superior spines of the ilia, while the foot-piece is buckled to the exten sion-straps, leaving two and a half to three inches between the sole of the foot and the top of the foot-piece. By means of the rachet and key extension is then made until the patient is comfortable. As the splint projects below the level of the foot, an extra sole and heel must be added to the shoe of the opposite side, which should usually be about four inches high, and the splint should be so regulated that, when the proper amount of traction is made, the patient being upright, the length of the splint and the length of the sound leg with the high shoe will be the same. The splint should be sufficiently long to prevent the patient from touching the foot to the floor, and, if the elevation on the oppo site shoe is not high enough to compen sate for this elongation, walking will be very uncomfortable. In the majority of cases a splint of this kind gives adequate protection and results in excellent cures. But if it is found that the parents do not fully understand the home management of the apparatus, or if the patient lives at a distance, so that it is seen at infre quent intervals, it may be wise to add to the splint a thorax-belt, which is joined to the pelvis-belt by means of a rod continuous with that passing down the side of the leg. This form of splint prevents the occurrence of flexion after the patient is allowed to walk, which sometimes takes place with the other splint if improperly applied, but it has the disadvantage of limiting the motions of the patient very materially, and being much more cumbersome. With the pa tients, however, who live at a distance, and where home co-operation is not in telligent, it is wise to employ it. The mistake must not be made of placing a joint in the bar that runs from the foot to the thorax-belt, as this will render the apparatus worthless. In some cases, also, instead of the perineal bands, it may be better to use a ring, as suggested by Dr. A. M. Phelps, for the latter cannot be tampered with by careless attendants, and, if it is fitted to the limb with proper care and sufficiently well padded, can be used with a fair degree of comfort. In adult cases where dependence can be placed upon intelligent co-operation of the patient, the use of the short traction splint and crutches may be advisable. In this form of splint the side-rod ter minates at the knee-joint and is joined to a pair of hoop-shaped metal bars, which pass across the front of the femur and arc supplied with two jaws on each side of the knee just above the condyles. Adhesive plasters are fastened to the thigh, terminating in broad, webbing bands, which are reversed over the jaws of the splint and fastened to buckles. By means of a rachet and key traction on the joint is made in the same manner as in the case of the long splint.