Absorbent cotton-wool affords the most tempting padding; it should, however, he sparingly used. The writer, when in charge of the fracture cases in his house-surgeon days, discarded it entirely, owing to its liability to become lumpy and uneven, and used instead a padding of strips of good old flannel, which best answers every purpose.
Some surgeons discard all wooden and metallic splints in the treatment of most simple fractures of the leg, and at once employ an immovable plaster of Paris casing for the entire limb, made by applying over cotton wool wetted bandages previously impregnated with the dry powder. By carrying the casing above the knee the patient may be permitted to walk about in a few days; this " ambulatory method of treatment is one, however, which the inexperienced surgeon should be slow to follow. The objections to the plaster of Paris treatment are that it prevents inspection of the seat of fracture, and offers a harrier to massage and early passive movements; these difficulties may be overcome by sawing the bandage through vertically so that the casing may be easily removed and reapplied with the aid of buckles or bandages. Starch, Glue, Gum and Chalk are used in a similar manner. The best use that these immovable casings can be put to is to employ them at a later stage to replace the ordinary splints after union has been well started between the broken fragments.
It will often be necessary to apply other splints in addition to those adjusted round the broken bone with a view of securing complete rest to the joints above and below the fracture, when their movement tends to disturb the position of the fragments. Extension and counter-extension may be required in special cases. Space will not permit of any enumera tion of the various special appliances which are used in the treatment of different fractures. Those of them of any use fulfil their purpose only in as far as they carry out the simple indication of insuring rest and accurate approximation of the fragments of the broken hone while nature makes good their repair.
Of late years considerable advance has been made in the more radical fixation of the fragments by cutting down upon the site of injury and suturing them together with silver wire, or securing immovable apposition by the insertion of steel plates and screws, staples with perforated metal plates, ivory pegs, or steel pins. These methods are invaluable in many cases where time is of overwhelming importance, as they can enable the patient often with safety to attend to important duties which cannot be postponed.
Treatment by open operation is indicated in transverse fracture of the patella and fracture of the olecranon owing to the wide separation of the fragments. In the former case it will usually be sufficient to suture the soft tissues with strong chromicised catgut. This was successful in holding together a fractured patella, though the patient developed delirium tremens after the operation and succeeded in divesting himself of his splints. For fracture of the olecranon a long screw or wire loop may be used for bringing the parts together.
For fractures following gunshot wounds, where the bone shows loss of substance and non-union occurs, the gap should be made good by insertion of a bone graft usually taken from the inner surface of the tibia.
Fractures of the lower jaw may be held in position by Hammond's dental splint, by a plate applied along the lower border through a skin wound, or by a bone graft.
In the treatment of simple fractures a subject of vital importance is the duration of the time during which immobility is to be strictly maintained; 32 years ago L. Championniere pointed out that immobility was not necessary, and that more callous was thrown out if the fragments were not kept rigidly fixed in apposition by immovable splints. In the first edition of the present work written 26 rears ago the writer stated : " As a rule it may be said that the mistake is sure to be made of keeping the entire limb in a state of absolute rest long after the necessity for such has passed away, to the great retardation of recovery. most cases gentle massage, or kneading and cautious passive movements, may he commenced after the middle or end of the third week, the splints being again applied. This effectually prevents the formation of adhesions, and greatly increases the vitality of the tissues, and minimises subsequent pain and stiffness," These views were considered by many authorities at that date as hetero dox, notwithstanding the doctrine of L. Championniere, but the exhaus tive researches of Mr. W. IL Bennett and others have since demonstrated their truth, and early massage is accepted by all authorities as an important if not essential routine in the treatment of the fracture. But the pendulum in the opinion of the writer has swung too far in the direction opposite to the old malpractice, and massage and joint move ments are carried out on the first or second and subsequent days of the fracture. When there is much edema and effusion, massage certainly should be commenced at once.