NOTES ON MANAGEMENT OF FRACTURES OF THE LOWER EXTREMITY WITH HODGEN'S SPLINT, WITH REPORT OF CASES

W. T. ADAMS, M. D.

Elgin

It is my purpose to discuss the use of Hodgen's splint with a modification of Buck's extension, in the management of fractures of the lower extremity, particularly with reference to fractures of the femur, with a special view as to technique, believing as I do that the splint would be used more frequently than it is if the technique were better understood, and the wide range of application appreciated.

In selecting a dressing for a fracture, there are two considerations paramount to all others; first, to secure the member so that there is perfect coaptation of the fragments and hold them in perfect alignment; second, to secure the greatest amount of comfort for the patient. Another important consideration is an apparatus that is always easily obtainable, readily applied, and that will require the least amount of care afterward.

To my mind the splint under consideration meets these requirements better than anything yet devised, and while it is mentioned in many of the works on surgery, a definite technique is not clearly set forth in any of them. It is to that end, therefore, that I invite your attention, while I give the technique I am in the habit of using, hoping that it is sufficiently near the original to justify the name, Hodgen's splint.

The splint consists of a frame made preferably of quarter inch round iron. For a patient who measures five feet ten inches in height, the inner bar should measure thirty-seven, and the outer bar forty-two, inches in length. Join the

lower ends with a cross-bar four and a half inches long, so that the ends are even. Join the upper ends with an oblique, over-arching bar, and join the middle of the long bars with another over-arching bar, at a point about fifteen inches from the upper end of the inner bar. The arched bars should arch upward six inches. The distance between the long bars is easily adjusted by bending the arched bars, and should be wide enough apart to allow a space of an inch or inch and a half on both sides of the limb when applied. All joints between the different parts of the frame are to be securely welded, and can be made by any ordinary blacksmith.

When the frame is adjusted to the limb, the upper end of the inner bar should come in close proximity to the perineum, and of the outer bar, above the trochanter, close to the crest of the ilium, while the arched bar, which joins the same, inscribes a line corresponding with the groin. The opposite end of the frame will reach a point some six or more inches beyond the sole of the foot, which allows for the application of the extension, as will presently be seen. The length of the frame is easily altered to suit the individual case. It is better to have a frame too long than too short, as the extra length does no harm, while if the frame is too short the extension cannot be properly applied. It is desirable to arch the frame upward two or three inches, to provide for more or less flexion of the knee.

The splint, which, when adjusted, hangs anteriorly to the limb, and gives it the name "anterior splint," is now to be provided with a bottom or bed upon which the limb rests. This is best accomplished for simple fractures by sewing a piece of cloth, preferably a good firm piece of stockinet, securely across the frame from bar to bar, thus forming a basket in which the limb rests. Care should be taken in every instance to have this covering or "basket" extend well up to the upper end of both side bars, so that good support is given to the trochanteric region and hipjoint. This is of the utmost importance in dressing hipjoint and other fractures in the upper region of the femur.

In preparing the splint for compound fractures, it is better to construct the bottom or "basket" with strips of strong muslin, or, preferably, of bleached cotton flannel, about three inches wide, sewed securely to the inner bar, while the fastening to the outer bar is best made with pins. This allows the opening of the dressings at any given point, without disturbing the limb. It is well to adjust the "basket" so that, when the limb is resting in it, it will sink about onethird to one-half of its depth below the side bars. This makes it convenient to add such padding to the sides of the limb as may be required to secure its fixation. It is well to provide the basket with a long pad of cotton loosely wrapped in gauze, extending the whole length of the splint for the limb to rest upon.

SUSPENDING THE SPLINT-Locate the patient's bed as pleasantly as possible, with the head of the bed far enough from the wall to allow it to be moved back and forth, lengthwise, about two feet. A pulley is now screwed into the ceiling directly over the patient's ankle and provided with a soft flexible rope or sash-cord, eight or ten feet long, with an iron ring, an inch and a half or two inches in diameter, securely tied to one end of it. To this ring hang the splint with two pieces of muslin bandage rather more than a yard long by passing them through the ring, then securely tying both ends of one piece to one bar, and of the other to the other bar of the splint, at points about midway of the patient's thigh, and midway between the knee and ankle, respectively. The splint is now suspended by making traction upon the rope, raising it just high enough to clear the bed, then the free end of the rope should be securely fastened to the bedstead. The pieces of muslin passing through the ring, allow the limb to seek its most comfortable position, and a certain freedom of motion, without being detrimenta! to the fracture.

The amount of extension is increased or diminished at will by pushing the bed farther under or away from the pulley. If considerable extension is required, it is well to elevate the foot of the bed three or four inches, and a foot rest

is required to enable the patient to keep up in bed. The foot board of the bed should be low enough to allow the splint to project over it.

TO APPLY THE SPLINT.-Apply strips of plaster to the limb in the same manner as for Buck's extension, using preferably, zinc oxide rubber adhesive plaster, as it will not excoriate, taking care to extend the plaster as far up the limb as the seat of fracture, so as to distribute the pressure as widely as possible, to relieve the knee-joint from strain and subsequent tenderness, and extend it eight or ten inches beyond the sole of the foot. A muslin or gauze roller should now be applied so as to support the plaster its entire length as far down the limb as the malleoli. From this point the plaster should not be included in the roller, but left free. The limb is now placed in the splint with the upper end of the inner bar close to the perineum, and the free ends of the plaster are to be securely fastened to the cross bar, as widely apart as possible, to prevent pressure on the malleoli. Extension may now be applied as directed, and any further padding or adjusting required, may be added.

The amount of extension to be applied must be determined by the operator in each case, and should be just enough to secure the proper length and adjustment of the limb. It is my belief that that object is gained better by the lifting and oblique pull with this splint, and with less fatigue to the patient than by any other form of dressing. The point must not be lost sight of that the extension is applied by the obliquity of the rope, and is increased or diminished by increasing or diminishing the obliquity by pushing the bed forward or backward under the pully, and the extension is transmitted to the limb by the strips of plaster fastened to the foot of the splint.

I know of no form of fracture, simple or compound, of the lower extremity, that may not be safely and comfortably cared for with this splint. The operator has perfect control of the limb all the while and can inspect any and all parts of it at any time without disturbing the patient, and once well applied it is less likely to be misplaced by the patient than

most other forms of dressings; besides it gives the patient more freedom of motion about the bed than most other dressings. To this dressing may be added any amount of padding and adjusting splints desired in special cases, and permit me to suggest right here that the old-fashioned many tailed bandage is one of the greatest conveniences there is in managing compound fractures, especially with this splint. There is no fracture box that possesses any advantages over this splint, and while I would not advocate it as strongly for fractures below the knee as above, yet I know of no dressing that excels it for any fracture of the lower extremity.

Another point I will suggest is the amount of bodily exercise the patient may enjoy with this splint, which obviously carries him through the ordeal in better shape, and enables him to use his limb more readily when released from the dressings, than other forms of dressings that confine him more closely. Most patients can be bolstered up a good deal every day, without injury to the fracture.

CASE I-Q, 72 years of age, stepped out of the door on ice, slipped and fell heavily, striking squarely on his right hip, sustaining an impacted fracture of the neck of the femur. Dressed the limb with Hodgen's splint, in which it was retained for about seven weeks, when the patient was allowed to be up on crutches, and at the end of three months from the date of injury, he was able to go about with the aid of a cane, and in a short time could get about nearly as well as before the injury.

CASE 2. D——, laborer, 35 years of age, fell from a barn loft, a distance of fifteen feet, striking upon his right side on a plank floor, sustained a fracture through the trochanter. His injury aside from the fracture was considerable, and he suffered severely from shock. He was placed in bed and his leg dressed with Hodgen's splint. He made a good recovery and was allowed to be around on crutches at the end of seven weeks. The fracture was firmly united and has given no further trouble. He is lame and his leg is very much shortened as the result of a previous fracture.