or six weeks more, and in case of failure (and the chances are it would be), the operative measures would mean several more weeks. The points against the above treatment are after extension and bringing the fragments in apposition and friction it would not be advisable to apply a cast at once on account of the danger of swelling and interference with the nutrition of the parts, and by simply applying a weight, and a posterior splint until the swelling subsided your work would go for naught. There would be absolutely nothing to keep the parts from assuming their abnormal position. Even with the cast applied at once the fragments would slip, on account of the powerful muscular contractions of the Hamstring muscles, especially the inner Hamstring on account of its attachment to the tibia, together with the muscles of the anterior and posterior tibio fibular regions. While thinking the cast over and the choice between wiring or using the ivory or steel pins, the idea of using a screw was suggested to me by Dr. M. M. Johnson. Acting on this suggestion, and with the approval of the staff, the young man was operated on September 30th, (the sixth day after entering the hospital), and six weeks after the accident. The patient was prepared by shaving the entire leg and applying a green soap poultice the night before, followed by scrubbing and a bi-chloride dressing in the morning. At 11 A.M. the patient was etherized and placed on the operating table. The parts were rubbed briskly to set up irritation and stimulate union. A large shoe having a steel sole with hook attached was placed on the injured leg. A perineal strap was attached to the hook in the shoe running through a ring in the opposite wall. Gentle and steady traction was made until the fragments were in apposition as near as possible to their normal position. An incision was then made about one and one- half inches in length down to the tibia, about the middle of the fracture. The bone was denuded of peritoneum, and the drill was then inserted, using the large drill, first, corresponding with the smooth part of the screw. After boring through the upper fragment the small drill was used, for the lower fragment, corresponding with the thread on the screw. The upper fragment was then counter-sunk to allow the head of the screw to drop a little below the bone. The screw, an ordinary wrought iron screw, 11⁄2 inches in length and 3-16 inches in diameter, silver plated, was placed in a position with a screw driver. The wound was closed with silk-worm gut and plain aseptic dressing used. The leg was placed in a posterior splint, with a tenpound weight attached, for ten days. At the expiration of that time, when the swelling subsided, a plaster cast the whole length of the leg was applied, and in two weeks the patient was allowed to get about on crutches. The stitches were removed before applying the plaster cast, and the wound had healed by primary union. The advantage of using a screw instead of wiring was, in this case, great. First, simplicity and an almost bloodless operation, secured less danger of infection. The advantage over steel or ivory pins is that steel pins are allowed to remain in position until union has taken place, then removed, thus leaving an open wound and danger of infection. The ivory pins are not removed after being placed in position. But here again the screw has the advantage, for in driving the pin you may separate the fragments, and if the parts are brought in apposition, the pins, being smooth, will allow slipping, and separation of the fracture. The idea of using the smaller drill for the under fragment, is to allow the thread of the screw to catch and draw the fragment up, and when once inserted properly, there is no slipping or separating. The only surgery in which I find this method described is "Wharton and Curtis." I am indebted to my colleagues, Dr. Joseph E. Root and Dr. M. M. Johnson, for their valuable assistance, also to Dr. A. J. Wolff, for taking the "X-Rays," and developing the photographs. On November 9th, the patient left the hospital with good union, and has been for some time working at his trade, that of spinner. The left leg, the injured one, is about one-fourth of an inch shorter than the right leg, which necessitates a lift on the heel, and thus he walks with an almost imperceptable lameness. |