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Setting of a Broken Bone.
First, - To restore the broken ends to their natural position.
Second.-To keep them in this position.
The first of these - the restoration of the bone to its proper position - is what is popularly known as ''setting" the bone.
The chief difficulty, both in replacing the ends of the bones and in holding them in position, lies in the resistance of the muscles of the limb. These muscles are irritated either by the original injury or by the sharp ends of the bones which project into them. As a result of this, as well as of the natural tendency of the muscles to contract, the limb is shortened. The amount of shortening varies extremely both with the strength of the muscles involved and with the obliquity of the fracture. Thus a fracture of the thigh is always followed by a considerable degree of shortening, which it is indeed very hard to overcome. A fracture of the leg is also accompanied by shortening, though this is somewhat more readily remedied. In setting the bone we must first of all remember that we have to overcome the muscular force by which the limb is rendered shorter than the other ; for if we neglect to do this, and apply the dressing without returning the limb to its proper length, the broken ends of the bone will unite in this unnatural position, and the limb will remain permanently shorter than its fellow.
To overcome this muscular contraction, we place the limb in a position in which the muscles are relaxed as much as possible. Thus if we have to treat a fracture of the forearm we bend the arm at the elbow, and usually at the wrist, so that the fingers are turned upward toward the front of the arm.
The simple position of the injured member sometimes suffices to overcome the contraction of the muscles and to restore the broken bone to something like its natural position. Yet, in most cases, it becomes necessary to employ additional means to accomplish this object by pulling the lower fragment away from the upper. This must be done with care and yet with considerable force. One person should grasp the limb firmly below the point of injury, while another seizes it above this point. Care should be taken that the upper fragment is grasped below the next joint above the wound. Thus if the leg be broken five or six inches from the ankle, one person should grasp the calf, not the thigh; for if a joint be allowed to intervene between the points which are grasped in the hands of the operators, the force which should be expended in pulling the lower fragment away from the upper, will probably do little more than stretch the ligaments of the joints and separate the surfaces of the bones. Thus if the leg be broken above the ankle, and the attempt be made to restore the position of the limb by pulling on the foot while another person holds the thigh, it is probable that although the ankle and the knee-joint may be severally stretched, the broken end of the bone will not be forced into position.
In every case, therefore, care should be taken that the force is applied directly to the two fragments of the broken bone itself and not to distant parts of the same limb. Thus in the example which we have taken for illustration (a fracture of the leg five or six inches above the ankle), one person should grasp the limb just above the ankle as well as the foot, while another should take hold of the leg just below the most prominent part of the calf.
As to the degree of force which should be employed in restoring the bone to its proper position, we can only say that this restoration must be accomplished, and that so much force must be used as is necessary to effect it. The degree of force required varies of course with the size and strength of the muscles whose contraction is to be overcome. Thus a fracture of the forearm can usually be set without the exercise of much strength, while a fracture of the thigh can be placed in position only by the most strenuous efforts.
In consequence of the difficulty which is thus experienced in overcoming the muscles of the injured limb, and of the pain which is inflicted upon the patient by this effort, surgeons usually administer ether when they have occasion to set a broken thigh, or even a broken leg. The administration of ether accomplishes two objects.
First, the patient suffers no pain during the setting of the bone.
Second and chiefly, the muscles are relaxed by the effects of the ether, so that they offer no further resistance to the surgeon's efforts in replacing the broken ends of the bone in their natural position. This measure is absolutely necessary in order to accomplish the perfect setting of a broken bone which is surrounded by large and powerful muscles.
Cases occur in which the bone retains its natural length even after a complete fracture, so that no effort is required on the part of the surgeon to lengthen the injured limb. In these cases the bone is broken square across. These instances occur most frequently in the forearm and in the leg, where the member contains two bones. If only one of these bones be broken, and the fracture be made transversely - that is, square across-the limb often remains in position, because its shape and length are preserved by the second and uninjured bone.
We may know that we have succeeded in " setting the bone " if the limb resumes its natural length and outline. In many cases we can feel, moreover, that the fragments are now in position instead of projecting one over the other as before. In order to be perfectly sure, we must measure the length of the limb and compare this with that of its sound fellow.
If the thigh be broken, a strip of stout inelastic cord or tape may be used, one end of it being placed at the navel, while the other end is carried to the outside edge of the kneepan at its middle. After this has been done on one side, the length between the navel and the corresponding point of the kneepan on the other leg should be measured. The two should coincide either exactly or within a small fraction of an inch. A certain difference - amounting in cases of fractured thigh to half an inch - may be disregarded ; first, because there is often a difference between the length of the two limbs in persons who have never suffered any fracture ; and second, because a certain amount of shortening is usually inevitable in fractures of the thigh.
In making comparative measurements of the two limbs in this way, care must be taken to avoid sundry errors into which we may readily fall. Thus it must be carefully noted that the patient's limbs lie parallel with the axis of the trunk - that is, that they form no angle with the body at the hips - for if the legs are not straight, if they happen to be inclined a little to the right or the left, the distance from the navel to the knee will, of course, be greater in one than in the other.
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