A CASE OF VOLKMANN'S ISCHEMIC CONTRACTURE
Journal of the American Medical Association
The disposal of individual cases may well be left with the instructor, but the proposition as a whole should be discouraged. Occasionally a case may arise in which a special line of work may be undertaken without previous study of the protozoa; but in most instances the student*quickly discovers his weakness and applies to the instructor for aid. Such aid, of necessity, involves a course.of special instruction which it is not practicable to give outside of the regular courses. With the protozoa
... . With the protozoa it is scarcely possible for a student to obtain the best results from a study of one particular species or order without a knowledge of the group of protozoa as a whole. In the foregoing I have tried to outline a scheme for instruction in protozoology to medical students. To "ne who is not particularly conversant with the subject, the program may sound exceedingly formidable and unnecessarily detailed ; but from my experience in teaching not only Americans, but Filipinos as well, I have found it not too hard for any of them. Indeed, the scope of the work I have outlined is really no broader than the usual course in bacteriology, and it seems to me to be fully as important. After all, the protozoologist must be largely self-developed, and must build up on such a foundation as I have outlined. But a small proportion of students so trained take up protozoology as a specialty. That, in fact, is not the end sought. The endeavor rather is either to fit the men for more advanced medical and sanitary work, or to give such of them as fancy it the foundation on which they may, by their own efforts, become specialists in that group which to me is formed of the most' fascinating members of the animal kingdom the protozoa. NEW YORK This case serves to emphasize the danger of improper or indifferent application of plaster-of-Paris bandages, and the value of early treatment of the deformity following prolonged ischemia. REPORT OF CASE W. H., boy, aged 8 years, fell, Aug. 14, 1915, and injured his left forearm. A physician found a fracture of the forearm, and applied a plaster-of-Paris dressing extending from the elbow to the fingers and completely including them. According to the mother's story, the only protection to the limb under the plaster was a single layer of ordinary gauze. No cotton or other similar material was placed between the fingers, which were entirely hidden from observation. The plaster was left on three weeks. During this time the boy did not complain of any pain, but he could not move his fingers, which were evidently cramped together. At the end of three weeks the physician for some unexplained reason found it necessary to give the patient an anesthetic to remove the plaster, which was apparently extremely thick. On removal of the plaster it was found that the boy had no power in his hand. Tbe skin about the wrist was discolored and bruised, and the hand was swollen. Nothing was thought of this condition until the lapse of one week when, the swelling having diminished, it was observed that tbe hand and fingers were contracted and the boy bad very little power. Becoming alarmed, the mother brought the boy to my clinic at the Lebanon Hospital Dispensary. The hand was still moderately swollen, and the skin of the baud and fingers glossy. The wrist and fingers were flexed. When the wrist was passively extended the fingers became markedly flexed, and attempts to extend them were painful and unsuccessful. When the wrist was flexed, the fingers could be straightened out. We were dealing, therefore, with what was evidently the typical deformity of Volkmann's ischémie contracture. At the middle of the forearm there was a circumferential thickening due to the callus formed at tbe site of fracture. The treatment for Volkmann's contracture advised by Mr. Robert Jones was promptly instituted. Individual splints were applied to tbe palmar surfaces of the fingers, and by means of adhesive tapes the fingers were gradually stretched into complete extension. The splints were kept on continuously, except for a brief period each day when they were removed for massage of the fingers, hand and forearm. At the end of one week the fingers could readily be fully extended without pain when the wrist was only moderately flexed. The finger splints were then removed and an aluminum splint was applied to the flexor surface of the forearm, extending from near tbe elbow to slightly beyond the linger lips. The splint differed from that recommended by Mr. Jones, who uses a single sheet of aluminum from elbow to fingers in addition to the individual finger splints. The distal part of the splint I used was divided by longitudinal indentations, thus providing a separate extension for each finger. I believe this is an advantage, as we have one instead of several splints to deal with, and in addition tbe extensions for the fingers arc part of one and the same splint. At first the splint was bent down at the wrist to such an angle as to allow easy and complete extension of the fingers. Two straps of webbing held the brace to the forearm, and strips of adhesive plaster were used to keep the fingers extended. About every other day the splint was straightened a little and finally bent backward into hypercxtensioii, watch being kept that the fingers were always extended. Twice daily the brace was removed and the band and forearm massaged and manipulated. Within one month the patient's hand had been extended to 150 degrees, and active flexion and extension of the hand and fingers were rapidly returning. Two months later, in February, 1916, the boy had such excellent use of his band, the swelling and glossiness having entirely disappeared, that the apparatus was discarded. The band was examined again, April 14, 1916, when it was found that there was a complete anatomic and functional cure. COMMENT This case demonstrates the importance and necessity of adequate protection under any plaster dressing. When plaster is applied to a limb which is deformed or diseased but not likely to swell, we may apply witll safety a plaster dressing over only a slight amount of protection, as a flannel bandage. In the case of an injury, as a fracture, however, in which the trauma to blood vessels causes extravasation of blood and consequent swelling, it is essential to surround the affected limb with some such material as sheet cotton, which is compressible and will allow for swelling without danger of undue compression. It is further advisable to leave the fingers exposed or at least accessible to observation. We must instruct the patient that the color of the fingers must at all times be normal, and the patient should at all times be able to move them. The ability to move the fingers freely is, of course, positive proof that the plaster is not applied too tightly. Swelling, extreme pallor or cyanosis of the fingers or inability to move them are danger signals which demand immediate attention. Should such an untoward condition arise, we must promptly remove the splint and apply another more cautiously. It should be remembered that for purposes of fixation a thin plaster is just as effective as a thick one.