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The knickerbocker tongs (or calipers)
I
II
fNEW
INSTRUMENT%
THE KNICKERBOCKER TONGS (OR CALIPERS) AS APPLIED TO FRACTURES OF THE SHAFT OF THE HUMERUS A PRELIMINARY REPORT
AND FEMUR
EDWARD RAYMOND EASTON, M.D. NEW YORK CITY
T
HE value of catiper traction in fractures of the Iong bones has been adequateIy demonstrated by Besley, CriIe and others, but certain defects in the instruments used have detracted from its completeIy satisfactory performance. As a resuIt of some discussions with the Director of the SurgicaI Service of the Knickerbocker HospitaI, an attempt was made during the Iast few months to design a new type of caliper (or tongs) which wouId avoid the diffIcuIties usuaIIy encountered. FinaIIy an instrument was devised which can be used in fractures of both humerus and femur. It is a modification of the Besley caIiper, with the addition of severa features caIcuIated to extend and faciIitate its usefuIness.* By referring to Figure I, it wiI1 be seen that these tongs have a different set of curves from the BesIey mode1 now on the market. Its shanks aIso differ, in that they are terminated by a two-prong fork arrangement that curves inward and the inner surface of the prongs is corrugated to give a Iarger gripping area without deepIy puncturing the bone. The entire instrument measures 10% inches in Iength. The shanks are approximateIy 2 inches long. The arms of the tongs extend backward from the shanks 3% inches, whence they begin to curve inward to their point of union at the screw,
and backward to the traction Ioops. The points can be compIeteIy approximated or spread to a width of 5% inches. Near the junction of the two arms is a bar furnished with a Iock screw and wing nut, which sets the points of the instrument immovabIy at any spread that may be desired, thus insuring firm fixation without danger of joggIing. The instrument was recentIy used on a case of obIique fracture of the humerus at the junction of middIe and Iower thirds:
* The present design was evolved by the writer through the suggestions of Dr. ElIsworth EIiot, Director of the SurgicaI Service, Miss Moore, Superintendent, and Mr. Maier, Purchasing Agent. Technical advice was generousIy given by severa instrument makers. We are stiI1 working on another model, which wiII embody more particularly the ideas of Doctor Eliot.
The tongs were apphed without diff&Ity through biIatera1 incisions above the internal and externa1 epicondylar regions. Care was exercised in the insertion, and the tongs were pIaced above the internal epicondyIe so that they did not encroach in any way upon the uInar nerve. After traction had been appIied for twenty-three days, the displacement was markedIy corrected and the union firm. The tongs were removed without the diffIcuIty ordinariIy encountered, and the patient’s arm pIaced in a ffexed position, with a sIing hoIding it up toward the chin. About one week Iater massage and eIbow movements were begun, and at the present time (eIeven weeks after operation) the function of the arm has returned to a considerabIe extent, the patient stiI1 receiving physiotherapy in the dispensary. Wounds healed in ten days after remova of tongs. X-ray showed no damage from the instrument at the site of penetration. After appIication of the tongs the patient remained practicaIIy without pain at any time, either in the fracture or at the points gripped by the instrument. By means of a suspension apparatus (Fig. 3), he was able at almost a11 times to use his hand, wrist and forearm, and thus maintain their normaI function.
398
NEW
SERIES VOL.XXVI. No. 2
Easton-Knickerbocker
For fractures of the femur, ashght change has been made in design, to aIIowing compIete extension of the Ieg at the knee
FIG. I.
Tongs
journal
or
surgery
399
just been perfected and no opportunity has yet occurred to make a practica1 test, it is the opinion of severa other surgeons
FIG. 2.
during treatment. One of the chief objections to the earlier modeIs was that they prevented straightening of the Ieg: the instrument, Iying in a straight Iine with the Iong axis of the femur, wouId impinge upon the anterior surface of the tibia when an attempt at extension was made. This difhcuhy was surmounted by CriIe, who used adjustabIe pins which might penetrate the bone to any depth, and to which traction might be applied in any desired direction, whiIe the arms of the caliper, in an upright position, could be used as a suspension. Langworthy described an instrument in which the same principIe was invoIved, aIthough the arms of his apparatus, instead of suspending the leg, passed beneath and hung beIow the knee. The second design for the Knickerbocker tongs makes both of these maneuvers unnecessary, by the introduction of two right-angled offsets in the arms (Fig. 2). These offsets are 1% inches in Iength and are placed at a point 2% inches from the attachment of the shank. By this means, traction can be obtained at the condyIes without the instrument’s coming in contact with the tibia, the Ieg being suspended in a Jones spIint with an additiona hinge attachment at the knee to aIIow for flexion and extension of the leg at wiI1 through the use of a puIIey arrangement as shown in Langworthy’s articIe. Although this new deveIopment has
American
FIG. 3.
at the Hospital that it shouId obviate al1 the diffIcuIties which have arisen in caIiper traction. As far as can be determined by the writer, these are the onIy tongs in which doubIe prongs and offsets have been used. The
chief
advantages
are:
I. They do not pierce the bone cortex. 2. There is no tendency to puncture the bone further on traction. 3. They Iock so tension on the bone remains the same throughout treatment. 4. By reason of the Iock screw they are prevented from sIipping. 5. They are easy to remove. The wounds do not become infected. 6. There is no risk of OsteomyeIitis. 7. The wounds hea kindIy within a week to ten days. 8. They are especiaIIy designed for the anatomica structure of the part. g. The instrument can be used for fractures of the femur, humerus or tibia, and is appIicabIe to the bones of a smaI1 chiId or a very Iarge aduIt. REFERENCES BESLEY, F. A. VaIue of the caIiper in obtaining extension in compound fractures of the femur. J. A. M. A., 70: 87-89 (Jan. 12) rgr8. CRILE, D. W. Fracture of the femur on cahper extension. J. A. M. A., 72: 789-794 (March 15) ,919. LANGWORTHY,M. A new traction frame and caliper for fractured femurs. Surg. Gynec. Obst., p. 125, ,925.
II
fNEW
INSTRUMENT%
THE KNICKERBOCKER TONGS (OR CALIPERS) AS APPLIED TO FRACTURES OF THE SHAFT OF THE HUMERUS A PRELIMINARY REPORT
AND FEMUR
EDWARD RAYMOND EASTON, M.D. NEW YORK CITY
T
HE value of catiper traction in fractures of the Iong bones has been adequateIy demonstrated by Besley, CriIe and others, but certain defects in the instruments used have detracted from its completeIy satisfactory performance. As a resuIt of some discussions with the Director of the SurgicaI Service of the Knickerbocker HospitaI, an attempt was made during the Iast few months to design a new type of caliper (or tongs) which wouId avoid the diffIcuIties usuaIIy encountered. FinaIIy an instrument was devised which can be used in fractures of both humerus and femur. It is a modification of the Besley caIiper, with the addition of severa features caIcuIated to extend and faciIitate its usefuIness.* By referring to Figure I, it wiI1 be seen that these tongs have a different set of curves from the BesIey mode1 now on the market. Its shanks aIso differ, in that they are terminated by a two-prong fork arrangement that curves inward and the inner surface of the prongs is corrugated to give a Iarger gripping area without deepIy puncturing the bone. The entire instrument measures 10% inches in Iength. The shanks are approximateIy 2 inches long. The arms of the tongs extend backward from the shanks 3% inches, whence they begin to curve inward to their point of union at the screw,
and backward to the traction Ioops. The points can be compIeteIy approximated or spread to a width of 5% inches. Near the junction of the two arms is a bar furnished with a Iock screw and wing nut, which sets the points of the instrument immovabIy at any spread that may be desired, thus insuring firm fixation without danger of joggIing. The instrument was recentIy used on a case of obIique fracture of the humerus at the junction of middIe and Iower thirds:
* The present design was evolved by the writer through the suggestions of Dr. ElIsworth EIiot, Director of the SurgicaI Service, Miss Moore, Superintendent, and Mr. Maier, Purchasing Agent. Technical advice was generousIy given by severa instrument makers. We are stiI1 working on another model, which wiII embody more particularly the ideas of Doctor Eliot.
The tongs were apphed without diff&Ity through biIatera1 incisions above the internal and externa1 epicondylar regions. Care was exercised in the insertion, and the tongs were pIaced above the internal epicondyIe so that they did not encroach in any way upon the uInar nerve. After traction had been appIied for twenty-three days, the displacement was markedIy corrected and the union firm. The tongs were removed without the diffIcuIty ordinariIy encountered, and the patient’s arm pIaced in a ffexed position, with a sIing hoIding it up toward the chin. About one week Iater massage and eIbow movements were begun, and at the present time (eIeven weeks after operation) the function of the arm has returned to a considerabIe extent, the patient stiI1 receiving physiotherapy in the dispensary. Wounds healed in ten days after remova of tongs. X-ray showed no damage from the instrument at the site of penetration. After appIication of the tongs the patient remained practicaIIy without pain at any time, either in the fracture or at the points gripped by the instrument. By means of a suspension apparatus (Fig. 3), he was able at almost a11 times to use his hand, wrist and forearm, and thus maintain their normaI function.
398
NEW
SERIES VOL.XXVI. No. 2
Easton-Knickerbocker
For fractures of the femur, ashght change has been made in design, to aIIowing compIete extension of the Ieg at the knee
FIG. I.
Tongs
journal
or
surgery
399
just been perfected and no opportunity has yet occurred to make a practica1 test, it is the opinion of severa other surgeons
FIG. 2.
during treatment. One of the chief objections to the earlier modeIs was that they prevented straightening of the Ieg: the instrument, Iying in a straight Iine with the Iong axis of the femur, wouId impinge upon the anterior surface of the tibia when an attempt at extension was made. This difhcuhy was surmounted by CriIe, who used adjustabIe pins which might penetrate the bone to any depth, and to which traction might be applied in any desired direction, whiIe the arms of the caliper, in an upright position, could be used as a suspension. Langworthy described an instrument in which the same principIe was invoIved, aIthough the arms of his apparatus, instead of suspending the leg, passed beneath and hung beIow the knee. The second design for the Knickerbocker tongs makes both of these maneuvers unnecessary, by the introduction of two right-angled offsets in the arms (Fig. 2). These offsets are 1% inches in Iength and are placed at a point 2% inches from the attachment of the shank. By this means, traction can be obtained at the condyIes without the instrument’s coming in contact with the tibia, the Ieg being suspended in a Jones spIint with an additiona hinge attachment at the knee to aIIow for flexion and extension of the leg at wiI1 through the use of a puIIey arrangement as shown in Langworthy’s articIe. Although this new deveIopment has
American
FIG. 3.
at the Hospital that it shouId obviate al1 the diffIcuIties which have arisen in caIiper traction. As far as can be determined by the writer, these are the onIy tongs in which doubIe prongs and offsets have been used. The
chief
advantages
are:
I. They do not pierce the bone cortex. 2. There is no tendency to puncture the bone further on traction. 3. They Iock so tension on the bone remains the same throughout treatment. 4. By reason of the Iock screw they are prevented from sIipping. 5. They are easy to remove. The wounds do not become infected. 6. There is no risk of OsteomyeIitis. 7. The wounds hea kindIy within a week to ten days. 8. They are especiaIIy designed for the anatomica structure of the part. g. The instrument can be used for fractures of the femur, humerus or tibia, and is appIicabIe to the bones of a smaI1 chiId or a very Iarge aduIt. REFERENCES BESLEY, F. A. VaIue of the caIiper in obtaining extension in compound fractures of the femur. J. A. M. A., 70: 87-89 (Jan. 12) rgr8. CRILE, D. W. Fracture of the femur on cahper extension. J. A. M. A., 72: 789-794 (March 15) ,919. LANGWORTHY,M. A new traction frame and caliper for fractured femurs. Surg. Gynec. Obst., p. 125, ,925.