sufficient to thoroughly and repeatedly stretch the sural muscles,
but, in the more severe forms, tenotomy of the tendo Achillis, with
subcutaneous or perhaps open division of the plantar structures,
will be needed. In paralytic cases tendon grafting (_q. v._) will be
required, probably with one or more of the measures mentioned above.
In some instances nerve grafting might be profitably employed. After
recovery from operation, braces adapted to each particular case will in
all probability be required, at least for a time.

4. =Talipes Calcaneus.=--In this deformity the anterior part of the
foot is drawn upward by its anterior flexors and a little to the outer
side, while the sural muscles are relaxed; thus the patient walks upon
the heel. The condition is often more or less combined with talipes
valgus. It is rarely of congenital origin, but is generally due to
paralysis of the distal muscles following injury or poliomyelitis. It
is sometimes of hysterical origin, and it may occur as the result of
muscle spasm following bone or joint disease (Fig. 266).

[Illustration: FIG. 266

Talipes calcaneus.]

[Illustration: FIG. 267

Pes cavus, hollow clawfoot.]

Those forms due to infantile paralysis are to be treated mainly by
tendon grafting or some similar expedient, and this to be followed by a
suitable shoe containing a sole plate with an upright attachment and a
joint opposite the ankle. Other forms must be treated, each on its own
merits, but according to general principles already enunciated.

=Pes Cavus.=--Here the anterior part of the foot is drawn backward and
the plantar arch made much more prominent. It may even be converted
into a Gothic arch. Extremes of this type are seen in the feet of
Chinese women. One form is due to contraction of the peroneus longus,
owing to paralysis of the sural muscles, by which the long flexors
are permitted to work to extra advantage; and yet another form is
often of congenital origin, having its explanation in paralysis of the
interossei and other small intrinsic muscles of the foot (Fig. 267).

When an ordinary metal sole plate fails to give relief a subcutaneous
or open division of the contracted structures may be practised.

CONGENITAL MISPLACEMENT (DISLOCATION) OF THE HIP.

Perhaps a more proper name for this congenital deformity would be
“misplacement” rather than dislocation. It is seen much oftener in
females than in males. It may be either unilateral or bilateral. The
displacement is usually upward and backward upon the dorsum of the
ilium. In rarer instances it is anterior and sometimes the head of the
femur lies not far away from the anterior superior spine of the ilium.

Regarding its cause absolutely nothing is known. It represents
defective development rather than arrest, and is a condition of
intra-uterine life. The acetabulum is usually found incomplete, but
whether this is the cause of the misplacement or whether it fails to
develop because of the absence of the head of the femur from this
cavity it is not easy to decide. The influence of heredity in these
cases is undeniable, for it is known to have prevailed in certain
families. Thirty years ago but little was known in regard to the
affection, and nothing could be done to atone for it. Of late years it
has been the subject of special study by numerous investigators (Figs.
268 and 269).

[Illustration: FIG. 268

Double congenital displacement of the hip. Buffalo Clinic. (Skiagram by
Dr. Plummer.)]

[Illustration: FIG. 269

Skiagram of coxa vara; deformity most marked at the epiphyseal
junction. This illustrates the mechanical limitation of abduction
caused by the deformity, and the compensatory tilting of the pelvis.
(Whitman.)]

[Illustration: FIG. 270

Congenital misplacement, with consequent atrophy and shortening.
(Calot.)]

Pathological changes are noted in the capsule itself, as well as in the
bony components of the joint. Thus the capsule is usually elongated
and stretched out of shape, while its lower portion may be adherent to
the margin of the acetabulum or may be shut off into a small cavity
by itself, this cavity having but a small connection with the balance
of the capsule and affording irresistible obstacles to reduction. With
changed joint relations the muscular arrangements are also changed,
some being lengthened, others shortened, as would naturally follow
from the approximation or separation of their points of origin and
insertion. Conspicuous change is seen in the upper end of the femur,
which is often atrophied, while the neck is shorter than normal, its
angle lessened, and the head of the bone often altered in shape. A
secondary acetabulum is in time formed and is usually found upon the
side of the ilium. This is shallow and insufficient to ensure firm
support for the head of the femur, even were this well developed.
Aside from these changes the pelvis is usually poorly developed on the
affected side, its inclination increased, the sacrum forced forward and
downward, the pelvic outlet widened, while a considerable degree of
lumbar lordosis is present (Fig. 270).

The condition is rarely noted until a growing infant begins to learn
to walk. The condition is one which has _no symptoms, only signs_, and
these do not at first attract attention. Sometimes it will have been
noted that there is an abnormality about the hip, with too free play,
or a snapping sound about the joint. When the condition is unilateral
there is a marked limp which increases with the age of the child.
With each step the femoral head is pushed upward on the side of the
ilium, and, in consequence, the pelvis is tilted toward the outside,
as well as twisted downward and forward. The limb being thus actually
shortened, the limp or waddling gait is easily accounted for. Along
with it there is usually flattening of the tibia, while the trochanter
may be felt and often seen on a level considerably above that where it
properly belongs. Motility in the joint is abnormally free, and with a
child on its back, by alternately pulling and pushing, the abnormally
free play of the upper end of the femur may be easily demonstrated,
either with the limb in its extended or the flexed position.

When the misplacement is _bilateral_ the individual is more
symmetrically deformed. The lordosis is increased, the abdomen
protrudes, the thighs are separated more widely than is normal, leaving
perhaps a considerable space in the perineum; the gait is of a peculiar
waddling character, which makes locomotion apparently difficult,
although it is free from pain. In these cases abnormal mobility of the
hip may be demonstrated on each side.

As these patients grow through adolescence into maturity they sometimes
improve, but usually suffer more and more difficulty in locomotion,
while the abdominal protrusion and the lordosis become more and more
pronounced.

Three varieties of congenital misplacement are described as _backward_,
_upward_, and _forward_. It is in those instances where the head of
the bone rests well back or well forward upon the ilium that the gait
is most pronounced, but in all instances the great trochanter will be
found above Nélaton’s line.

=Diagnosis.=--The diagnosis offers few difficulties. The peculiar
waddling gait may be seen in extreme cases of bow-legs, but then the
hip-joints will be normal. Extreme lordosis may be seen in cases of
lumbar spinal caries, but here again the hip-joints will be normal,
while the spinal muscles will be rigid and the patient disinclined
to walk. Traumatic dislocations and the results of hip-joint disease
will be indicated by a history to correspond, as will also early acute
joint affections following the exanthems. The diagnosis is to be made
principally from _coxa vara_, considered below, and the various defects
following infantile palsy. In coxa vara there is no corresponding
abnormality of motion, while in the paralytic cases there will often be
failure in muscle power, which is not present in cases of congenital
misplacement. Finally in instances which offer difficulties the Röntgen
rays now afford a method of diagnosis.

=Treatment.=--For a long time after this condition was recognized its
treatment was unsatisfactory, and it was not until Hoffa, about fifteen
years ago, advanced his operative method of relief that surgeons felt
at all like advising operation in well-marked cases. Then came Paci and
Lorenz, first with improvements on the Hoffa operation, and then with a
method of so-called “bloodless” reposition, which has been under severe
test and testimony. Last of all come Bradford and Sherman with their
improved methods of operation, which seem to me the most promising of
all as well as the most scientific.

[Illustration: FIG. 271

A plaster bandage applied by Lorenz, illustrating the extreme thickness
of the pelvic portion and discoloration of the adductor region.
(Whitman.)]

Lorenz was doubtless correct when he stated that the principal
obstruction to reduction is the narrowed part of the capsule, just
at the upper part of the acetabulum, and that if this could be torn
here sufficiently to permit the passage of the head, reduction
could be accomplished by manipulation alone, and maintained if the
acetabulum were sufficiently deep. An almost insuperable difficulty
in most cases is, however, this narrowed capsule, and the number of
accidents, including not only fractures of the femur and the pelvis,
but various other injuries which have resulted from too great violence,
is altogether too large and too disturbing to justify the use of such
force as has often been used. Of more than one hundred children upon
whom Lorenz operated when making a tour through the United States,
but little over 10 per cent. have given anything like ideal results;
while the danger from fracture and laceration of muscles and nerves,
as well as of bloodvessels, is fully as great as that pertaining to
any open operation. It may therefore be maintained that the percentage
of success from the use of manual force without incision does not
justify the risks of the method. Sherman argues that if we may open a
knee-joint without hesitation to take out a small piece of cartilage,
we need not fear to open a hip-joint in order to clear away a small
obstacle. The patient is thereby saved from many dangers and exposed to
so few that it seems more humane and desirable in every respect.

Sherman’s method is to make traction upon the limb, drawing the
femoral head down to a point just below the anterior superior crest,
where it can easily be felt, and to here make an incision over it
in the direction of muscular fibers so that they are not divided.
After division of the capsule the head of the bone is exposed and
retractors substituted by long loops of suture, put in on either
side of the opening in the capsules. In many cases a tenotomy of the
adductor tendons close to the pubis will also be of advantage. The leg
is next released from traction and the head of the bone allowed to
glide upward, while the finger is slipped into the capsule and down
toward the acetabulum. Upon this finger as a guide a long, straight,
probe-pointed bistoury is passed, and with it the narrower portion
of the capsule is cut through, down to the bone, taking care to not
cut off the ileopsoas tendon. The incision must be large enough to
give free access to the acetabulum. Traction is then again made with
sufficient manipulation so that the femoral head may be forced into
its proper cavity. When the head is in the acetabulum the retracting
sutures are tied together so as to close the upper part of the capsule,
and other sutures are introduced, as needed, to close the wound,
leaving space for a cigarette drain. The limb is then put into a
position of abduction of from 50 to 90 degrees, rotated in or not, as
needed, and a comprehensive plaster-of-Paris spica applied. In this
both limbs or only one may be included. The drain should be removed in
two days and the dressing left otherwise undisturbed for three months.

Bradford has added somewhat to our methods by showing not only the
arrangement of the capsule, but the fact that the acetabulum is often
filled with dense fibrous tissue which sometimes obliterates it, and
that this tissue can be curetted out, but that if it could be utilized
to aid in retaining the reduced head of the femur it would be a great
benefit. He operates as follows: The hip is subjected to preliminary
forcible stretching of all soft parts which can be stretched by manual
or mechanical force. A posterior incision is then made, which, without
dividing muscles, permits free opening into the capsule and affords a
channel to the deepest portion of the acetabulum. The posterior wall
of the capsule is then split, after which all constricting and other
obstacles at any point are carefully divided. These may be detected
by the finger, and can also be seen by a small electric light passed
down inside of a sterilized glass test tube. The capsular wound is then
retracted by deep retaining silk sutures, placed at the lower rim of
the acetabulum, thus affording a pathway for the reduction of the head.
After this has been accomplished as described above, the sutures are
tied closely around the femoral neck, and these retain it in position.
The other portions of the split capsule are then sewed around the head
and neck, to the trochanter and fascia, in such a way as to retain the
bone where it has been placed.[37]

  [37] American Journal of Orthopedic Surgery, October, 1905.

The earlier the operation is done the better. It is necessary to always
maintain the limb in a position of well-marked abduction, and for a
long time, nor can patients be released from this at the expiration of
the first dressing period, usually twelve to fifteen weeks, although
the abduction can usually be reduced with each dressing until at last
the limbs are permitted to come together after the expiration of nine
to eighteen months. Even after the lapse of this length of time it
may be necessary to provide some form of apparatus by which too much
rotation in either direction may be prevented, or by which pressure
may still be made over the trochanter, in order that it may be kept
constantly pushed into the acetabulum (Figs. 271 and 272).

[Illustration: FIG. 272

Unilateral congenital dislocation, showing the fixation bandage. A
shoe with a cork sole about two inches in height should be worn on
the operated side, while the attitude of exaggerated abduction is
maintained. (Whitman.)]

[Illustration: FIG. 273

Coxa valga, with defective development of the right femur. (Albert.)]

COXA VARA AND VALGA.

This term is applied to an _abnormality in the shape of the neck of the
femur_, consisting of a downward curvature or bending of the femoral
neck, which is thus displaced until it stands almost at a right angle
with the shaft instead of at the normal obtuse angle. At the same time
there is often posterior curvature, or sometimes an anterior curve,
of the neck, which causes a corresponding rotation of the axis of the
whole limb. The pelvic side of the hip-joint is unaffected, the change
occurring usually solely in the upper end of the femur, the joint
not being involved. It may appear in congenital form and then may be
attributed either to intra-uterine pressure or to antenatal rickets or
osteomalacia. The acquired form is usually due to a non-inflammatory
softening, or to structural changes which permit of yielding, as above
described. Doubtless different cases have different causes, and they
are not to be included in one brief sentence. The condition corresponds
to those abnormalities at the knee which produce knock-knee and
bow-leg. Were the bone as easily examined at the upper end of the femur
as at the knee the condition would be more easily recognized. Therefore
the term has reference not so much to the results of active disease as
to deformities of congenital or acquired character. Fully three-fourths
of the cases are met with in male subjects, and the majority of
these occur only on one side. Thus of 190 quoted by Whitman, 85 were
unilateral, while only 26 occurred in females.

The more nearly the angle of fixation of the neck of the femur
approaches a right angle the further above Nélaton’s line will the
trochanter appear, and the more conspicuous this change the greater the
difficulty in abduction. Moreover, to shortening may be added internal
or external rotation, with consequent tilting of the pelvis and
compensatory alteration of the spinal curves.

The disease is by no means often of traumatic origin, although
traumatisms may produce an arthritis deformans, even in juvenile cases,
and that this may simulate a non-symptomatic coxa valga is now well
established (Fig. 273).

=Symptoms.=--Coxa vara produces certain symptoms, among them pain in
the joint, radiating down the front and inside of the thigh. If the
deformity be very marked, joint function is impaired. Tenderness is
rarely present. When pain or tenderness occur they may lead to the
mistaken diagnosis of rheumatism or neuralgia. The condition may arise
as the result of an acute ostitis, in which case patients will be
confined to bed for some time. Actual shortening may vary from one
to one and a half inches, while the limb will be found adducted, the
gluteal region flattened, with a deep curve between the trochanter and
the gluteal muscles.

=Diagnosis.=--The diagnosis is to be made mainly between this condition
and hip-joint disease or misplacement. When abnormalities in the
shape or position of the limbs in the young occur in a comparatively
short time, coxa vara may be suspected, especially in the absence of
that disability which coxitis usually produces. The patient should be
examined in both the upright and horizontal position. Coxa vara may
have an abrupt onset, but it never produces abscess. It is practically
self-limited and will be followed, sooner or later, by spontaneous
cessation of all acute features, while coxitis is progressive, with a
destructive tendency. In coxa vara we do not have the starting pains
nor muscle spasms of coxitis, while the actual shortening is much more
marked. In doubtful cases the cathode rays may be employed and will
often greatly facilitate diagnosis. The condition may be bilateral,
but will still fail to show the muscle atrophy so significant of
tuberculous disease.

As between coxa vara and that senile form of coxitis already described
in the chapter on Joints as arthritis deformans, it should be
remembered that the latter is a disease of advanced life, while the
former occurs rather in its earlier periods. Moreover, in the former
there is no tendency to change in the femorocervical angle, no matter
what changes may occur in other respects about the joint. When in
the senile disease shortening really occurs it results from actual
absorption of bone.

Coxa vara tends usually to _spontaneous cessation_, which may be
considered recovery. Acute symptoms after a time subside, and function
is regained to the full extent permitted by whatever changes have
occurred in the shape of the bone. If symptoms are at all severe they
demand physiological rest in bed, with traction, and the limb should
not be used until pain has entirely subsided. Conspicuous deformity
may call for correction by subcutaneous osteotomy made just below the
trochanter. Only in exceedingly serious cases is exsection of the joint
necessary.

DEFORMITIES CAUSED BY INFANTILE PALSIES.

Deformities induced by more or less acute affections of the cord and
brain, or by hemorrhages, have assumed an ever-increasing importance
in orthopedic work. Most of them resolve themselves into those due to
acute anterior poliomyelitis and those due to cerebral hemorrhages.

[Illustration: FIG. 274

Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing
quadrupedal locomotion. (Gibney.)]

=Anterior Poliomyelitis.=--Anterior poliomyelitis is an acute
inflammation manifested especially in the gray matter of the anterior
cornua of the spinal cord, involving both the neuroglia and the cells,
producing atrophy of the same and consequent paralysis of muscles
supplied by the motor nerves. It may assume an acute febrile type,
with rapid onset of paralysis, or it may be of slower development.
Usually conceded to be of infectious origin, it still lacks the minute
explanation for many of its attendant phenomena. It may appear with
acute symptoms, febrile and convulsive, paralysis appearing more or
less promptly. With the subsidence of other serious symptoms this
paralysis remains. There may then be a period of partial improvement
in the muscular condition, with disappearance of some of the most
pronounced phenomena. Finally with the growth and development of
the child more expressions of damage remain, and produce various
distortions and deformities, varying with the muscle groups affected.
Not only do deformities result, but there is more or less arrest of
development, with disproportion in size between the limbs involved and
those which have been spared. It is the early paralytic features which
may permit diagnosis to be made in the early days of the acute febrile
attack.

=Cerebral Palsies.=--The cerebral palsies, so called, are the result
of hemorrhages or acute disorganization of the brain. The former are
usually unilateral and give rise to a corresponding hemiplegia, with
either paralysis or spastic rigidity, and usually with atrophy. The
paralysis may not be complete, but is rather of the paretic type,
involving the entire limb, the reflexes being increased and the muscles
stiffened rather than flaccid, with loss of electrical reactions.

_A paraplegia points rather to lesion in the spinal cord and hemorrhage
than to cerebral lesion._ Transverse myelitis is rare in children.
Multiple neuritis may produce somewhat similar effects, as may also
the toxic paralyses due either to drugs (especially lead or arsenic)
or that following diphtheria, in which case it is the muscles of the
throat and neck which are likely to be involved. Figs. 274 and 275
portray extreme types which are rare, but instances of minor degree of
affection are frequent.

[Illustration: FIG. 275

Anterior poliomyelitis. Duration seven years. Showing atrophy and
slight lateral curvature of the spine; two and a quarter inches of
shortening. (Whitman.)]

=Treatment.=--As two cases of this kind are seldom alike, treatment
should be planned to meet the indications. Massage, electricity,
hot-air baths, and similar non-operative measures find here a large
field of usefulness, but, save in the milder cases, are insufficient.
In no class of cases do tendon grafting and nerve grafting find a wider
range of applicability, while tenotomy, myotomy, aponeurotomy, and
occasionally osteotomy will permit of atonement for deformity which has
not been treated. These operative measures have been considered.

CHAPTER XXXIV.

FRACTURES.

The term _fracture_ is, in surgery, applied to such injury of bone
and cartilage as effects break in continuity. This injury is effected
instantly, and it is rarely that fracture is produced by any slowly
acting cause, although this latter may so affect or disintegrate
bone as to permit fracture upon the application of a mild degree of
force. Fractures are variously classified and grouped for convenience
of description; thus we speak of _traumatic_ and _pathological
fractures_, implying by the former those which occur by violence in
normal conditions of health, and by the latter those which are produced
only because of some previous disease in the bone. The difference
is that in the former case there is no preëxisting disease, whereas
in the latter it is an essential feature of the case. Fractures
are also classified as _complete_ or _incomplete_, the former term
implying injury to the whole thickness of the bone, while the latter
are separately classified: (_a_) _Fissure_, in which there is a line
of fracture by which there is no complete separation of fragment, it
being essentially a crack; (_b_) the _green-stick fracture_, such as
occurs in the young, where the bone is not thoroughly calcified, but is
capable of bending to some extent, while a portion of it breaks; (_c_)
_depressed fracture_, which is generally produced by direct violence,
and occurs in a flat bone, _i. e._, the skull, the scapula, etc.;
(_d_) _detachment_ of a fragment or separation of an epiphysis; (_e_)
_partial fractures_, corresponding much to the green-stick, but without
deformity or change in shape or position.

[Illustration: FIG. 276

Impacted fracture of the shaft of the femur produced by a fall upon
the knee in a man aged eighty-three years. Illustrating impaction.
(Bryant.)]

Fractures are also described by means of the following adjectives,
which practically explain themselves, for instance:

_A._ _Complete_, _transverse_, _oblique_, _longitudinal_, _dentated_,
etc. _Spiral_ fracture is also described and occasionally seen. It
involves only the long bones, and not only implies a considerable
degree of violence, but is itself regarded as exceedingly serious.

_B._ In number they are _single_, _multiple_, or _comminuted_, as when
there are a number of fragments.

_C._ They are often _impacted_, which means that one fragment is
driven into and more or less embedded in the other. This impaction or
interlocking of fragments occurs usually in the neck of the femur and
the lower end of the radius. In the former locality it is advisable not
to interfere with it; in the latter it should always be dislodged in
order to restore the fragment to its proper position (Fig. 276).

_D._ As to their nature and location, fractures are referred to as
_pathological_, _gunshot_, _intra-articular_, or _extra-articular_,
etc., the latter terms referring to involvement of a joint. If blood
can escape from the site of the fracture into a joint cavity, or if
synovial fluid can escape from the latter into the former, then the
fracture is called _intra-articular_.

_Pathological fractures_ imply preëxisting disease. This may be
constitutional, as in the case of the fragilitas ossium, already
described in the chapter on the Bones, or it may be due to some
secondary deposit of cancer or a primary sarcoma. In adults, especially
those with a cancerous history, any spontaneous fracture, or even
one occurring with trifling violence, should lead to suspicion of a
metastatic focus in the bone at the site of its yielding. The atrophic
changes which notably occur in various bones as old age comes on lead
also to a condition which is pathological, _i. e._, it permits of
fracture from what would appear to be a trifling injury.

_Gunshot fractures are practically always comminuted_, save perhaps
some of those inflicted with the modern military weapons. A Mauser
bullet will frequently make an almost clean perforation, but the
gunshot fractures met with in civil practice are almost invariably
comminuted, especially those of the skull (Fig. 277).

_E._ The term _compound_ is applied to any fracture in which there is
wound of the soft tissues and so located as to permit access of air
to the injured bone. There is a distinction between a compound and a
complicated fracture. A fracture of the femur accompanied by a gash
or extensive wound, so long as air cannot come in contact with the
broken bone, would be described as a fracture of the femur complicated
by a lacerated wound. On the other hand, if through the slightest
puncture of the skin, even at a distance from the fracture, air can
even theoretically enter and come in contact with bone surfaces at the
site of the fracture, such an injury constitutes a compound fracture.
This distinction is not a trifling one, for upon the exclusion of air,
which to a certain extent means the exclusion of germs, depends very
much the rapidity and perfection of recovery. _Compound fractures
are all dangerous in proportion as they permit of infection_, and
while air infection is not necessarily the most serious of any, it
nevertheless is often sufficiently so to set up sepsis and interfere
with consolidation, even if it does not prevent it. Fractures are
made compound by _direct violence_ from the outside or by _indirect
violence_, as where a bone end perforates soft parts and the skin. Even
if a sharp point of bone thus protruded from within is quickly drawn
back again it is enough, since both the skin and the air in contact
with it are sources of germ activity. Thus it may happen that a slight
and apparently trivial injury of this kind is more serious than one
which is extensive.

[Illustration: FIG. 277

Skiagram of compound comminuted (gunshot) fracture of elbow, inflicted
with a Dumdum bullet. Illustrating the extreme of comminution. (Lexer.)]

_F._ _Epiphyseal separations_ constitute a somewhat distinct form of
injury, having at the same time the importance and dignity of fractures
in the truer sense of the term. In the chapter on Diseases of the
Joints will be found a table of the ages at which epiphyses unite. In
childhood and youth a fracture near the joint is most likely to partake
of this character, and it is of importance that it should be recognized
as such when it occurs. Injuries occurring beyond the ages mentioned in
the table are not likely to be of this character unless ossification is
delayed by some morbid process.

By virtue of their occupations and habits men suffer fractures more
frequently than women. Fractures are, moreover, ten times as frequent
as are dislocations. The aged, by virtue of their atrophic changes,
are more subject to fractures than others. Fracture in the vicinity of
certain joints predisposes as well to dislocation of these joints,
and it often happens that the treatment for the dislocation is
reduction and treatment of the fracture. So far as the external causes
of fracture are concerned they are frequently referred to as (_a_)
fracture by external violence, and (_b_) fracture by muscle activity.
The former are easily explained; the latter occur from excessive muscle
action, as in violently throwing a ball, or, as in one case with which
the writer was conversant, where a colored preacher in the vehemence
of his gesticulations fractured his own humerus. Obviously the long
or large bones are more liable to fracture than those which are short
and irregular. Certain bones, especially the clavicle, are peculiarly
exposed.

_Intra-uterine fractures_ have not as yet been mentioned. These occur
during the intra-uterine life of the fetus; this term does not include
such fractures as may be inflicted during delivery with or without
instruments. In a fetus already affected with congenital rickets it
may not require any severe contusion upon the abdomen of the mother to
inflict a fracture. Starvation (_i. e._, scurvy, syphilis, and struma)
in the mother may so disturb nutrition as to weaken the osseous system
of her offspring.

Such previous conditions as ensue from osteomyelitis (_i. e._, caries
and necrosis) may often weaken the bone. Nevertheless with distinct
necrosis there is usually so much new bone formation as to strengthen
rather than weaken the part. Bones may also become fragile as the
result of syphilis, especially when gummas develop within them.

Fractures frequently produce certain _deformities_ which are more
or less conspicuous and easily recognized. They are designated as
_angular_, _lateral_, or _axial_ (_i. e._, when the axes of bone
are considerably displaced, even though they may be more or less
parallel), _longitudinal_ (when ends overlap), _rotary_, etc.; while
by the interposition of muscles and other soft tissues more or less
wide _separation_ may be produced, the same result occurring when the
olecranon or the upper half of the patella is widely separated from the
main bone or portion by muscle pull.

DIAGNOSIS OF FRACTURES.

Fractures give rise to subjective symptoms and objective signs. In
diagnosis the history is also of value, especially in those cases
where it is a question of some constitutional affection and a minimum
or absolute absence of violence. The apparent immunity which the
intoxicated enjoy is in large measure due to the fact that by virtue of
their condition one of the predisposing causes of fracture is avoided.
There can be no doubt but what _muscle tension_, due to voluntary or
instinctive efforts to avoid harm, is a contributing factor in the
separation of many bones or their processes. A patient stupidly drunk
will not make these efforts, and will fall in a relaxed condition,
in which violence will probably be much less extensive, and the
consequences less disastrous than if he made an effort to save himself
from falling.

_Pain and tenderness_ are evidences of injury, and will often serve for
its location; even the reference of pain is somewhat suggestive. It
is stated as a universal rule that when pressure is applied laterally
or in the long axis of a bone and evokes pain, referred to a distance
from the point where pressure is made, it will indicate fracture at the
point to which it is referred. There is always _impairment_, usually
_loss of function_, while effort to move a thus injured limb will give
rise again to localized pain and tenderness. The pain of contusion is
usually diffuse, and that of fracture is referred to a limited area.
The tenderness produced by handling or examination will vary with the
stolidity, the age, and the character of the patient, as well as the
nature of the injury.

Objective signs are _crepitus_, _mobility_, _deformity_, _ecchymosis_,
_redisplacement_. _Crepitus_ means the sensation of grating or rubbing
produced when fractured bone surfaces are moved upon each other. It is
recognized by the sense of touch, sometimes by that of hearing. Its
presence is pathognomonic, but its absence is a negative sign, and
an effort should be made to obtain it. To repeat the demonstration,
especially to demonstrate it to others, means superfluous manipulation,
which is not to the best interest of the patient. Crepitus, then,
should be carefully sought for; once detected it should be sufficient.

_Abnormal mobility_ is explained only by fracture. It is easy to
detect it in the shaft of a long bone, but when near the joint it
is confusing. Its determination by manipulation is not seen in
green-stick or impacted fracture unless these are further broken up
by manipulation. When evident it should serve as a caution against
unnecessary or rough handling, for if it be easily recognizable
crepitus need not be sought.

_Deformity_ is a striking and pathognomonic feature of fracture. It
may be imitated by hematoma or sudden swelling of the soft parts or
of joints. It may consist of shortening or of angular, lateral, or
rotary displacement, or perhaps of depression or indentation. Careful
inspection, then, and palpation should precede other methods of
examination, as they are often sufficient to indicate the location, the
nature, and sometimes even the character of the active causes.

_Inspection of the injured part alone is not always sufficient._
Careful comparison between the two sides of the body should be made
in order that actual measurement or comparative examination may
reveal what mere inspection would not. In connection with inspection
it should be ascertained whether the individual has ever received
previous injuries. The writer recalls a case where a physician claimed
a recovery after fracture of the femur, treated by incompetent method,
yet with ideal result, inasmuch as he said there was absolutely no
shortening. A personal question, however, to the patient revealed the
fact that he had had the other thigh broken some years previously, and
that an apparently similar amount of shortening followed in each case.

The ordinary indications of fracture are frequently followed by
_ecchymosis_. This will appear at a date corresponding with the depth
of the injury beneath the skin (it may occur within an hour or three
or four days). The blood will follow the fascial planes and work its
way to the surface along them. The sign is of the greatest value in the
diagnosis of basal fractures of the skull and certain fractures of the
hip and pelvis. When it occurs after an interval it is a confirmatory
rather than a promptly available sign.

_Redisplacement_ implies that the parts when properly put into
apposition quickly fall out of it unless mechanically supported--that
is, they _do not stay reduced_. This sign is not universally
applicable. It applies especially to the fractures of the long bones of
the extremities, and particularly to the humerus, the femur, or double
fractures of the radius and ulna in the forearm or both bones of the
leg.

=Diagnostic Aid Afforded by the Fluoroscope and the Skiagram.=--Since
Röntgen’s memorable discovery the _cathode or x-rays_ have been of
greater and greater use in the diagnosis and portrayal of injuries and
morbid conditions in the osseous system. To such an extent is this
now true that well-equipped hospitals have ample conveniences for
fluoroscopic and photographic work, while many medical men are doing it
in their private practice. There can be no question but that diagnosis
and methods of treatment have been made more perfect since this new
method of investigation has been made available. On one hand, however,
it has led perhaps to something of neglect of the methods previously in
vogue, which necessitated anatomical knowledge and logical reasoning.
On the other hand, the knowledge thus obtained has been sometimes a
two-edged sword, since the display of skiagrams, or _x_-ray pictures,
in court has too often worked harm or discredit to the surgeon or the
institution with which he was connected. Moreover, even this method of
diagnosis, with its apparent certainties, is not always reliable, and
disappointments have sometimes followed.

=Intra-articular Fractures= are subject to peculiar complications which
enhance the difficulty of treatment and jeopardized the result. Among
the more common of these are the following:

1. Too wide separation of fragments by hemorrhage or distention, with
failure in resorption of fluid before fixation in bad position has
resulted.

2. Complete or partial rotary displacement, preventing proper
apposition of bone surfaces.

3. Interposition of soft or fibrous tissues between fragments by which
bony union is prevented. This is conspicuously common in fractures
of the olecranon and patella, and is of itself sufficient reason to
justify operation in otherwise suitable cases.

4. Separation of a fragment within a joint capsule, by which its blood
supply is cut off, making it essentially a foreign body. This occurs
especially at the anatomical necks of both the humerus and femur.

5. Exuberance of callus with consequent limitation of motion.

6. Insufficient amount or absence of callus, which, when bone ends are
bathed in joint fluids, is not often thrown out.

All of these are _immediate consequences_. The following are among the
more undesirable _remote consequences_ of the same injuries:

1. Exuberant callus, which may be the result of too early attempt to
move the parts, or may result from other causes; it offers more or less
mechanical obstruction to joint movements.

2. Separation of fragments to an extent precluding the possibility of
repair, and interfering with function.

3. Pseudo-ankylosis, as a result of condensation and organization of
blood clot between joint surfaces.

4. Adhesion of tendons to surrounding callus or within their own
sheaths.

5. Displacement and distortion of bone ends with vicious union, for
which the medical attendant is _sometimes_ responsible. Unfortunate
consequences of this kind are generally seen at the elbow after
fractures of the condyles; at the wrist, after incomplete reduction of
Colles’ fracture; at the hip, when insufficient traction has been made;
at the ankle, after the complete form of Pott’s fracture.

6. Exostoses and osteophytic outgrowths, which often complicate
fractures.

7. Absorption of bone, which is usually seen after fractures of the
neck of the femur.

8. Involvement of nerves by pressure of callus, most often seen about
the elbow.

9. Thrombosis leading to obliteration of the deeper and enlargement of
the more superficial veins.

10. Edema, also the result of venous obstruction by pressure of callus.

11. Chronic hydrarthrosis.

12. Arthritis deformans traumatica. This is usually a remote result of
fractures, and manifests itself by slow changes in shape and position,
with deformity and disability. It occurs most often in the aged.

13. Necrosis, which may be the result of failure in the process of
repair and will probably necessitate operation.

14. Malignant changes. These have to do with the occurrence of sarcoma
in bone callus, a complication which is known to occasionally arise.
(See Sarcoma.) It also refers to primary sarcoma, by which bone is
weakened, or secondary carcinoma, which produces the same result.

15. Syphilis. Chronic syphilitic disease is well known to weaken bones
by atrophic processes as well as by the deposition of gumma. It is
known also to delay, or sometimes almost prevent, the process of callus
formation, ossification, and later absorption. Syphilitic patients with
fractures need to be kept under antispecific medicines.

REPAIR OF FRACTURES.

The immediate consequence of a fracture is outpour of blood both from
the broken-bone surfaces and from whatever other tissues may have been
lacerated. This produces, first, a hematoma, which is followed by a
certain degree of local edema, perhaps even of general edema of the
distal parts. The latter will subside with a rapidity proportionate
to the promptness of suitable treatment and the nature of the injury.
The blood begins to coagulate within a short time, while with the
disappearance of the more fluid portion granulations begin to form from
the periosteum, as well as bone surfaces, externally and internally,
and even from the marrow. The clot loses its original characteristics
and is permeated more or less rapidly by granulations. With the site
of the injury wrapped in a mass of granulation tissue we speak of the
so-called _provisional callus_, whose amount will depend upon the
severity of the injury and the accuracy of the replacement of the
parts. If laceration has been but trifling and the bones are accurately
apposed the amount of callus will be small, otherwise it may be
large; so large, in fact, as to be easily palpated and even to cause
edema and pain by pressure. Repair of the fracture is effected by the
gradual conversion of this callus into cartilaginous tissue and then
into bone. So much of it, at least, as lies on the outer side of the
bone and is known as _external callus_ goes through this change. The
_internal callus_, _i. e._, that within the marrow cavity, undergoes a
more direct transformation, which amounts to immediate ossification.
The internal callus usually ossifies completely, and then forms a
_medullary plug_ that serves as an internal splint and affords support
and strength. In time it completely disappears, this time varying in
different cases.

The external callus is converted into bone by passing through the
intermediary condition of cartilage. Between the broken-bone ends
granulation occurs more slowly, and repair at this point is delayed,
partly because of poor circulation and nutrition; but the internal
callus acting as a bobbin within, and the external callus acting as a
solder on the outside, give sufficient support and strength to effect a
final and absolute ossification of all the interfragmentary granulation
tissue. When the time comes when callus is no longer necessary it
begins to disappear by absorption. When everything proceeds normally
callus is absorbed in a proportion commensurate with its loss of
utility. When bone ends have badly united considerable callus remains
permanently. When apposition has been ideal it almost completely
disappears, even the medullary cavity being restored.

Fragments which are completely detached may be reunited by practically
the same primary process, but fragments of considerable size usually
become surrounded by granulation tissue, by which they are nourished
and may be finally reunited, with more or less departure from their
original shape and location. It is in this way that a comminuted
fracture may heal. Fragments that are separated sometimes necrose and
have to be removed.

[Illustration: FIG. 278

FIG. 279

Compound fractures resulting from arm being caught in belting and wound
around shafting. End of radius united to ulna and lower end of ulna to
the radial fragment. Pseudarthrosis of humerus, thrice operated, the
third time in the Buffalo Clinic. (Skiagram by Dr. Plummer.) (Arch.
Phys. Therap., May, 1905.)]

The repair of the flat bones is effected by a similar process, which
is referred to as callus formation. In the skull it is brought about
chiefly through the agency of the diploë, whose powers in this
direction are somewhat limited. Cancellous bone tissue usually throws
out but little callus. Its repair occurs from within. _Cartilage_
heals by a very similar process, though it is not now ossific tissue
but _fibrous_ which reunites the fractured surfaces. Instances of both
kinds can be seen when a fracture has crossed a joint surface.

In a compound fracture much will depend upon the existence or absence
of septic complications. In a clean wound, whence blood and fluid
may have escaped, there will be little but granulation tissue.
Should this wound suppurate the exposed bone surfaces will undergo
at least a superficial necrosis, necrotic particles being removed
by the same granulation tissue which will later bind the bone ends
together. Here, too, the internal callus plays the largest role in the
process of repair. The bone tissue first formed is always coarse and
soft. Complete calcification and restoration of original density and
vascularity occur slowly. Neither cartilage nor bloodvessels alone
appear capable of forming bone; the latter is produced only under the
influence of the _osteoblasts, which penetrate from the periosteum and
the bone itself_ along the course of the bloodvessels.

The process is one of conversion of blood clot into provisional callus,
which then changes into granulation tissue or into cartilage, both of
these materials undergoing subsequent conversion into bone through the
medium of the osteoblasts and osteoclasts (or giant bone cells), the
neighboring bone itself undergoing a rarefying ostitis, to change back
into its original condition with the final changes of the callus.

Repair of intra-articular fractures has already been described as
influenced by the presence of synovial fluid and cartilage. The latter
does not proliferate, and the line of fracture usually appears as a
groove on its surface. At epiphyseal junctions union is usually rapid
and satisfactory, for the changes taking place at this point are in the
direct line of what is needed for repair.

DELAYED UNION; NON-UNION.

The above description refers to the process which is supposed to take
place in normal bone repair. When, however, this is disturbed, as it
may be from a variety of causes, there may be _delayed union_; when it
completely fails we have _non-union_. General conditions have bearing
on these local failures. Whatever makes a strain upon the system may
interrupt the process, _e. g._, pregnancy, lactation, exhausting
hemorrhages, acute diseases, starvation. Again, failure may result from
purely local conditions, such as marked displacement, and particularly
the intervention of some of the soft tissues, or any foreign body.
_Suppuration_ will also frequently cause great disappointment. The
humerus is the bone most often troublesome in this direction; next
the bones of the leg, the femur, and the bones of the forearm. It is
necessary to distinguish between delayed union and absolute non-union.
In the former normal processes may be simply retarded. _When thus
delayed they may be stimulated_ by rough handling, rubbing the bones
together, or by perforating the callus with the point of a drill, from
several directions. This method of drilling was introduced by Brainard,
of Chicago. The existence of syphilis has much to do with delay, and
should be combated by free use of antispecifics. Many patients will be
found to have _phosphaturia_, _i. e._, to be eliminating phosphates
which should go to repairing the bone. Such patients should be given
phosphoric acid, with some of the phosphates, preferably of calcium,
in order to make up for loss in this direction. Much can be done also
by massage, and by everything which stimulates nutrition and general
health (Fig. 280).

[Illustration: FIG. 280

Vicious union with great deformity after fracture, requiring extensive
operation. (Buffalo Clinic.)]

In _non-union_ efforts at repair are at a standstill; the bone ends
become rounded off, the marrow cavity is plugged on either side, while
in time the surrounding granulation or connective tissue undergoes
condensation, as well as organization, and a _capsule_ is formed in
which a certain amount of fluid resembling true synovia collects,
and thus is formed sometimes an almost perfect _pseudarthrosis or
false joint_, whose perfection as a joint must be admired, although
its presence is so deplored. The causes of non-union are now better
understood than formerly, and consist largely in the interposition
of fibrous and muscular tissues, that act as a barrier and keep the
granulation tissue or the callus on one side from coalescing with that
on the other.

_Treatment_ of these cases will vary with their causes. In _delayed
union_ patients should be encouraged to use the parts, thereby causing
greater activity, but in the presence of an actual _false joint_ no
method is of avail except that of actual exposure, by incision, with
removal of all intervening fibrous tissue, and freshening of the bone
surfaces by saw or chisel, the endeavor being to so shape them that
they may lie in contact, and then be so maintained, by some mechanical
expedient, such as a wire nail or suture, an ivory peg, a chromicized
tendon, a bone ring, a small metal brace fastened with screws, or by
any other expedient which may suggest itself to the ingenuity and
the means of the operator. There are, however, occasions when one
deliberately endeavors to secure a pseudarthrosis, as after ankylosis
of the shoulder-joint, if in making powerful effort to break up
adhesions the neck of the humerus should snap it would be better to
prevent union rather than favor it, as in this way something resembling
the original joint, so far as function is concerned, would be obtained.
At the hip, also, after such an accident, the same principles may be
adhered to or more deliberately secured by a subcutaneous osteotomy, as
is sometimes done for relief of deformity.

_Fibrous union_ implies such organization of granulation tissue as
converts it into simple fibrous or ligamentous tissue, the change
stopping here and not going on to formation of cartilage or bone.
There are three localities especially where fibrous union is sometimes
the best that can be obtained and often proves sufficient of itself;
these are the olecranon, the patella, and the neck of the femur.
Even though the halves of the patella be separated by two inches of
ligamentous tissue the patient may still have reasonable use of the
limb. A separation of half an inch to one inch at the olecranon does
not materially disable the arm, while at the hip-joint two or three
inches of ligamentous tissue between the main end of the bone and the
fragment will not totally interfere with locomotion, except so far as
it permits an equivalent amount of shortening of the leg. There are,
then, occasions especially when the hip is involved in elderly and
decrepit people, when ligamentous union is the best that can be hoped
for or attained.

TREATMENT OF FRACTURES.

In principle the treatment of fractures is very simple. It consists
in _putting the parts in apposition and maintaining them there_ for
sufficient time to permit of complete repair. That which is so simple
in theory is often very difficult and sometimes even impossible in
practice, made so by the nature of the injury or the disposition of the
patient. In the aged, who cannot lie long in one position for fear of
pulmonary stasis; also in the insane, in the epileptic, and in those
suffering from delirium tremens, will be met difficulties which are
insuperable. In such instances the first indication is to preserve the
life of the patient, the second is to get a good result, the third
is to do the best we can. Good management is not the least important
feature of such treatment. This will include suitable nutrition,
provision for elimination, prevention of bed-sores or pressure-sores,
and many other less important features.

Diagnosis having been made, the surgeon should study how he may best
carry out the fundamental principle of putting the parts in apposition
and so maintaining them.

The greatest obstacle to reduction and maintenance in position is
_muscle pull_. After an injury of this kind there will be more or less
muscle spasm, the more powerful groups displacing bones in the natural
direction of their pull. In the humerus and femur especially all arm
or thigh muscles will coöperate to produce shortening. As indicated
in the chapter on Joint Affections, nothing so thoroughly overcomes
chronic muscle spasm as _traction_. The principle underlying treatment
by traction is exceedingly simple, but there are numerous ways and
mechanical expedients for effecting it. In the lower limb, whether this
shall be done by anterior suspension, by weight and pulley, by elastic
contraction, or by some of the more complicated splints, matters little
so long as it be efficiently made. Of all these methods it may be said
in general the simplest is the best. In the upper extremity traction
may be made by similar methods with the patient in bed, or the patient
may be allowed to rise and be about with a weight hanging from the
elbow or some simple expedient of this kind.

The method of traction is one to be combined usually with further
protection, by which not only longitudinal but lateral displacement
maybe overcome. This suggests the use of _splints_ in addition to mere
traction methods.

It is not always possible to put in operation at first that method
which we may prefer a little later, as _swelling_ is usually so
pronounced as to make it advisable only to put the parts at rest and
hasten absorption. The same is true of hemorrhage. In rarer instances
it may be a question as to whether the distal parts may undergo
gangrene from the disturbance of circulation. These are matters to be
duly regarded before the later and more complete dressing. _Mechanical
aids_, usually in the shape of splints, are therefore necessary. The
physiological rest which it is so necessary to ensure will lead to a
certain wasting of muscles and stiffening of joints, which are only
temporary, but which by no means lessen disability when splints are
removed. _That splint is best for a given case which best fits it and
permits the surgeon to carry out its peculiar indications._ The writer
is opposed to manufactured splints, as they seldom fit the part. This
can be obviated by packing cotton or other compressible material into
the splint. For temporary purposes they will frequently suffice. For
fixed dressing, however, it is preferable to make a splint which shall
fit the limb to which it is affixed. Immobilization is difficult of
accomplishment and at many points impossible. Thus in fracture of the
ribs or clavicle it is impossible to avoid a certain amount of motion
with each respiratory effort, even though an uncomfortably tight
dressing be applied.

Splints are made of various materials, metal, wood, various
compositions hardened in molds, plaster of Paris, or some of its
substitutes, _i. e._, glue, soluble glass, or a composition like one
made of equal parts of powdered starch and fine isinglass, added to a
solution of potassium silicate, this being allowed to stand for several
days, after which a little fine boric acid powder is added; when this
is painted over gauze dressings it solidifies and forms a light and
rigid splint. There is one objection to all methods which comprise a
solution that hardens slowly--that is, that during the time required
for the purpose redisplacement may occur. It is not advisable to dress
a recent fracture in a wet pasteboard splint or in such a composition
as that mentioned above. Later, when a certain amount of consolidation
has already occurred they may serve a useful purpose.[38]

  [38] Jenkins’ packing, such as is used on some engines, has been
  recommended by Spotswood as a substitute for plaster-of-Paris
  bandages, its advantages being that it is not affected by any
  antiseptic washes as a plaster dressing would be, that it is lighter,
  and that by placing it in hot water it can be molded to assume the
  shape of the limb.

There are two methods of using plaster of Paris: one is gauze bandages
sprinkled with it, rolled, and kept ready for use, to be placed in
water at the time of their employment. A limb may be enveloped in
these, after being covered with a layer of wadding or some other
protective material, by which the plaster shall not come in actual
contact with the skin. It is also a good plan to place a strip of tin
or pasteboard along the exposed surface of the limb, over which the
surgeon cuts to remove the splint. Thus one may avoid any danger of
injuring the skin with the point of the knife. It is also a good plan
to make at least a part of this cut before the plaster has sufficiently
hardened, _i. e._, to do most of the work, leaving perhaps a layer or
two of gauze to be cut through some time later. It is necessary to
impress the fact that when a quickly hardening fixed dressing is used
approximation should be ensured by the greatest attention, maintaining
it until the splint is so hardened that redislocation is impossible.
Another method of using plaster of Paris is by sopping strips of
surgeons’ lint, ordinary canton flannel, or almost any other similar
material, in plaster-of-Paris cream, then molding these to the injured
limb, maintaining the same rigid precaution as to the proper position
of the same while the splint hardens. In this way a splint can be
adapted to the part, and, at the same time, made removable, permitting
as frequent access to it as may be desired.

COMPOUND FRACTURES AND THEIR TREATMENT.

As already stated, it is the communication of fractured bone surfaces
with the external air which makes a fracture compound in the strictly
surgical sense. This may occur through a minute and tortuous opening
or through a large and extensive wound. Although the communication is
with the atmosphere the danger comes not so much from germs floating
in the air as from those on the surface of the body and within the
pores of the skin, or else from foreign material admitted through the
external wound. Obviously the great danger is of septic infection.
Whether the tissues may prove more or less susceptible, and thus
resist or break down, cannot at the outset be foretold. This leaves
but one imperative ride to follow, _to act in every instance as though
serious injection had occurred and to take precautions accordingly_.
Even a small puncture made by a spicule of bone may permit germs to
be withdrawn into the tissues as the bone is replaced. If, then, the
surgeon seals such a puncture he necessarily takes the chances and must
abide the result. Whether he shall do this or not will depend upon the
patient and the injury. At all events, the site of puncture should be
carefully cleansed and disinfected and the case so dressed that it
may be carefully watched. Complete sterilization of every particle of
exposed tissue is absolutely necessary, and for this purpose hydrogen
dioxide or some of its later substitutes will prove effective. A
protruding splinter of bone should be removed with cutting forceps,
unless the wound must be enlarged as a part of the treatment of the
fracture. In most instances it will be safer to pursue this course,
_i. e._, to extend the wound which makes the fracture compound, to a
degree permitting thorough exploration and cleansing. Not infrequently
fragments of bone will be found, which when nearly or completely
detached should be removed. Such a free opening permits also of wiring,
or other means of fastening together bone ends, by which apposition may
be more perfectly secured. _A compound fracture which has been long
unattended may be safely assumed to be septic._ Here free incision,
with cleansing and ample drainage, will be a far safer course than
non-compliance with the general rule.

_Compound fractures of the skull_ are nearly always depressed
fractures, and practically always call for operation. Their proper
treatment will be dealt with when considering Injuries to the Head. A
fracture of the ribs may be made compound by penetration of a sharp
bone end, and such injury to the lung as may permit air to escape into
the pleural cavity. Such a pneumothorax may be followed by a hemothorax
and hydrothorax, and these perhaps by empyema. Compound fractures of
the pelvis are not infrequently complicated by perforation of the
bladder or bowel, or rupture of the urethra, or some other serious
visceral injury which may determine their fate. Compound fractures
are difficult of treatment because they entail frequent changes of
dressing and prevent the use of desirable splints. These fractures
are also sometimes so serious as to necessitate amputation, which may
be necessitated either by such comminution of bone as to make repair
impossible, or such injury to vessels as may determine gangrene. If
the circulation can be shown to be sufficient, either at the time or
perhaps by delay of a few hours or a day, a limb may be saved by the
resection of one or both bones, which in pre-antiseptic days would have
required amputation.

The surgeon does not always see these cases in their recent or
fresh state. He may be called to a case complicated by suppuration,
cellulitis, and sepsis. Here though amputation may be required he may
still delay it, hoping to improve local conditions, and thus to make it
more promising, or he may have to resort to various expedients, such as
suspension with constant irrigation, or temporary packing with yeast,
in order to justify any further attack upon the parts already involved.

In the treatment of compound as of simple fractures we should never
lose sight of the _dangers of too tight bandaging and of pressure
sores_. I have seen both these lead to gangrene, with its necessary
mutilation, in cases where the attendant has forgotten the proneness of
injured parts to swell, and has either not allowed for this within the
dressings or has not atoned for it in time when it has already occurred.

In the treatment of all these cases the operator should never forget
the medicolegal aspects of such a case nor the necessity for constant
attention and caution on his part. He should remember that his minutest
precautions will often be disobeyed. He may, however, be cheered
by the fact that only in cases of carelessness will he incur legal
responsibility.

SPECIAL FRACTURES.

Fractures of the skull and of the vertebræ will be considered under the
respective headings of Injuries to the Head and to the Spine.

FRACTURES OF THE NOSE.

The nose is the most frequently broken of all the bony parts about the
face. One nasal bone or both may be broken, and each may be separated
from its bony supports as well as from the other. The fracture may be
compound in either direction, most frequently so into the nasal cavity,
as a result of which infection may as easily take place from within as
from without. The cartilages may also participate in the injury.

The injury would be easy of recognition were it not for the amount
of swelling that often accompanies it. The signs are mobility and
crepitus, with more or less deformity. So long as the nose can be
grasped between the fingers recognition of fracture is easy. If
swelling prevents this an instrument or the finger can be passed into
one nostril and combined manipulation practised. There is generally
more or less bleeding from the nose, and sometimes considerable
emphysema. Swelling and ecchymosis are also often pronounced. This
will all subside under cool and soothing applications. The most
important indication is to replace the nose and hold it where it should
remain. The difficulty is increased by the efforts which the patient
instinctively makes to dislodge clot or secretion. The importance
of accurate reposition is in some cases sufficient to justify an
anesthetic and instrumental help. This will permit of the application
of such force as may be necessary to elevate or to shift fragments,
while a gutta-percha splint may be molded upon the outside, or a
sterilized pin or needle made to transfix the nose from one side to
the other (Mason), passing behind the fragments and through the septum
in such a way as to keep it from dropping backward. A good plan is to
introduce a tube into each nostril, perhaps a piece of silk catheter,
around which a certain amount of gauze can be packed, and which can
thus be used as an internal splint, while on either side and externally
a little roll of gauze is held in place by adhesive plaster crossing
the cheeks. The operator should take as much pains to see that the
septum is in its original position as in attending to outside and
cosmetic effects. The septum can be controlled by a pair of forceps.

A nose properly held in place will heal within a few days, to a point
requiring little if any support. A transfixion pin should not be
needed, if used, for more than four or five days. An internal splint
should be removed each day, so that the nose may be sprayed with
cleansing solution (Dobell’s) and retained secretions removed.

The disfigurement resulting after this injury is dropping in at the
root of the nose, constituting the so-called _saddle-nose_ defect.
Such disfigurement as results can be later atoned for by subcutaneous
injection of paraffin. (See chapter on Surgery of the Face.)

FRACTURES OF THE SUPERIOR MAXILLA, WITH OR WITHOUT OTHER BONES OF THE
FACE.

The more protected portions of the upper jaw are rarely fractured,
save by extreme violence. The _alveolar process_, with one or several
teeth, may be partially or completely detached. Such fractures are
compound, and after replacement need antiseptic mouth-washes as well as
other attention. Usually the teeth in the fragment can be utilized for
the purpose of fastening it back into place by means of the uninjured
teeth, retention being secured by wire or waxed silk. Extensive
detachment may necessitate sutures through drill holes. The lower jaw
can usually be utilized as a splint for the upper by binding the jaws
firmly together and feeding the patient on fluid food. When one or two
teeth are loosened or displaced it will often be possible, if they
can be promptly secured, to successfully _reimplant_ them in their
sockets. Both the sockets and the teeth should be thoroughly cleansed.
After replacement it will be necessary only to ensure absolute rest and
retention in position.

In regard to other _facial bones_ there is no injury which may not
occur, as the result of direct violence. The _zygoma_ and the _malar
bone_ may be broken away, or the entire collection of facial bones may
be loosened from their connection with the bones of the skull proper.
The margins of the _orbit_, or its walls, may also be injured, and the
sinuses opened, with perhaps more or less entrance of foreign material.
These fractures are generally compound and are accompanied sometimes by
injuries to the soft tissues. It becomes then a question not merely of
cosmetic result, but of avoiding infection and saving life. The latter
is the more important, and measures should first be directed to that
object. Satisfactory results can be attained by drilling and holding
bone fragments together with tendon or other sutures, and by neatly
trimming and cleaning wounded surfaces and bringing them together.
Subcutaneous sutures should be used for this purpose.

FRACTURES OF THE INFERIOR MAXILLA.

This bone is broken nearly as often as the nose, and almost invariably
by direct violence. Here, as in the upper jaw, there may be trifling or
serious fractures of the _alveolar process_, which should be treated
on the same principle as above set forth. Fractures of the rami occur
more often in those parts which are occupied by teeth, or from which
teeth have dropped out by senile changes, the jaw being weakened at
these locations. The most frequent seat of fracture is near the middle
line. Fractures of the _ascending ramus_ and of the upper processes
are rare. Double fractures are not infrequent, the lines of separation
being rarely symmetrical. The gum and the skin are often torn and the
majority of these fractures are compound. The bone is considered to
be weakened at the dental foramen; at all events it often yields in
this vicinity. By fracture with much displacement posterior to this
opening the inferior dental nerve may be injured or torn. The condyle,
after extreme violence, has been known to have been driven up into the
cranial cavity through the base of the skull. _Gunshot fractures_ are
nearly always comminuted (Figs. 281, 282 and 283).

[Illustration: FIG. 281

Use of silver wire in fixation of fragments by utilizing the teeth.]

[Illustration: FIG. 282

FIG. 283

Bandage and splint for fracture of lower jaw. (Bryant.)]

The _signs_ of fracture of the lower jaw are unnatural mobility,
crepitus, displacement, pain, and loss of function. No bone in the
body is more easily investigated by sight and touch, and recognition
of these fractures is usually easy. Pain is provoked by attempting to
move the jaw, even in talking, and depends on the extent to which the
inferior dental nerve is injured. Irregularity in the line of the teeth
will sometimes permit recognition. These fractures furnish excellent
illustrations of the effect of muscles in producing displacement. Those
of the tongue and the floor of the mouth, as well as the anterior
muscles of the neck, will pull the fragments in various directions,
according to the direction of the line of fracture and its location.
This displacement may be trifling or serious. These fractures are
often compound, internally or externally, such injuries constituting
an unpleasant complication, but affording occasionally an opportunity
for fastening fragments by drill or wire suture, which would
otherwise require an opening to be made. In every instance antiseptic
mouth-washes should be frequently used.

=Treatment.=--The treatment is simplified when the dentition is good
and regular so that the fragments may be fastened together with wire
or waxed silk ligature around the adjoining teeth, and then fixation
accomplished with a simple molded gutta-percha or plaster-of-Paris
splint, by which the lower jaw is held firmly against the upper. Such
a dressing is held in position by a four-tailed bandage (Fig. 283). A
silk or wire loop, used for the purpose just mentioned, should include
two teeth on either side of the fracture, for by constant tension the
nearest tooth will soon loosen, and if this were next to the break
the effect of such displacement would be injurious (Fig. 281). When
the line of fracture is oblique there is often greater difficulty in
adjustment.

While the simplest means by which the fragments may be kept in position
are the best, there should be no hesitation in serious cases to resort
to operative measures having for their purpose the insertion of wire
sutures or their equivalent. These are inserted after drilling the bone
at suitable points, and are introduced with a view to their subsequent
removal, the ends being left projecting in order to facilitate this. In
clean cases, where the incision is made in unbroken skin, the ends may
be twisted short and turned in, previously to closing the wound. Such
operative treatment is required when there has been a double fracture,
the central fragment being badly displaced by groups of muscles which
tend to pull it downward and backward.

A dentist should be consulted, as he may be able to make a mold and
then construct a plate or _interdental_ splint, by which a more perfect
reposition may be effected.

Swelling, emphysema, ecchymosis, etc., may be treated in the usual way.
Irritation is likely to provoke free secretion of saliva; this may be
combated by small doses of belladonna. Patients should be fed by fluid
or thin semifluid food, and mouth-washes should be frequently used.

FRACTURES OF THE HYOID BONE.

The hyoid may be broken by direct violence, either locally applied or
by forcing the head backward. Fracture of the bone itself is not so
serious as the lesions which accompany or follow it, either hemorrhage
or inflammation, with _edema of the larynx_, which may impede
respiration or cause strangulation. Fracture produces difficulty in
breathing, swelling, and pain on talking. It is doubtful if bony union
is attained, but fibrous union answers equally well. The treatment
consists essentially of physiological rest. Edema may necessitate
tracheotomy, and dysphagia feeding by an esophageal tube or by the
rectum. Should the fracture be compound, or should a fragment be
displaced so as to be detected, it may be removed through suitable
incision.

FRACTURES OF THE LARYNX.

This may be fractured by injuries of the same character as those which
fracture the hyoid, except that it is more exposed to the direct
violence of a blow, as from a baseball. In elderly people in whom
calcification of the laryngeal cartilages has occurred fracture is
more dangerous than in the young. Injuries which produce these lesions
are of a serious nature, as prompt swelling, either from hemorrhage
or edema, occurs and threatens respiration. For illustration a death
occurred on the baseball field within a few minutes after reception of
a blow upon the front of the neck with laryngeal fracture; the cause of
death was suffocation due to swelling, which might have been averted if
tracheotomy could have been performed. In the milder injuries of this
kind much can be done with sprays of cocaine and adrenalin, to quiet
laryngeal irritation and reduce vascularity.

FRACTURES OF THE STERNUM AND RIBS.

Fracture of the _sternum_ in childhood is exceedingly rare. In adults
it may occur in connection with other injuries or as a solitary lesion.
Such a fracture, of itself, would indicate in most cases excessive
violence. It is usually more or less transverse, the periosteum being
rarely so torn as to permit of much escape of blood. Cases are recorded
in which it has been broken in straining during the act of parturition.
It is most commonly injured by compressing and crushing injuries.

Sternal fractures are followed by much pain, aggravated by deep
respiration and made worse by pressure. Sometimes displacement can
be made out, while crepitus may be detected with the stethoscope.
Occasionally there is sufficient deformity to make the injury apparent
at a glance.

Displacement should be reduced and apposition then maintained by a
plaster-of-Paris jacket or other suitable apparatus. It is advisable in
some cases to anesthetize the patient and to make a sufficient opening
that instruments may be used by which fragments may be lifted or pried
into place. This should be done under aseptic precautions.

_Diastases or separations of ribs or cartilages_ from the sternum
or from each other have essentially the dignity of fractures, are
recognized by the same general signs, and are treated in the same
general way. A cartilage may snap in the young, and in the old, when
calcified, may break as would a bone or even a pipe-stem.

_The ribs_ are usually broken in their lateral aspects, but rarely
between the head and angle. They may be fractured by muscle action or
by external violence, examples of the former being violent efforts at
lifting or sneezing. Violence may be applied in so many ways that it
is not necessary to specify them. Fractures may pertain to one or to
several ribs in proportion to the extent and violence of the exciting
injury. In some crushing injuries an entire section of the chest wall
may be broken loose and depressed, this corresponding to a depressed
fracture of the skull. Rib fractures are usually of themselves
innocent, but may be made serious by _complications_, as when the
pleura is torn, or an intercostal artery bleeds profusely, or when a
jagged fragment of bone first scratches and then perforates a lung.
This will lead first to the outpour of blood and then of pleuritic
fluid, by which in a short time the lung will be separated from the
chest wall. Should infection occur through the injured lung, _i. e._,
entrance of germ-ladened air, then empyema may seriously complicate
matters and later necessitate operation. Even the heart has been
injured, in several reported cases, by projecting fragments of bone.
Gunshot fractures of the thoracic wall imply those features pertaining
to every compound fracture, plus the injury possibly done to the lungs,
heart, or mediastinal contents, such as hemothorax or pneumothorax.

The first and second ribs are so protected and the eleventh and twelfth
so movable that by far the greater proportion of rib fractures pertain
to the eight intervening ribs.

=Symptoms.=--These are often vague, when but a single rib has been
cracked through and not displaced, and comprise pain on pressure,
as well as that provoked by deep breathing, coughing, and certain
other movements. Should this pain be limited, or constant and
made worse by pressure, fracture of the rib may be suspected. If
auscultation crepitus can be heard, diagnosis is at once made. When
abnormal mobility is unmistakable, or when by any means crepitus is
elicited, the signs are positive. Sometimes the patient himself will
recognize crepitus. This may be learned either by auscultation or by
pressure with the flat hand over the affected area. _Emphysema_ is an
unmistakable evidence of fracture with perforation, while the signs of
the presence of fluid in the chest cavity will also indicate fracture.

=Treatment.=--Fracture of one or two ribs with displacement is
ordinarily a matter of trivial import, the adjoining ribs acting as
splints. It necessitates practically nothing but physiological rest,
which may be best afforded by keeping the patient in bed, with _firm
compression_ around the chest, made either with a binder of strong
cloth or a broad piece of adhesive plaster carried nearly around the
body, or in more aggravated cases by a plaster-of-Paris jacket. In thin
individuals the formation of callus can be recognized by the sense of
touch. So soon as this is fairly formed displacement is less likely
to occur and uncomfortable compression may be relaxed. Should there
be external angular displacement this may be corrected by pressure. A
projecting fragment which threatens to perforate should be cut away
with bone forceps through a small incision, taking pains to permit as
little air as possible to enter. If there be a _traumatic pneumothorax_
the air should be removed with an aspirating needle. When it is evident
that there is serious injury to the chest wall and that air has already
separated the lung from it (traumatic atelectasis) the parts should be
freely exposed, to permit the rounding off of bone ends, the seizure
of intercostal vessels, the cleansing out of the pleural cavity, with
perhaps later wiring of fragments or else their complete removal and
closure of the external wound with or without drainage, as may be
required. If blood or air has already escaped into the pleural cavity
the blood should be speedily removed. The same plan is advisable
in fractures of the cartilages. Sedatives to check cough, _e. g._,
heroine, are also indicated.

FRACTURES OF THE CLAVICLE.

The clavicle and the radius are the two bones most frequently broken,
the former more often in the young, the latter in the elderly; the
clavicle yields both to direct violence, as by blows on the shoulder,
and that which is transmitted through the arm from the elbow or hand.
For convenience of description the bone is divided into thirds, the
most common location for fracture being near the junction of the middle
and outer third. Save for epiphyseal separations the extremities of the
bone are seldom broken. In spite of its subcutaneous position and its
proximity to large vessels, compound injuries or other complications
are quite uncommon.

The clavicle is the brace which keeps the shoulder proper from falling
upon and around the thorax. _Consequently when it is broken the
shoulder tends to drop downward, forward, and inward_, except in a
green-stick fracture, while even then there may be some displacement in
these directions. Deformity is usually easily recognized, one or other
fragment projecting beneath the skin in such a way as to be easily
palpated. There is enough spasm of cervical muscles to draw the head
over toward the affected side, while there is loss of function in the
affected arm. Pain is made worse by pressing the shoulder inward as
well as by moving it in any direction.

In young children the bone is often broken with a minimum of
displacement. Fracture of both clavicles is not so very rare. Trouble
may occur later in the course of the case from pressure of exuberant
callus upon nerves and even vessels. This is to be prevented by
foresight and by careful attention to maintenance of parts in proper
position.

=Treatment.=--The multiplicity of dressings which have been suggested
for fractures of the clavicle attest the fact that so long as primary
indications are observed the treatment can be made very simple. These
indications are to _keep the shoulder upward, outward, and backward_,
as it tends to drop in the opposite way. The action of three muscles is
of great importance in considering the proper treatment of these cases,
_i. e._, the sternomastoid and the trapezius, because they tend to pull
fragments upward, and the pectoralis major because advantage can be
taken of its arrangement to overcome upward displacement. It was Moore,
of Rochester, who taught many years in Buffalo, who showed how this
could be done. The fibers of the great pectoral which arise highest,
_i. e._, from the clavicle, are those which are inserted lowest along
the bicipital groove of the humerus, because of the semi-revolution
made by the tendon of this muscle as it passes to its insertion. By
putting the arm in such a position that these fibers are pulled upon
the operator may counteract the upward pull of the other muscles just
mentioned. This is the underlying feature of Moore’s suggestion; to
force the elbow far backward, into a position which is for the time
being uncomfortable, in order thus to pull down fragments which jut
up beneath the skin. Any dressing which permits this position to be
maintained will be equally serviceable. Moore suggests for this purpose
what he calls a double figure-of-eight, which is shown in Figs. 284 and
285. It is put on as follows: A strip of cloth, sheeting, or anything
of the kind, about two yards in length and folded sufficiently to make
a strong strip eight inches wide, is held near its middle over the
surgeon’s hand. This hand is placed beneath the elbow of the injured
side, so that the strip crosses the under surface of the flexed forearm
at the elbow. One end, which should be the longer, lying to the inner
side, is passed upward and in front of the arm, carried over the
shoulder across the back and under the opposite axilla, then over in
front of the sound shoulder, meeting on the back the other end, which
is carried up first over the outside of the forearm, then behind the
shoulder and across the spine. This bandage should be pulled tightly,
while an assistant holds the elbow as far backward and upward as the
patient can tolerate it, as the more the position is exaggerated the
more are the clavicular fibers of the muscle pulled upon and the
better are the fragments held in place. This dressing not only meets
the three primary indications laid down, but gives the added advantage
just described. By it the shoulders are drawn backward and fixed to
each other. The _elbow should be lifted_ as the dressing is applied, so
as to lift the shoulder. Most of the cloth materials used for such a
dressing are more or less elastic, and it may need to be tightened once
or twice a day during the time that it is worn. After a few days, when
consolidation should have occurred, it may be changed for some other
less irksome form of dressing. The hand should be supported in a sling.
This dressing is useful in dislocations of the clavicle, especially of
its outer end, and in every kind of injury in which the indication
is to hold the shoulder upward and backward. In simple cases without
much displacement the primary indications may be more simply met by a
dressing of adhesive plaster, known in the East as Sayre’s and in the
West as Freer’s. It consists of two strips of plaster of about the
width of the arm itself. One of them is wound around the upper end of
the arm, close to the shoulder, in such a way that, as it is passed
around the back and brought over the chest, the arm and shoulder are
pulled backward. The other strip passes from beneath the elbow of the
injured side obliquely up and over the opposite shoulder. When it is
applied the elbow should be _firmly lifted_. After the completion of
either of these dressings the injured shoulder should appear at least
one inch higher than the well one. Should the patient’s arm and chest
be hairy they should be shaved before the application of the plaster
strips. Like other material, plaster will stretch and slip, and these,
like other dressings, should be readjusted every day or two, _for the
shoulder should be kept elevated for at least a week_.

[Illustration: FIG. 284

Moore’s apparatus (back view).]

[Illustration: FIG. 285

Moore’s apparatus (front view).]

When the case is complicated by other injuries necessitating
confinement in bed it is sufficient to keep the patient flat upon
the back and without a pillow. In this position the shoulder falls
naturally in the direction desired, and perhaps no other attention will
be required. Many other methods are combined with a figure-of-eight
bandage, crossing the back and forming a loop over each shoulder, so as
to keep it from dropping forward.

While the results of treatment are nearly always good, if one is
insistent upon a minimum of deformity, confinement upon the back on
a hard bed is the surest way to obtain satisfactory results. Cases
in which there is little or no tendency to deformity need only the
simplest support by which rest may be ensured.

Epiphyseal separations are to be treated as fractures.

FRACTURES OF THE SCAPULA.

The most frequent fracture of the scapula is that of the _acromion_;
this is usually the result of direct violence, such as a fall upon the
tip of the shoulder. Detachment of this fragment permits a peculiar
flattening of the shoulder, but without dislocation. The fragment
can be easily felt, while the deltoid is displaced and its rounded
contour lost. Treatment consists solely in _forcing the arm upward_, by
dressings applied beneath the elbow, thus lifting the fragment into its
place; fibrous union occurring here much more often than osseous, the
latter is possible only in case a good apposition be maintained. Any
form of dressing, then, by which the elbow is crowded upward and rest
maintained will be appropriate.

The _surgical neck_ is occasionally detached, sometimes with and
sometimes without the coracoid process. As the humerus is attached
to it by the capsular ligament the arm drops with the fragment when
the patient is in the upright position, and the elbow will be found
lower than that of the injured side. The arm is unduly mobile, and the
fragment can usually be seized and crepitus obtained within the axilla.
Here it is necessary to hold the arm up, as it controls the position of
the fragment. It is usually sufficient to lift the elbow up and bind
the arm firmly to the side, the scapula being immobilized by broad
straps of adhesive plaster.

The _coracoid process_ is occasionally detached, usually by muscular
violence, _i. e._, it is pulled off by the coracobrachialis and
the coracoid head of the biceps which arise from it. The injury is
recognized by failure to detect the process in its proper place, and
usually by discovery of the fragment at a point below its normal
position, to which it has been drawn out by the muscles arising from
it. Ligamentous union can be secured by relaxing these muscles, which
is done by placing the hand over the opposite shoulder and dressing the
arm firmly against the chest. I have seen paralysis of the arm result
from excessive callus after fracture of the coracoid.

The _spine_, _body_, and the _angles_ of the scapula are occasionally
broken by severe violence. In the aged comminution may occur. Crepitus
can be nearly always obtained. It may be necessary to distinguish
the scapular fracture from one of the ribs beneath it. The treatment
consists in simply fixing the shoulder-blade upon the chest, to which
it is naturally adapted, by firm bandages, which shall immobilize not
only it but the arm as well.

FRACTURES OF THE HUMERUS.

At the _upper end_ of the humerus we deal with fracture of the
processes, _i. e._, the _tuberosities_, which may be torn off by
violent action of the muscles therein inserted; of the _anatomical
neck_, which is rare and occurs most often in the aged; of the
_surgical neck_, which is the most common; or, in the young,
_epiphyseal separation_, which is the equivalent of the last named.
Separation of the tuberosities is diagnosticated mainly by exclusion,
possibly by _x_-rays. The _anatomical neck_ lies within the capsule,
and should the head be thus detached it might remain as a foreign body
in the joint, having no means of securing nutrition. Fractures of
the _head of the bone_ are not classical and are usually the result
of gunshot injuries or extreme violence. In all of these injuries
there will be swelling, loss of function, while crepitus is sometimes
obtained, but is very difficult to locate, even under an anesthetic.
The diagnosis is to be made mostly by exclusion.

The _surgical neck_ is the most frequently broken; the line of fracture
passing below the tuberosities and above the muscles inserted along the
bicipital groove. Therefore the pectoralis and the latissimus muscles
will both conspire to pull the upper end of the shaft toward the thorax
to such an extent that it can be felt in the axilla. This gives its
axis a different direction, while all the muscles extending from the
shoulder to the forearm will tend to produce shortening. Deformity
is usually distinct, crepitus is easily obtained, and undue mobility
is well marked. The head of the bone can be detected in its proper
place beneath the deltoid, but does not rotate with the shaft. In rare
instances a certain amount of impaction may make this evidence of
fracture obscure. _Epiphyseal separation_ will give the same signs and
symptoms.

=Treatment.=--The primary indication here is to overcome muscle pull
by traction in a direction toward the crest of the pelvis of the same
side. At the same time, with a certain degree of coaxing of the upper
end of the shaft outward and a little forward, it may be possible to
so re-apply broken surfaces to each other, and so affix the arm to
the thorax, as to be effective. When serious difficulty, however, is
encountered the writer advises traction, applied to the arm alone, if
the patient be able to be upright, or to the arm and forearm, if he be
confined in bed. It will take considerable stretching to overcome the
combined action of all the muscles which tend to produce displacement.
Along with such treatment a coaptation splint should be applied, the
best being that which can be carefully molded to the parts and adapted
to their needs. For this purpose a molded plaster-of-Paris splint is
preferable to one of metal made to some standard size. In the dressing
it is necessary to include not only the shoulder and arm but also the
forearm, otherwise the principle of physiological rest would not be
enforced. Fig. 286 illustrates the common tendency to displacement in
these injuries.

_Fracture_ of the surgical neck is occasionally combined with
_dislocation_ of the head of the humerus, by which such an injury is
seriously complicated. Reduction may be attempted by manipulation.
Until recently it was generally advised to wait for a week or ten days,
and until consolidation had occurred, and then to make the attempt at
reduction; but Porter and McBurney have shown that it is advisable
to cut down upon the dislocated upper fragment, and, fixing it with
forceps or with an instrument shaped like a corkscrew or hook, to
force it back into place again. If this be done under the strictest
precautions it lends no serious features to the case, while, in most
respects, such a procedure would greatly simplify it, the wound being
closed with or without drainage, and the usual fracture dressing being
applied.

In cases of _old fracture and dislocation_ the head of the bone should
be exsected, the functional result thus obtained being excellent.

_Epiphyseal separation has been too often mistaken for dislocation._
Fig. 287, from Moore, shows how the periosteum is not necessarily
entirely detached, but is stripped up to form a hinge, the fragment
displaced forward, and its outer aspect often turned upward. This
makes traction in an outward direction an essential feature of the
replacement of the fractured surfaces, the manipulation being combined
with fixation of the fragment so far as it can be seized through the
axilla. If the epiphysis is properly slipped over upon the end of the
humerus the case assumes ordinary features, and is to be dressed as
usual.

[Illustration: FIG. 286

Fracture of the surgical neck of humerus. (Hoffa.)]

[Illustration: FIG. 287

Separation of the upper epiphysis of the humerus; displacement forward
of the lower fragment. (Moore.)]

The shaft of the bone is frequently broken, lines of fracture
running in all directions and occurring at all levels. A variety of
displacement may take place. The evidences of fracture are usually
recognizable and diagnosis is not difficult. The brachial artery and
the musculospiral nerve are occasionally involved, either in callus
or by primary injury from a spicule of bone. These fractures are more
liable to delay in union or even to non-union than almost any others.
These occur often without evident cause, while more or less absorption
of bone has been known, by which complications are produced.

In the _treatment of fractures of the shaft_ posture is necessary to
observe, the fragments not only being held in position, but the axis
of the bone being maintained. An external splint, extending up to and
rounded over the shoulder, and an internal splint molded to the inner
side of the arm, taking in the elbow and forearm, and placed at a right
angle, and then the immobilization of the entire arm by its fixation to
the body will give the best result. The writer prefers to make these
of plaster of Paris, by molding strips of surgeons’ lint sopped in
plaster cream, and maintaining the limb in the desired position while
they harden. Should comminution be extreme, or shortening difficult
to overcome, a few days’ confinement in bed, with traction upon the
forearm, either extended or included in the above dressing, by the
usual method, with weight and pulley, will give the best result. So
soon as callus has bound the ends of the bone together the patient may
be released from bed and the arm left in the right-angle position, in
plaster, as above. Or over such a splint as has been described, made
of molded plaster, may be hung by a bandage at the elbow sufficient
weight (a bag containing shot) to maintain constant traction upon the
lower fragment, while the patient is in the upright position, and to
influence for good any overlapping or displacement of any kind during
the critical period when the bone ends are being united by callus.

The _epicondyles_ are occasionally chipped off from the condyles,
the internal being the more frequently injured. These detachments
are extra-articular and are relatively unimportant, the fragments
being kept from displacement by their fibrous investments. If such an
injury should be compound any fragment completely loosened should be
removed. It is sufficient to dress such an injured elbow with cold
wet compresses in the flexed position. _Supracondyloid_ fracture, or
its equivalent in the young (an _epiphyseal separation_) are somewhat
similar, the latter occurring nearer to the articulation than the
former. In each of these injuries the arm is flexed and shortened,
the fragment lying usually in front of the shaft and the olecranon
protruding posteriorly. The more the arm is extended the more prominent
the deformity, while by flexion it is much diminished. Hence the
advantage of dressing it in the position of overflexion sometimes
called Jones’ position.[39] Injury to the vessels at the bend of the
elbow may occur in these fractures. If not dressed in this position
the elbow should be put at a right angle, while a weight is slung over
the elbow, as already mentioned above. Joint function will be greatly
hampered if complete extension and reduction be not effected (Fig. 288).

  [39] In supracondyloid fractures there is almost always posterior and
  upper displacement of the lower fragment. When the parts are found
  in this position, and especially when the skiagram shows the line of
  fracture in the usual location (from above downward and forward), the
  fracture should be treated by flexion of the arm in the so-called
  Jones’ position. By this the fragment is best restored to its proper
  position, being pried there by the muscular cushions of the forearm
  and arm. (Ashhurst.)

[Illustration: FIG. 288

Supracondyloid fracture or epiphyseal separation. (Lejars.)]

In considering fractures about the elbow no greater aid can be obtained
than by a study of the relations of the three prominent or salient
anatomical points to each other. These are the internal and external
condyles and the tip of the olecranon. They afford a key to nearly
all the displacements which may be produced after fracture or even
dislocation, and the only conditions under which they cannot be made
available are those where there has been tremendous swelling before the
case is seen by the surgeon. A fourth prominent feature, the head of
the radius, is also of much assistance, but is less often available,
especially in muscular or swollen forearms. When a normal arm is
flexed to a right angle and viewed from behind the three points above
mentioned constitute the angles of a nearly equilateral triangle.
When seen from the side the point of the olecranon is just below the
external condyle and in the same plane; when the arm is completely
extended and viewed from behind these three points are practically in
the same line. By a careful study of the variations from the above
relations which are produced by injury diagnosis can be greatly
facilitated.

[Illustration: FIG. 289

T-fracture of humerus. (Helferich.)]

[Illustration: FIG. 290

T-shaped fracture of lower epiphysis of humerus.]

[Illustration: FIG. 291

Intracondyloid fracture of humerus. Almost perfect functional result.
(Parmenter.)]

[Illustration: FIG. 292

Gunstock deformity after fracture of internal condyle, illustrating
neglect of precautions mentioned in text. (Beatson.)]

The _condyles_ may each be broken loose by itself, or they may be _both
broken_ at the same time. Fig. 291 illustrates what is known sometimes
as a T-fracture, where the lower extremity is not only separated
from the shaft but is broken into halves; such fractures imply great
violence, and are particularly difficult to treat. Should the condyles
be detached in such a way as to leave the lower end of the humerus in
pointed wedge shape it may perforate or do much harm to the soft parts
(Fig. 290). In these _intercondyloid_ fractures the writer would advise
dressing in the extended position, with a molded plaster-of-Paris
anterior splint and a gentle degree of traction, the patient being
confined to bed for a few days. In applying such a splint the surgeon
should give extreme care to holding the fragments in proper position
while the splint hardens, and in preserving the “carrying function”
(Fig. 291). (See below.)

[Illustration: PLATE XXXIX

Supracondyloid Fracture. (Child, nine years old.) Union with deformity,
fragment so joined to lower end of shaft of humerus at an angle that
when forearm is completely flexed upon this fragment it yet is only at
right angle with the arm. Operation indicated. (X-ray picture.)]

The _external condyle_ when fractured is displaced by muscle pull;
when the _internal condyle_ is broken the tendency is to backward
displacement of the fragment and widening of the joint.

_Fracture of the internal condyle_ is often an exceedingly serious
matter, because it is so often associated with more or less dislocation
and with permanent deformity, as a result of inattention to the
anatomical relations of the bones. The ulna sustains peculiar relations
to the inner condyle; at its upper end it is wrapped around the
process, holding it much as a monkey-wrench can be made to seize an
ordinary object, and being held to it by the internal lateral ligament.
Herein lies the secret of success or failure in treatment, for the
fragment, being so fixed to the ulna, should be controlled by it, _i.
e._, the position of the ulna is the most essential feature of the
treatment of the fracture. The forearm makes an angle with the arm
proper, by which a considerable degree of divergence is maintained.
This has been alluded to by Allis and others as the “carrying
function.” It can _only be estimated in the extended position, and be
accurately judged by comparison with the other arm._ If the arm be
flexed all possibility of estimating it is lost; therefore to _dress
such a fracture in the right-angle position is bad practice_ (Fig.
292). The only position in which the carrying function can be preserved
is the extended, or one a little short of it for the purpose of
comfort. If the ulna is put in the proper position the fragment will be
held equally so or as nearly as possible (Fig. 294).

[Illustration: FIG. 293

Fracture of external condyle. (Lejars.)]

In the _treatment of fractures of the inner condyle_ the patient, if
a child, should be anesthetized, the upper part of the body exposed,
both arms extended, and the injured arm made to correspond exactly with
the other so far as concerns the angle of divergence. Upon the arm so
placed an anterior plaster-of-Paris molded splint should be carefully
applied, extending from axilla to wrist, and then lightly secured with
bandages, the surgeon holding the arm in the proper position _until
the plaster is sufficiently hardened to permit no displacement._ The
arm should be kept in this position for at least ten days, after which
the splint may be removed and gentle motion practised. It may then
be reapplied for two or three days, after which we may begin to flex
the arm, applying either a new plaster splint or any other that seems
suitable, and in such a way that at the expiration of another week the
forearm is brought to a comfortable position of right angle, where it
may be maintained with a light splint or simply with a sling, according
to the age and tractability of the patient. Fig. 294 illustrates the
splint and the position, which is the only one in which the surgeon
maintains his own security and can properly estimate the carrying
function. The mistake has been in dressing this fracture, like most
others at the elbow, in the right-angle position.

In _fractures of the outer condyle_ these anatomical conditions do
not prevail, and these may be dressed in whatever position best meets
the indications of comfort and accurate reduction. _Intercondyloid
fractures_ are subject to the same conditions as those of the
_internal condyle_, plus others which are added, and should therefore
be dressed in the _same position_.

[Illustration: FIG. 294

Molded plaster splint for entire arm, and especially for fractures of
the internal condyle, showing proper position for dressing same.]

_Epiphyseal separations_, as well as supracondyloid fractures, should
be dressed either with traction in a somewhat extended position, or in
that of extreme flexion, called also Jones’ position, according as the
fragments may best fall into place in one or the other.

[Illustration: FIG. 295

Molded plaster splint for arm.]

[Illustration: FIG. 296

Molded plaster splint for forearm.]

The writer has for his own purposes discarded almost all other splint
material for the upper extremity in favor of the plaster-of-Paris
splints already mentioned. Figs. 294, 295 and 296, may illustrate
the method and purpose of their use; many other modifications can be
devised as may be demanded. It is customary, after such a splint is
hard and firm, to remove it for a few moments, trim it, smooth the
edges, line it with a fresh piece of soft lint or its equivalent,
and then reapply it to the arm with a roller or starch bandage, the
arm meantime not having been disturbed, but maintained in its proper
position, and being restored to the splint and made to take its
previous position. Such a splint fits accurately the individual for
whom it is made. It is worthless for anyone else; nor should it ever
be used again, the _intent being to mold a splint for each case which
shall serve its individual purpose and none other_.

Too early passive motion with the intent to regain mobility is
inadvisable and often dangerous. A fractured joint should be kept at
rest until the bone is consolidated. If callus be thus reduced to the
minimum, and consolidation be undisturbed, the patient will, in due
time, recover motion, often to the extreme limit. In fractures of the
humerus five or six weeks are required for the attainment of perfect
union. In spite of precaution callus formation will sometimes be
excessive and interfere with motion. Absorption of exuberant material
then is most desirable. This can be encouraged by constant but gentle
pressure. Thus when callus in front of the lower articular surface of
the humerus obstructs the coronoid process of the ulna and prevents
complete flexion the patient should wear for several hours at a time an
elastic sling, made with a piece of Martin rubber bandage sufficiently
long to make a loop around the neck, into which the hand is passed. It
should be made so tight as to exert gentle but constant pressure; the
result of this will be to cause rapid disappearance of the callus upon
which it is made. Conditions may be reversed when necessary, and the
patient may have some weight affixed to the hand by which, when the arm
hangs down, reversed pressure shall be made, or when desirable these
measures may be alternated. One should not, however, be tempted into
resorting to them too early, since much is done, even in unfavorable
cases, by purely natural processes, this being especially true of
children who are growing rapidly.

FRACTURES OF THE FOREARM; THE ULNA.

At the upper end of the _ulna_ the most frequent fracture is that
of the _olecranon_, whose separation by direct or indirect violence
corresponds to fracture of the patella. The fragment is pulled upward
along the back of the arm by the triceps muscle, and the power of
extension is almost lost. There is rarely any difficulty in diagnosis,
except in conditions of extreme swelling, which of itself would be
suspicious, as under hardly any other circumstances could a joint be so
distended (Figs. 297 and 298).

[Illustration: FIG. 297

Fracture of olecranon. (Erichsen.)]

[Illustration: FIG. 298

Fracture of ulna, upper end. (Lejars.)]

[Illustration: FIG. 299

Fracture of olecranon with fibrous union. (Park.)]

=Treatment.=--The difficulty here, in _treatment_, consists in the
necessity for counteracting the pull of the triceps. The arm first
of all should be dressed in the _extended position_. Sometimes it is
possible, by partly encircling the posterior surface of the arm just
above the fragment with a strong piece of adhesive plaster, to which
is attached some rubber tubing, to make a constant elastic pull upon
the fragment, the tubes being brought down and attached to the sides of
the anterior splint below the elbow. In the absence of swelling this
can often be made quite effective. So long as much fluid is present
no means will be efficient. It may, therefore, be well to wait two or
three days until the fluid has disappeared, aspirating the joint if
necessary. In young and otherwise healthy subjects there is strong
reason for advising _operation_, as only by absolutely approximating
the fragment to the main bone and maintaining it in position can bony
union be secured. In properly selected cases, and when performed
with every precaution, this measure frequently gives ideal results.
A short ligamentous union is represented in Fig. 299. At other times
the fibrous band will stretch out to an inch or more, not completely
disabling the arm but weakening it. The extended position may be
relaxed within a week after operation, but not for at least two weeks
after other treatment. Passive motion should not be begun too early in
the latter cases.

Fracture of the _coracoid process_ is often combined with _backward
dislocation of the forearm_, which is no doubt an incident of the
injury or may occur later by mere muscle pull. The brachialis anticus,
which is inserted into it, will pull the fragment up against the
anterior surface of the humerus. This fracture should be dressed in
the right-angle position, in order to relax the muscle, taking care to
prevent backward displacement, while ligamentous union is ordinarily
all that can be hoped for.

The _ulnar shaft_ may be broken at almost any point, usually as a
result of direct violence. As it is weaker in its lower half the
greater number of fractures occur here. Fracture of the shaft is easily
recognized, crepitus being always obtained, unless muscle tissue has
intervened, this being a condition which will occasionally prevent bony
union. If it can be established by _x_-rays that bony surfaces are
not in contact and cannot be so placed, it is advisable to cut down
upon the site of the fracture, remove the obstacle, and fasten the
fragments together. So long as one bone is broken in the forearm the
other may be relied on to act as a more or less efficient splint. There
is but one position in which any of these fractures can be dressed
with safety, that is _midway between pronation and supination_, _i.
e._, with the thumb pointing toward the patient’s face. Splints used
for this purpose should always be wider than the forearm itself, lest
by pressure the ends be forced toward the other bone. Some hold that
by gentle pressure along the line between the bones, as by a narrow
pad or splint, the muscles may be made to press the injured bone away
from the other; nevertheless only moderate pressure can be tolerated
for this uncertain purpose. It has been generally customary to use two
light wooden splints, one along the palmar, the other along the dorsal
surface of the forearm, padding them properly and securing them in
position by strips of adhesive plaster and suitable bandages. The same
plaster-molded splints mentioned above can, however, be made just as
effective for this purpose, if properly applied.

When either bone is broken near the wrist, and especially when both are
broken, we have to combat the tendency of the pronator quadratus, which
tends to pull the lower fragments together.

The _styloid_ process is occasionally detached, as in violent sprains,
or broken off in connection with other injuries. Inasmuch as it carries
the upper end of the internal lateral ligament its detachment can be
quickly recognized by the abnormal freedom of motion which such an
injury would permit.

[Illustration: FIG. 300

Obliteration of the interosseous space in a fracture of the forearm.]

FRACTURES OF THE RADIUS.

The radius vies in frequency of fracture with the clavicle. The _head_
is seldom broken, its fracture being most likely when the shaft is
driven against the humerus by falls upon the open hand. The _neck_ is
more frequently broken in children than in adults. These fractures have
sometimes to be determined by a process of exclusion or by the use of
the _x_-rays. In muscular forearms they lie so deeply that it is not
always possible to recognize them. Ordinarily, however, if the head
of the bone can be found to remain stationary while the rest of the
bone is being rotated, and if, at the same time, crepitus be felt, the
matter may be regarded as settled. So far as the _shaft_ of the radius
is concerned the remarks made above regarding the ulna mostly hold true
for its fellow-bone. When the neck of the bone is broken the shaft will
be pulled upward by the biceps tendon, while when the shaft is broken
below its insertion the upper fragment is displaced by it. In either
of these cases, then, the forearm should be dressed at a right angle
with the arm in order to relax the muscle. The supinator brevis and
the pronator radii teres should also not be neglected, for the former
will tend to rotate and the latter to more or less displace the upper
portion of a shaft broken high up. With a fracture near the upper end,
in a powerfully muscular arm, diagnosis is not always easy. Fractures
in the lower portion of the shaft are to be treated like those of the
ulna. But those high up should be dressed with the elbow at a right
angle and the forearm supinated. A plaster-of-Paris molded splint here
can be adapted to the needs of every individual case if the surgeon
will give minute care _at the time of its hardening_ to placing the
parts just as he desires them to remain.

FRACTURES OF BOTH BONES OF THE FOREARM.

These are not uncommon, though much less frequent than injuries to
either bone alone. They may occur at the same level or be quite widely
separated. The loss of function is complete in these instances, while
deformity will depend largely upon whether the fractures lie near
together or not. It is of the greatest importance to remember, in these
cases, that the mass of muscles around the upper fragments tends to
crowd them together, while the lower fragments are brought together
especially by the pronator quadratus. Everything then conspires to
convergence of the four fragments, a tendency which it is sometimes
difficult to combat. Every large museum contains specimens showing
a common callus, in which all four bone ends are involved, and
illustrating the permanent loss of rotation that ensues. This is to be
combated, not alone by rest, which tends to limit callus formation, but
by _position with the arm midway between pronation and supination_,
in which the bones are naturally farthest separated, and by _splints_
applied with such gentle pressure as may hold the bones apart. This
pressure should be applied between the dorsal and palmar surfaces,
while the lateral aspects of the forearm should be kept absolutely free
from it (Figs. 300 and 301).

[Illustration: FIG. 301

Fracture of both bones near lower extremity. (Lejars.)]

It is a serious matter to dress any of these injuries with moistened
pasteboard, or other material which does not take its desired shape and
strength promptly, for no matter how carefully the desired position may
be enforced at first the very nature of a material which remains too
long plastic will permit the loss of all that should be maintained. The
writer has seen malpractice suits instituted and men forced out of the
State by inattention to this precaution.

FRACTURE OF THE LOWER END OF THE RADIUS; COLLES’ FRACTURE.

This is perhaps one of the commonest fractures in the body, occurring
at all ages; when seen in growing children it is to be regarded as an
epiphyseal separation rather than as a distinct fracture. It derives
its name from the fact that until Colles, a Dublin surgeon, over one
hundred years ago, described this injury as a fracture it had been
always regarded as a peculiar dislocation at the wrist. It is produced
by falls upon the hand in the hyperextended position, the force
being usually transmitted through the carpus to the radial end. The
name is usually limited to those fractures which occur within one
and a quarter inches of the articular surface (Fig. 303). Here the
structure of the bone is cancellous and impaction may easily occur,
this being a decided feature in many of these accidents, and making
replacement more difficult. The deformity which results from the
fracture is characteristic and more or less uniform. This is called the
“silver-fork appearance,” the lower fragment being so displaced, and
usually more or less tilted, as to raise the tendons and the structures
on the back of the wrist; at the same time it is usually drawn toward
the radial side. The more the fragment is impacted or driven into the
shaft of the bone the less easily is crepitus elicited.

The fracture is more common than is supposed, and there is no doubt but
that many alleged sprains of the wrist illustrate cracks in the bone
without displacement, which, nevertheless, are slow to heal and are
sometimes followed by thickening and impairment of function. (See Plate
XL.)

Along with the radial fracture separation of the _styloid process_ of
the ulna may also occur, or, as Moore has shown, the process itself may
perforate the internal lateral ligament so as to protrude through the
skin; and the surgeon has occasionally to withdraw the styloid from
the ligament which has been impaled upon it. The radio-ulnar ligament
is also frequently injured, and this permits the ulna to become more
prominent than normal. If the styloid has perforated the skin it lends
a compound feature to the case. The interarticular fibrocartilage may
also be displaced.

=Treatment.=--The secret of obtaining a good result and the explanation
for failures lie in the completeness or incompleteness of the
reduction of the fragment. If the latter be _absolutely and accurately
replaced_ it makes but little difference what dressing is applied.
On the other hand any fragment not completely restored will lead to
subsequent deformity and impairment of function. _Successful reduction,
then, is the keynote to success_, and should be accomplished at any
reasonable cost. Sometimes it is not difficult, and then no anesthetic
is required; sometimes it is extremely difficult, and the operator
has to exert all the strength he has in his arms, aided by profound
anesthesia. Moderate cases can usually be dealt with successfully
under nitrous oxide gas. The surgeon grasps the hand as if to shake
hands, _i. e._, with his corresponding hand, the elbow being firmly
held by an assistant. Traction is then made upon the hand to which the
fragment is affixed, while with his other hand the operator makes such
pressure, rotation, or coaxing manipulation with his thumb and fingers
as may assist in restoring the fragment to its place. With whatever
other effort may be made traction should be combined. Forcible swaying
movements, combined with hyperextension, may be necessary to dislodge
an impacted fragment. Any degree of force is preferable to failure in
this respect. Perfect reduction is the key of success; without it, no
dressing is efficient; with it, almost anything will suffice.

[Illustration: FIG. 302

Comminuted but not compound fracture of wrist. (Beatson.)]

Reduction once accomplished it is usually an easy matter to hold the
arm in position. The writer prefers above all other means a molded
plaster-of-Paris splint, which should extend from the line of the
knuckles upon the palmar surface well up toward the elbow. It should
be fitted neatly to the hand and forearm, bandaged comfortably upon
it, while as it solidifies the surgeon should hold the hand slightly
flexed to the ulnar side as well as anteriorly. When the splint is
hardened and bandaged a simple sling will suffice. The hand should be
dressed with the thumb pointing toward the face, while upon the back of
the wrist an ice-bag can be applied. Ecchymosis is sometimes extreme;
I have seen it extend even to the shoulder after an apparently simple
break (Figs. 304 and 305).

[Illustration: PLATE XL

Skiagram of a Fracture of the Lower End of the Radius. (Wharton.)]

I have not described other splints for dressings, at this point, for
two reasons: the dressing given above is ample and sufficient for all
cases, and, aside from it, the number of splints and methods devised is
so large as to be confusing. It is much better to know one method well
than to have a slight working acquaintance with several.

[Illustration: FIG. 303

Colles’ fracture. (Anger.)]

[Illustration: FIG. 304

FIG. 305

Deformity from faulty union following fracture of wrist. Buffalo
Clinic. (Skiagrams by Dr. Plummer.)]

While Colles’ fracture is far more frequent than all other fractures
about the wrist, it is possible to have less-known forms with different
displacements; thus a fracture the reverse of Colles’ has been
described by Barton and by R. W. Smith, being occasionally produced by
falls upon the back of the hand instead of upon the palmar surface.
Figs. 306 and 307, from photographs given me by Dr. Beatson, of
Glasgow, illustrate both the clinical picture and the actual condition
of the bones. Of all these fractures it may be said that accurate
reposition, as in the case of Colles’ fracture, is the key to success.
Once the fragments are reduced the same plaster-of-Paris molded splints
will answer for these as for the others.

[Illustration: FIG. 306

A Barton or Smith fracture at wrist. (Beatson.)]

[Illustration: FIG. 307

Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case
represented in Fig. 306.)]

BENNETT’S FRACTURE.

When considerable force is applied to the distal end of the first
metacarpal, as in striking with the clenched fist, or, as in a fall
upon the outstretched thumb, the first metacarpal is often fractured
transversely at its neck or longitudinally, its interior basal
projection being broken off, both injuries being often associated.
This is a condition lately proved by Russ, of San Francisco, to be
more common than has been generally supposed. It was first described
by Bennett, of Dublin, in 1885, and is known as Bennett’s fracture of
the thumb. Its peculiar features can be best seen in a radiograph.
It produces much pain and swelling of the hand, with tenderness,
especially at the base of the bone involved, _i. e._, at the root of
the thumb. There may be more or less displacement of fragments. The
injured thumb should be treated by traction and with such coaptation
splints as may be extemporized or prepared for the purpose, in the
position of abduction. If accurate coaptation and sufficient traction
be made to overcome both deformity and muscle spasm the result obtained
will be satisfactory. Otherwise more or less loss of function and local
tenderness may long persist.

[Illustration: PLATE XLI

Skiagram of Fracture of the Proximal Phalanx of the Ring Finger.
(Wharton.)]

FRACTURES OF THE WRIST AND HAND.

Fractures of the carpal bones seldom occur, except when the parts have
been crushed. The _scaphoid_ is, however, broken much more often, and
doubtless many cases of so-called severe sprain include this injury.
The use of the _x_-rays has done more to teach the relative frequency
of carpal fractures than was ever previously appreciated. The scaphoid
ossifies by two centres, which do not appear until the eighth year.
When the bone has been thus cracked the usual signs of sprain are
present, which subside and leave a tender wrist and hand whose fingers
can be normally moved, but whose wrist movements are reduced one-half,
while attempts at motion beyond these limits produce great muscle
spasm and pain. Codman and Chase[40] have shown that the sheaths of
the radial extensor tendons are in close relation to the periosteum of
the bone at this point, as well as to that of the radius, so that by
injury here blood may escape into the sheath without appearing at other
parts; the result being a tense, fluctuating, triangular swelling over
the radial half of the wrist, the blood being effused so deeply as not
to discolor, or at least not at first. They regard the presence of such
an engorged bursa as diagnostic of fracture either of the radius or the
scaphoid.

  [40] Annals of Surgery, March, 1905.

While carpal fractures call ordinarily for treatment by absolute rest,
Codman and Chase have advised removal of any loose fragment, especially
of the scaphoid, by incision along the back of the wrist just to the
inner side of the long radial extensor. The annular ligament is to be
divided between it and the long extensors of the fingers, and without
opening tendon sheaths; inasmuch as this ligament does not retract when
divided its borders must be held apart. In this way the joint may be
completely exposed over the proximal half of the scaphoid. The line of
fracture being made out, a blunt hook is introduced into the fissure
and the fragment elevated, loosened by a tenotome, and removed, its
removal seeming nowise to interfere with the function of the whole bone
or the usefulness of the wrist.

The _metacarpal bones_ are frequently broken, usually as the result
of violence, the distal portions suffering more than the proximal.
The diagnosis is best made with the fingers closed, when any lack
of symmetry in the row of knuckles may be seen or any protrusion of
a fragment noted. Here the _x_-rays are useful. Such injury should
be treated by placing the hand upon a palmar splint extending well
up the forearm and maintaining rest by suitable pressure, with or
without traction upon the finger of the bone involved. For this purpose
adhesive plaster may be passed up and down the finger and attached to
an elastic band which is fixed to the end of the splint.

The same is true of fractures of the _phalanges_, which are often made
compound by the injury. Here the danger is not so much to the bone
as to the tendon sheaths or thecæ, along which infection may easily
spread. Widespread and prolonged suppuration might disable a hand thus
injured unless properly and promptly dressed. Ordinarily adjoining
fingers can be utilized for splints, and if the outstretched hand be
fastened upon a palmar splint and the injured finger kept in position
by its neighbors a good result can generally be obtained. Occasionally
distinct splints for one or more fingers are required, and occasionally
also the suggestion made above with regard to traction may need to be
enforced.

FRACTURES OF THE PELVIS.

Fracture of the pelvis may be serious not only in and of itself but
because of frequently accompanying injuries to the various pelvic
viscera. Save in the possible separations that may occur during
parturition it is always the result of direct violence. Such injuries
are usually divided into fractures of the _pelvic girdle_ and those of
the more exposed prominences, such as the _iliac crest_, the _ischiac
tuberosity_, the _coccyx_, etc. Lines of fracture may run at any
point, although it is at the synchondrosis that the pelvis is usually
broken loose from the sacrum. As in the skull and the lower jaw double