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Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.
by Alexander Miles
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Transcriber's note: The inverted 'Y' symbol used in this book has been transcribed as [inverted Y].



OXFORD MEDICAL PUBLICATIONS



MANUAL OF SURGERY



BY

ALEXIS THOMSON, F.R.C.S.Ed. AND Eng. PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH SURGEON EDINBURGH ROYAL INFIRMARY

AND

ALEXANDER MILES, F.R.C.S.Ed. SURGEON EDINBURGH ROYAL INFIRMARY

VOLUME SECOND EXTREMITIES—HEAD—NECK

SIXTH EDITION REVISED AND ENLARGED WITH 288 ILLUSTRATIONS



LONDON HENRY FROWDE and HODDER & STOUGHTON THE LANCET BUILDING 1 & 2 BEDFORD STREET, STRAND, W.C.2



First Edition 1904 Second Edition 1907 Third Edition 1909 Fourth Edition 1912 " " Second Impression 1913 Fifth Edition 1915 " " Second Impression 1919 Sixth Edition 1921



PRINTED IN GREAT BRITAIN BY MORRISON AND GIBB LTD., EDINBURGH



CONTENTS

PAGE CHAPTER I INJURIES OF BONES 1

CHAPTER II INJURIES OF JOINTS 32

CHAPTER III INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM 44

CHAPTER IV INJURIES IN THE REGION OF THE ELBOW AND FOREARM 79

CHAPTER V INJURIES IN THE REGION OF THE WRIST AND HAND 102

CHAPTER VI INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH 122

CHAPTER VII INJURIES IN THE REGION OF THE KNEE AND LEG 155

CHAPTER VIII INJURIES IN REGION OF ANKLE AND FOOT 185

CHAPTER IX DISEASES OF INDIVIDUAL JOINTS 201

CHAPTER X DEFORMITIES OF THE EXTREMITIES 241

CHAPTER XI THE SCALP 319

CHAPTER XII THE CRANIUM AND ITS CONTENTS 328

CHAPTER XIII INJURIES OF THE SKULL 361

CHAPTER XIV DISEASES OF THE BRAIN AND MEMBRANES 373

CHAPTER XV DISEASES OF THE CRANIAL BONES 406

CHAPTER XVI THE VERTEBRAL COLUMN AND SPINAL CORD 411

CHAPTER XVII DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD 431

CHAPTER XVIII DEVIATIONS OF THE VERTEBRAL COLUMN 461

CHAPTER XIX THE FACE, ORBIT, AND LIPS 474

CHAPTER XX THE MOUTH, FAUCES, AND PHARYNX 496

CHAPTER XXI THE JAWS, INCLUDING THE TEETH AND GUMS 507

CHAPTER XXII THE TONGUE 528

CHAPTER XXIII THE SALIVARY GLANDS 543

CHAPTER XXIV THE EAR 553

CHAPTER XXV THE NOSE AND NASO-PHARYNX 567

CHAPTER XXVI THE NECK 582

CHAPTER XXVII THE THYREOID GLAND 604

CHAPTER XXVIII THE OESOPHAGUS 616

CHAPTER XXIX THE LARYNX, TRACHEA, AND BRONCHI 634

INDEX 645



LIST OF ILLUSTRATIONS

FIG. PAGE

1. Multiple Fracture of both Bones of Leg 4

2. Radiogram showing Comminuted Fracture of both Bones of 5 Forearm

3. Oblique Fracture of Tibia; with partial Separation of 6 Epiphysis of Upper End of Fibula; and Incomplete Fracture of Fibula in Upper Third

4. Excess of Callus after Compound Fracture of Bones of 9 Forearm

5. Multiple Fractures of both Bones of Forearm showing 11 Mal-union

6. Radiogram of Un-united Fracture of Shaft of Ulna 13

7. Excessive Callus Formation after Infected Compound 27 Fracture of both Bones of Forearm

8. Partial Separation of Epiphysis, with Fracture running 29 into Diaphysis

9. Complete Separation of Epiphysis 29

10. Partial Separation with Fracture of Epiphysis 29

11. Complete Separation with Fracture of Epiphysis 29

12. Os Innominatum showing new Socket formed after 41 Old-standing Dislocation

13. Oblique Fracture of Right Clavicle in Middle Third, 45 united

14. Fracture of Acromial End of Clavicle 46

15. Adhesive Plaster applied for Fracture of Clavicle 49

16. Forward Dislocation of Sternal End of Right Clavicle 51

17. Diagram of most common varieties of Dislocation of the 53 Shoulder

18. Sub-coracoid Dislocation of Right Shoulder 55

19. Sub-coracoid Dislocation of Humerus 56

20. Kocher's Method of reducing Sub-coracoid 57 Dislocation—First Movement

21. Kocher's Method—Second Movement 58

22. Kocher's Method—Third Movement 59

23. Miller's Method of reducing Sub-coracoid 60 Dislocation—First Movement

24. Miller's Method—Second Movement 61

25. Dislocation of Shoulder with Fracture of Neck of Humerus 64

26. Transverse Fracture of Scapula 68

27. Fracture of Surgical Neck of Humerus, united with 70 Angular Displacement

28. Impacted Fracture of Neck of Humerus 71

29. Ambulatory Abduction Splint for Fracture of Humerus 72

30. Radiogram of Separation of Upper Epiphysis of Humerus 73

31. "Cock-up" Splint 77

32. Gooch Splints for Fracture of Shaft of Humerus; and Rectangular Splint to secure Elbow 77

33. Radiogram of Supra-condylar Fracture of Humerus in a 81 Child

34. Radiogram of T-shaped Fracture of Lower End of Humerus 83

35. Radiogram of Fracture of Olecranon Process 86

36. Backward Dislocation of Elbow in a Boy 89

37. Bony Outgrowth in relation to insertion of Brachialis 90 Muscle

38. Radiogram of Incomplete Backward Dislocation of Elbow 91

39. Forward Dislocation of Elbow, with Fracture of Olecranon 93

40. Radiogram of Forward Dislocation of Head of Radius, with 95 Fracture of Shaft of Ulna

41. Greenstick Fracture of both Bones of the Forearm 98

42. Gooch Splints for Fracture of both Bones of Forearm 99

43. Colles' Fracture showing Radial Deviation of Hand 103

44. Colles' Fracture showing undue prominence of Ulnar 103 Styloid

45. Radiogram showing the Line of Fracture and Upward 104 Displacement of the Radial Styloid in Colles' Fracture

46. Radiogram of Chauffeur's Fracture 107

47. Radiogram of Smith's Fracture 108

48. Manus Valga following Separation of Lower Radial 109 Epiphysis in Childhood

49. Radiogram showing Fracture of Navicular (Scaphoid) Bone 111

50. Dorsal Dislocation of Wrist at Radio-carpal Articulation 113

51. Radiogram showing Forward Dislocation of Navicular Bone 114

52. Extension Apparatus for Oblique Fracture of Metacarpals 117

53. Radiogram of Bennett's Fracture of Base of Metacarpal 118 of Right Thumb

54. Splints for Bennett's Fracture 119

55. Multiple Fracture of Pelvis through Horizontal and 123 Descending Rami of both Pubes, and Longitudinal Fracture of left side of Sacrum

56. Fracture of Left Iliac Bone; and of both Pubic Arches 124

57. Many-tailed Bandage and Binder for Fracture of Pelvic 125 Girdle

58. Nelaton's Line 128

59. Bryant's Line 129

60. Section through Hip-Joint to show Epiphyses at Upper 130 End of Femur, and their relation to the Joint

61. Fracture through Narrow Part of Neck of Femur on Section 131

62. Impacted Fracture through Narrow Part of Neck of Femur 132

63. Fracture of Neck of Right Femur, showing Shortening, 133 Abduction, and Eversion of Limb

64. Fracture of Narrow Part of Neck of Femur 134

65. Coxa Vara following Fracture of Neck of Femur in a Child 136

66. Non-impacted Fracture through Base of Neck 137

67. Fracture through Base of Neck of Femur with Impaction 137 into the Trochanters

68. Non-impacted Fracture through Base of Neck 138

69. Fracture of the Femur just below the small Trochanter, 140 united, showing Flexion and Lateral Rotation of Upper Fragment

70. Adjustable Double-inclined Plane 141

71. Diagram of the most Common Dislocations of the Hip 142

72. Dislocation of Right Femur on to Dorsum Ilii 143

73. Dislocation on to Dorsum Ilii 144

74. Dislocation into the Vicinity of the Ischiatic Notch 145

75. Longitudinal Section of Femur showing Fracture of Shaft 148 with Overriding of Fragments

76. Radiogram of Steinmann's Apparatus applied for Direct 150 Extension to the Femur

77. Hodgen's Splint 151

78. Long Splint with Perineal Band 152

79. Fracture of Thigh treated by Vertical Extension 153

80. Section of Knee-joint showing Extent of Synovial Cavity 156

81. Extension applied by means of Ice-tong Callipers for Fracture of Femur 158

82. Radiogram of Separation of Lower Epiphysis of Femur, 160 with Backward Displacement of the Diaphysis

83. Separation of Lower Epiphysis of Femur, with Fracture 161 of Lower End of Diaphysis

84. Radiogram of Fracture of Head of Tibia and upper Third 163 of Fibula

85. Radiogram illustrating Schlatter's Disease 164

86. Diagram of Longitudinal Tear of Posterior End of Right 171 Medial Semilunar Meniscus

87. Radiogram of Fracture of Patella 173

88. Fracture of Patella, showing wide Separation of Fragments 175

89. Radiogram of Transverse Fracture of both Bones of Leg 178 by Direct Violence

90. Radiogram of Oblique Fracture of both Bones of Leg by 178 Indirect Violence

91. Box Splint for Fractures of Leg 180

92. Box Splint applied 181

93. Section through Ankle-joint showing relation of 186 Epiphyses to Synovial Cavity

94. Radiogram of Pott's Fracture, with Lateral Displacement 187 of Foot

95. Ambulant Splint of Plaster of Paris 189

96. Dupuytren's Splint applied to Correct Eversion of Foot 190

97. Syme's Horse-shoe Splint applied to Correct Backward 191 Displacement of Foot

98. Radiogram of Fracture of Lower End of Fibula, with 192 Separation of Lower Epiphysis of Tibia

99. Radiogram of Backward Dislocation of Ankle 195

100. Compound Dislocation of Talus 197

101. Radiogram of Fracture-Dislocation of Talus 198

102. Radiogram of Dislocation of Toes 199

103. Arthropathy of Shoulder in Syringomyelia 203

104. Radiogram of Specimen of Arthropathy of Shoulder in 204 Syringomyelia

105. Radiogram showing Multiple partially Ossified 205 Cartilaginous Loose Bodies in Shoulder-joint

106. Diffuse Tuberculous Thickening of Synovial Membrane of 206 Elbow

107. Contracture of Elbow and Wrist following a Burn in 207 Childhood

108. Advanced Tuberculous Disease of Acetabulum with Caries 210 and Perforation into Pelvis

109. Early Tuberculous Disease of Right Hip-joint in a Boy 212

110. Disease of Left Hip; showing Moderate Flexion and 213 Lordosis

111. Disease of Left Hip; Disappearance of Lordosis on 213 further Flexion of the Hip

112. Disease of Left Hip; Exaggeration of Lordosis 214

113. Thomas' Flexion Test, showing Angle of Flexion at 214 Diseased Hip

114. Tuberculous Disease of Left Hip: Third Stage 215

115. Advanced Tuberculous Disease of Left Hip-joint in a Girl 216

116. Extension by Adhesive Plaster and Weight and Pulley 220

117. Stiles' Double Long Splint to admit of Abduction of 221 Diseased Limb

118. Thomas' Hip-splint applied for Disease of Right Hip 222

119. Arthritis Deformans, showing erosion of Cartilage and 225 lipping of Articular Edge of Head of Femur

120. Upper End of Femur in advanced Arthritis Deformans 226 of Hip

121. Femur in advanced Arthritis Deformans of Hip and Knee 227 Joints

122. Tuberculous Synovial Membrane of Knee 230

123. Lower End of Femur from an Advanced Case of Tuberculous 231 Arthritis of the Knee

124. Advanced Tuberculous Disease of Knee, with Backward 233 Displacement of Tibia

125. Thomas' Knee-splint applied 236

126. Tuberculous Disease of Right Ankle 239

127. Female Child showing the results of Poliomyelitis 243 affecting the Left Lower Extremity

128. Radiogram of Double Congenital Dislocation of Hip in 249 a Girl

129. Innominate Bone and Upper End of Femur from a case of 250 Congenital Dislocation of Hip

130. Congenital Dislocation of Left Hip in a Girl 251

131. Contracture Deformities of Upper and Lower Limbs 255 resulting from Spastic Cerebral Palsy in Infancy

132. Rachitic Coxa Vara 258

133. Coxa Vara, showing Adduction Curvature of Neck of Femur 260 associated with Arthritis of the Hip and Knee

134. Bilateral Coxa Vara, showing Scissors-leg Deformity 260

135. Genu Valgum and Genu Varum 265

136. Female Child with Right-sided Genu Valgum, the result of 266 Rickets

137. Double Genu Valgum; and Rickety Deformities of Arms 267

138. Radiogram of Case of Double Genu Valgum in a Child 268

139. Genu Valgum in a Child. Patient standing 269

140. Genu Valgum. Same Patient as Fig. 139, sitting 270

141. Bow-knee in Rickety Child 271

142. Bilateral Congenital Club-foot in an Infant 274

143. Radiogram of Bilateral Congenital Club-foot in an Infant 275

144. Congenital Talipes Equino-varus in a Man 277

145. Bilateral Pes Equinus in a Boy 280

146. Extreme form of Pes Equinus in a Girl 281

147. Skeleton of Foot from case of Pes Equinus due to 282 Poliomyelitis

148. Pes Calcaneo-valgus with excessive arching of Foot 284

149. Pes Calcaneo-valgus, the result of Poliomyelitis 285

150. Pes Cavus in Association with Pes Equinus, the Result 286 of Poliomyelitis

151. Radiogram of Foot of Adult, showing Changes in the 286 Bones in Pes Cavus

152. Adolescent Flat-Foot 287

153. Flat-Foot, showing Loss of Arch 288

154. Imprint of Normal and of Flat Foot 290

155. Bilateral Pes Valgus and Hallux Valgus in a Girl 293

156. Radiogram of Spur on Under Aspect of Calcaneus 295

157. Radiogram of Hallux Valgus 296

158. Radiogram of Hallux Varus or Pigeon-Toe 298

159. Hallux Rigidus and Flexus in a Boy 299

160. Hammer-Toe 300

161. Section of Hammer-Toe 301

162. Congenital Hypertrophy of Left Lower Extremity in a Boy 302

163. Supernumerary Great Toe 303

164. Congenital Elevation of Left Scapula in a Girl: also 304 shows Hairy Mole over Sacrum

165. Winged Scapula 305

166. Arrested Growth and Wasting of Tissues of Right Upper 307 Extremity

167. Lower End of Humerus from case of Cubitus Varus 309

168. Intra-Uterine Amputation of Forearm 310

169. Radiogram of Arm of Patient shown in Fig. 168 310

170. Congenital Absence of Left Radius and Tibia in a Child 311

171. Club-Hand, the Result of Imperfect Development of Radius 312

172. Congenital Contraction of Ring and Little Fingers 314

173. Dupuytren's Contraction 315

174. Splint used after Operation for Dupuytren's Contraction 316

175. Supernumerary Thumb 317

176. Trigger Finger 318

177. Multiple Wens 324

178. Adenoma of Scalp 325

179. Relations of the Motor and Sensory Areas to the 330 Convolutions and to Chiene's Lines

180. Diagram of the Course of Motor and Sensory Nerve Fibres 333

181. Chiene's Method of Cerebral Localisation 336

182. To illustrate the Site of Various Operations on the Skull 337

183. Localisation of Site for Introduction of Needle in Lumbar 338 Puncture

184. Contusion and Laceration of Brain 343

185. Charts of Pyrexia in Head Injuries 348

186. Relations of the Middle Meningeal Artery and Lateral 353 Sinus to the Surface as indicated by Chiene's Lines

187. Extra-Dural Clot resulting from Haemorrhage from the 354 Middle Meningeal Artery

188. Depressed Fracture of Frontal Bones with Fissured 365 Fracture

189. Depressed and Comminuted Fracture of Right Parietal 365 Bone: Pond Fracture

190. Pond Fracture of Left Frontal Bone, produced during 366 Delivery

191. Transverse Fracture through Middle Fossa of Base of Skull 368

192. Diagram of Extra-Dural Abscess 374

193. Pott's Puffy Tumour in case of Extra-Dural Abscess 375 following Compound Fracture of Orbital Margin

194. Diagram of Sub-Dural Abscess 376

195. Diagram illustrating sequence of Paralysis, caused by 380 Abscess in Temporal Lobe

196. Chart of case of Sinus Phlebitis following Middle Ear 384 Disease

197. Occipital Meningocele 388

198. Frontal Hydrencephalocele 389

199. Naevus at Root of Nose, simulating Cephalocele 390

200. Hydrocephalus in a Child 391

201. Patient suffering from Left Facial Paralysis 402

202. Skull of Woman illustrating the appearances of Tertiary 408 Syphilis of Frontal Bone—Corona Veneris—in the Healed Condition

203. Sarcoma of Orbital Plate of Frontal Bone in a Child at 409 Age of 11 months and 18 months

204. Destruction of Bones of Left Orbit, caused by Rodent 410 Cancer

205. Distribution of the Segments of the Spinal Cord 417

206. Attitude of Upper Extremities in Traumatic Lesions of 418 the Sixth Cervical Segment

207. Compression Fracture of Bodies of Third and Fourth 426 Lumbar Vertebrae

208. Fracture-Dislocation of Ninth Thoracic Vertebra 428

209. Fracture of Odontoid Process of Axis Vertebra 429

210. Tuberculous Osteomyelitis affecting several Vertebrae at 432 Thoracico-Lumbar Junction

211. Osseous Ankylosis of Bodies (a) of Dorsal Vertebrae, 434 (b) of Lumbar Vertebrae following Pott's Disease

212. Radiogram of Museum Specimen of Pott's Disease in a Child 435

213. Radiogram of Child's Thorax showing Spindle-shaped 437 Shadow at Site of Pott's Disease of Fourth, Fifth, and Sixth Thoracic Vertebrae

214. Attitude of Patient suffering from Tuberculous Disease 441 of the Cervical Spine

215. Thomas' Double Splint for Tuberculous Disease of the 442 Spine

216. Hunch-back Deformity following Pott's Disease of Thoracic 443 Vertebrae

217. Attitude in Pott's Disease of Thoracico-Lumbar Region of 444 Spine

218. Arthritis Deformans of Spine 449

219. Meningo-Myelocele of Thoracico-Lumbar Region 454

220. Meningo-Myelocele of Cervical Spine 454

221. Meningo-Myelocele in Thoracic Region 456

222. Tail-like Appendage over Spina Bifida Occulta in a Boy 457

223. Congenital Sacro-Coccygeal Tumour 458

224. Scoliosis following upon Poliomyelitis affecting Right 463 Arm and Leg

225. Rickety Scoliosis in a Child 464

226. Vertebrae from case of Scoliosis showing Alteration in 466 Shape of Bones

227. Adolescent Scoliosis in a Girl 467

228. Scoliosis with Primary Curve in Thoracic Region 468

229. Scoliosis showing Rotation of Bodies of Vertebrae, and 469 widening of Intercostal Spaces on side of Convexity

230. Diagram of Attitudes in Klapp's Four-Footed Exercises for 473 Scoliosis

231. Head of Human Embryo about 29 days old 475

232. Simple Hare-Lip 476

233. Unilateral Hare-Lip with Cleft Alveolus 477

234. Double Hare-Lip in a Girl 478

235. Double Hare-Lip with Projection of the Os Incisivum 479

236. Asymmetrical Cleft Palate extending through Alveolar 480 Process on Left Side

237. Illustrating the Deformities caused by Lupus Vulgaris 483

238. Sarcoma of Orbit causing Exophthalmos and Downward 488 Displacement of the Eye, and Projecting in Temporal Region

239. Sarcoma of Eyelid in Child 489

240. Dermoid Cyst at Outer Angle of Orbital Margin 490

241. Macrocheilia 492

242. Squamous Epithelioma of Lower Lip in a Man 493

243. Advanced Epithelioma of Lower Lip 494

244. Recurrent Epithelioma in Glands of Neck adherent to 495 Mandible

245. Cancrum Oris 497

246. Perforation of Palate, the Result of Syphilis, and Gumma 498 of Right Frontal Bone

247. Cario-necrosis of Mandible 510

248. Diffuse Syphilitic Disease of Mandible 512

249. Epulis of Mandible 513

250. Sarcoma of the Maxilla 515

251. Malignant Disease of Left Maxilla 516

252. Dentigerous Cyst of Mandible containing Rudimentary Tooth 517

253. Osseous Shell of Myeloma of Mandible 518

254. Multiple Fracture of Mandible 520

255. Four-Tailed Bandage applied for Fracture of Mandible 522

256. Defective Development of Mandible from Fixation of Jaw 526 due to Tuberculous Osteomyelitis in Infancy

257. Leucoplakia of the Tongue 531

258. Papillomatous Angioma of Left Side of Tongue in a Woman 538

259. Dermoid Cyst in Middle Line of Neck 539

260. Temporary Unilateral Paralysis of Tongue 541

261. Series of Salivary Calculi 545

262. Acute Suppurative Parotitis 546

263. Mixed Tumour of Parotid 550

264. Mixed Tumour of the Parotid of over twenty years' 551 duration

265. Acute Mastoid Disease showing Oedema and Projection of 565 Auricle

266. Rhinophyma or Lipoma Nasi 569

267. The Outer Wall of Left Nasal Chamber after removal of 571 the Middle Turbinated Body

268. Congenital Branchial Cyst in a Woman 584

269. Bilateral Cervical Ribs 586

270. Transient Wry-Neck 587

271. Congenital Wry-Neck in a Boy 589

272. Congenital Wry-Neck seen from behind to show Scoliosis 590

273. Recovery from Suicidal Cut-Throat after Low Tracheotomy 596 and Gastrostomy

274. Hygroma of Neck 599

275. Lympho-Sarcoma of Neck 600

276. Branchial Carcinoma 601

277. Parenchymatous Goitre in a Girl 606

278. Larynx and Trachea surrounded by Goitre 607

279. Section of Goitre shown in Fig. 278 to illustrate 607 Compression of Trachea

280. Multiple Adenomata of Thyreoid in a Woman 611

281. Cyst of Left Lobe of Thyreoid 612

282. Exophthalmic Goitre 614

283. Radiogram of Safety-Pin impacted in the Gullet and 620 Perforating the Larynx

284. Denture Impacted in Oesophagus 621

285. Radiogram, after swallowing an Opaque Meal, in a Man 626 suffering from Malignant Stricture of Lower End of Gullet

286. Diverticulum of the Oesophagus at its Junction with the 627 Pharynx

287. Larynx from case of Sudden Death due to Oedema of 637 Ary-Epiglottic Folds

288. Papilloma of Larynx 641



MANUAL OF SURGERY



CHAPTER I

INJURIES OF BONES

Contusions—Wounds—FRACTURES: Pathological; Traumatic; Varieties—Simple fractures—Compound fractures—Repair of fractures—Interference with repair—Gun-shot fractures—SEPARATION OF EPIPHYSES.

The injuries to which a bone is liable are Contusions, Open Wounds, and Fractures.

Contusions of Bone are almost of necessity associated with a similar injury of the overlying soft parts. The mildest degree consists in a bruising of the periosteum, which is raised from the bone by an effusion of blood, constituting a haematoma of the periosteum. This may be absorbed, or it may give place to a persistent thickening of the bone—traumatic node.

Open Wounds of Bone of the incised and contused varieties are usually produced by sabres, axes, butcher's knives, scythes, or circular saws. Punctured wounds are caused by bayonets, arrows, or other pointed instruments. They are all equivalent to compound, incomplete fractures.

FRACTURES

A fracture may be defined as a sudden solution in the continuity of a bone.

PATHOLOGICAL FRACTURES

A pathological fracture has as its primary cause some diseased state of the bone, which permits of its giving way on the application of a force which would be insufficient to break a healthy bone. It cannot be too strongly emphasised that when a bone is found to have been broken by a slight degree of violence, the presence of some pathological condition should be suspected, and a careful examination made with the X-rays and by other means, before arriving at a conclusion as to the cause of the fracture. Many cases are on record in which such an accident has first drawn attention to the presence of a new-growth, or other serious lesion in the bone. The following conditions, which are more fully described with diseases of bone, may be mentioned as the causes of pathological fractures.

Atrophy of bone may proceed to such an extent in old people, or in those who for long periods have been bed-ridden, that slight violence suffices to determine a fracture. This most frequently occurs in the neck of the femur in old women, the mere catching of the foot in the bedclothes while the patient is turning in bed being sometimes sufficient to cause the bone to give way. Atrophy from the pressure of an aneurysm or of a simple tumour may erode the whole thickness of a bone, or may thin it out to such an extent that slight force is sufficient to break it. In general paralysis, and in the advanced stages of locomotor ataxia and other chronic diseases of the nervous system, an atrophy of all the bones sometimes takes place, and may proceed so far that multiple fractures are induced by comparatively slight causes. They occur most frequently in the ribs or long bones of the limbs, are not attended with pain, and usually unite satisfactorily, although with an excessive amount of callus. Attendants and nurses, especially in asylums, must be warned against using force in handling such patients, as otherwise they may be unfairly blamed for causing these fractures.

Among diseases which affect the skeleton as a whole and render the bones abnormally fragile, the most important are rickets, osteomalacia, and fibrous osteomyelitis. In these conditions multiple pathological fractures may occur, and they are prone to heal with considerable deformity. In osteomalacia, the bones are profoundly altered, but they are more liable to bend than to break; in rickets the liability is towards greenstick fractures.

Of the diseases affecting individual bones and predisposing them to fracture may be mentioned suppurative osteomyelitis, hydatid cysts, tuberculosis, syphilitic gummata, and various forms of new-growth, particularly sarcoma and secondary cancer. It is not unusual for the sudden breaking of the bone to be the first intimation of the presence of a new-growth. In adolescents, fibrous osteomyelitis affecting a single bone, and in adults, secondary cancer, are the commonest local causes of pathological fracture.

Intra-uterine fractures and fractures occurring during birth are usually associated with some form of violence, but in the majority of cases the foetus is the subject of constitutional disease which renders the bones unduly fragile.

TRAUMATIC FRACTURES

Traumatic fractures are usually the result of a severe force acting from without, although sometimes they are produced by muscular contraction.

When the bone gives way at the point of impact of the force, the violence is said to be direct, and a "fracture by compression" results, the line of fracture being as a rule transverse. The soft parts overlying the fracture are more or less damaged according to the weight and shape of the impinging body. Fracture of both bones of the leg from the passage of a wheel over the limb, fracture of the shaft of the ulna in warding off a stroke aimed at the head, and fracture of a rib from a kick, are illustrative examples of fractures by direct violence.

When the force is transmitted to the seat of fracture from a distance, the violence is said to be indirect, and the bone is broken by "torsion" or by "bending." In such cases the bone gives way at its weakest point, and the line of fracture tends to be oblique. Thus both bones of the leg are frequently broken by a person jumping from a height and landing on the feet, the tibia breaking in its lower third, and the fibula at a higher level. Fracture of the clavicle in its middle third, or of the radius at its lower end, from a fall on the outstretched hand, are common accidents produced by indirect violence. The ribs also may be broken by indirect violence, as when the chest is crushed antero-posteriorly and the bones give way near their angles. In fractures by indirect violence the soft parts do not suffer by the violence causing the fracture, but they may be injured by displacement of the fragments.

In fractures by muscular action the bone is broken by "traction" or "tearing." The sudden and violent contraction of a muscle may tear off an epiphysis, such as the head of the fibula, the anterior superior iliac spine, or the coronoid process of the ulna; or a bony process may be separated, as, for example, the tuberosity of the calcaneus, the coracoid process of the scapula, or the larger tubercle (great tuberosity) of the humerus. Long bones also may be broken by muscular action. The clavicle has snapped across during the act of swinging a stick, the humerus in throwing a stone, and the femur when a kick has missed its object. Fractures of ribs have occurred during fits of coughing and in the violent efforts of parturition.

Before concluding that a given fracture is the result of muscular action, it is necessary to exclude the presence of any of the diseased conditions that lead to pathological fracture.

Although the force acting upon the bone is the primary factor in the production of fractures, there are certain subsidiary factors to be considered. Thus the age of the patient is of importance. During infancy and early childhood, fractures are less common than at any other period of life, and are usually transverse, incomplete, and of the nature of bends. During adult life, especially between the ages of thirty and forty, the frequency of fractures reaches its maximum. In aged persons, although the bones become more brittle by the marrow spaces in their interior becoming larger and filled with fat, fractures are less frequent, doubtless because the old are less exposed to such violence as is likely to produce fracture.

Males, from the nature of their occupations and recreations, sustain fractures more frequently than do females; in old age, however, fractures are more common in women than in men, partly because their bones are more liable to be the seat of fatty atrophy from senility and disease, and partly because of their clothing—a long skirt—they are more exposed to unexpected or sudden falls.



Clinical Varieties of Fractures.—The most important subdivision of fractures is that into simple and compound.

In a simple or subcutaneous fracture there is no communication, directly or indirectly, between the broken ends of the bone and the surface of the skin. In a compound or open fracture, on the other hand, such a communication exists, and, by furnishing a means of entrance for bacteria, may add materially to the gravity of the injury.

A simple fracture may be complicated by the existence of a wound of the soft parts, which, however, does not communicate with the broken bone.

Fractures, whether simple or compound, fall into other clinical groups, according to (1) the degree of damage done to the bone, (2) the direction of the break, and (3) the relative position of the fragments.

(1) According to the Degree of Damage done to the Bone.—A fracture may be incomplete, for example in greenstick fractures, which occur only in young persons—usually below the age of twelve—while the bones are still soft and flexible. They result from forcible bending of the bone, the osseous tissue on the convexity of the curve giving way, while that on the concavity is compressed. The clavicle and the bones of the forearm are those most frequently the seat of greenstick fracture (Fig. 41). Fissures occur on the flat bones of the skull, the pelvic bones, and the scapula; or in association with other fractures in long bones, when they often run into joint surfaces. Depressions or indentations are most common in the bones of the skull.

The bone at the seat of fracture may be broken into several pieces, constituting a comminuted fracture. This usually results from severe degrees of direct violence, such as are sustained in railway or machinery accidents, and in gun-shot injuries (Fig. 2).



Sub-periosteal fractures are those in which, although the bone is completely broken across, the periosteum remains intact. These are common in children, and as the thick periosteum prevents displacement, the existence of a fracture may be overlooked, even in such a large bone as the femur.

A bone may be broken at several places, constituting a multiple fracture (Fig. 1).

Separation of bony processes, such as the coracoid process, the epicondyle of the humerus, or the tuberosity of the calcaneus, may result from muscular action or from direct violence. Separation of epiphyses will be considered later.

(2) According to the Direction of the Break.Transverse fractures are those in which the bone gives way more or less exactly at right angles to its long axis. These usually result from direct violence or from end-to-end pressure. Longitudinal fractures extending the greater part of the length of a long bone are exceedingly rare. Oblique fractures are common, and result usually from indirect violence, bending, or torsion (Fig. 3). Spiral fractures result from forcible torsion of a long bone, and are met with most frequently in the tibia, femur, and humerus.



(3) According to the Relative Position of the Fragments.—The bone may be completely broken across, yet its ends remain in apposition, in which case there is said to be no displacement. There may be an angular displacement—for example, in greenstick fracture. In transverse fractures of the patella or of the olecranon there is often distraction or pulling apart of the fragments (Fig. 35). The broken ends, especially in oblique fractures, may override one another, and so give rise to shortening of the limb (Fig. 2). Where one fragment is acted upon by powerful muscles, a rotatory displacement may take place, as in fracture of the radius above the insertion of the pronator teres, or of the femur just below the small trochanter. The fragments may be depressed, as in the flat bones of the skull or the nasal bones. At the cancellated ends of the long bones, particularly the upper end of the femur and humerus, and the lower end of the radius, it is not uncommon for one fragment to be impacted or wedged into the substance of the other (Fig. 28).

Causes of Displacement.—The factors which influence displacement are chiefly mechanical in their action. Thus the direction and nature of the fracture play an important part. Transverse fractures with roughly serrated ends are less liable to displacement than those which are oblique with smooth surfaces. The direction of the causative force also is a dominant factor in determining the direction in which one or both of the fragments will be displaced. Gravity, acting chiefly upon the distal fragment, also plays a part in determining the displacement—for example, in fractures of the thigh or of the leg, where the lower segment of the limb rolls outwards, and in fractures of the shaft of the clavicle, where the weight of the arm carries the shoulder downwards, forwards, and medially. After the break has taken place and the force has ceased to act, displacement may be produced by rough handling on the part of those who render first aid, the careless or improper application of splints or bandages, or by the weight of the bedclothes.

In certain situations the contraction of unopposed, or of unequally opposed, groups of muscles plays a part in determining displacement. For example, in fracture immediately below the lesser trochanter of the femur, the ilio-psoas tends to tilt the upper fragment forward and laterally; in supra-condylar fracture of the femur, the muscles of the calf pull the lower fragment back towards the popliteal space; and in fracture of the humerus above the deltoid insertion, the muscles inserted into the inter-tubercular (bicipital) groove adduct the upper fragment.

REPAIR OF INJURIES OF BONE

In a simple fracture the vessels of the periosteum and the marrow being torn at the same time as the bone is broken, blood is poured out, and clots around and between the fragments. This clot is soon permeated by newly formed blood vessels, and by leucocytes and fibroblasts, the latter being derived from proliferation of the cells of the marrow and periosteum. The granulation tissue thus formed resembles in every particular that described in the repair of other tissues, except that the fibroblasts, being the offspring of cells which normally form bone, assume the functions of osteoblasts, and proceed to the formation of bone. The new bone may be formed either by a direct conversion of the fibrous tissue into osseous tissue, the osteoblasts arranging themselves concentrically in the recesses of the capillary loops, and secreting a homogeneous matrix in which lime salts are speedily deposited; or there may be an intermediate stage of cartilage formation, especially in young subjects, and in cases where the fragments are incompletely immobilised. The newly formed bone is at first arranged in little masses or in the form of rods which unite with each other to form a network of spongy bone, the meshes of which contain marrow.

The reparative material, consisting of granulation tissue in the process of conversion into bone, is called callus, on account of its hard and unyielding character. In a fracture of a long bone, that which surrounds the fragments is called the external or ensheathing callus, and may be likened to the mass of solder which surrounds the junction of pipes in plumber-work; that which occupies the position of the medullary canal is called the internal or medullary callus; and that which intervenes between the fragments and maintains the continuity of the cortical compact tissue of the shaft is called the intermediate callus. This intermediate callus is the only permanent portion of the reparative material, the external and internal callus being only temporary, and being largely re-absorbed through the agency of giant cells.

Detached fragments or splinters of bone are usually included in the callus and ultimately become incorporated in the new bone that bridges the gap.

In time all surplus bone is removed, the medullary canal is re-formed, the young spongy bone of the intermediate callus becomes more and more compact, and thus the original architectural arrangement of the bone may be faithfully reproduced. If, however, apposition is not perfect, some of the new bone is permanently required and some of the old bone is absorbed in order to meet the altered physiological strain upon the bone resulting from the alteration in its architectural form. In overriding displacement, even the dense cortical bone intervening between the medullary canal of the two fragments is ultimately absorbed and the continuity of the medullary canal is reproduced.

The amount of callus produced in the repair of a given fracture is greater when movement is permitted between the broken ends. It is also influenced by the character of the bone involved, being less in bones entirely ossified in membrane, such as the flat bones of the skull, than in those primarily ossified in cartilage.

If the fragments are widely separated from one another, or if some tissue, such as muscle, intervenes between them, callus may not be able to bring about a bony union between the fragments, and non-union results.

Bones divided in the course of an operation, for example in osteotomy for knock-knee, or wedge-shaped resection for bow-leg, are repaired by the same process as fractures.

Excess of Callus.—In comminuted fractures, and in fractures in which there is much displacement, the amount of callus is in excess, but this is necessary to ensure stability. In fractures in the vicinity of large joints, such as the hip or elbow, the formation of callus is sometimes excessive, and the projecting masses of new bone restrict the movements of the joint. When exuberant callus forms between the bones in fractures of the forearm, pronation and supination may be interfered with (Fig. 4). Certain nerve-trunks, such as the radial (musculo-spiral) in the middle of the arm, or the ulnar at the elbow-joint, may become included in or pressed upon by callus.



Absorption of Callus.—It sometimes happens that when an acute infective disease, especially one of the exanthemata, supervenes while a fracture is undergoing repair, the callus which has formed becomes softened and is absorbed. This may occur weeks or even months after the bone has united, with the result that the fragments again become movable, and it may be a considerable time before union finally takes place.

Tumours of Callus.—Tumours, such as chondroma and sarcoma, and cysts which are probably of the same nature as those met with in osteomyelitis fibrosa, are liable to occur in callus, or at the seat of old fractures, but the evidence so far is inconclusive as to the causative relationship of the injury to the new-growth. They are treated on the same lines as tumours occurring independently of fracture.

Badly United Fracture—Mal-Union.—Union with marked displacement of the fragments is most common in fractures that have not been properly treated—as, for example, those occurring in sailors at sea; and in cases in which the comminution was so great that accurate apposition was rendered impossible. It may also result from imperfect reduction, or because the apparatus employed permitted of secondary displacement. Restlessness on the part of the patient from intractability, delirium tremens, or mania, is the cause of mal-union in some cases; sometimes it has resulted because the patient was expected to die from some other lesion and the fracture was left untreated.

Whether or not any attempt should be made to improve matters depends largely on the degree of deformity and the amount of interference with function.

When interference is called for, if the callus is not yet firmly consolidated, it may be possible, under an anaesthetic, to bend the bone into position or to re-break it, either with the hands or by means of a strong mechanical contrivance known as an osteoclast. In the majority of cases, however, an open operation yields results which are more certain and satisfactory. When the deformity is comparatively slight, the bone is divided with an osteotome and straightened; when there is marked bending or angling, a wedge is taken from the convexity, as in the operation for bow-leg. To maintain the fragments in apposition it may be necessary to employ pegs, plates, bone-grafts, or other mechanical means. Splints and extension are then applied, and the condition is treated on the same lines as a compound fracture.



Delayed Union.—At the time when union should be firm and solid, it may be found that the fragments are only united by a soft cartilaginous callus, which for a prolonged period may undergo no further change, so that the limb remains incapable of bearing weight or otherwise performing its functions. The normal period required for union may be extended from various causes. The most important of these is general debility, but the presence of rickets or tuberculosis, or an intercurrent acute infectious disease, may delay the reparative process. The influence of syphilis, except in its gummatous form, in interfering with union is doubtful. The influence of old age as a factor in delaying union has been overestimated; in the great majority of cases, fractures in old people unite as rapidly and as firmly as those occurring at other periods of life.

Treatment.—The general condition of the patient should be improved, by dieting and tonics. One of the most reliable methods of hastening union in these cases is by inducing passive hyperaemia of the limb after the method advocated by Bier, and this plan should always be tried in the first instance. An elastic bandage is applied above the seat of fracture, sufficiently tightly to congest the limb beyond, and, to concentrate the congestion in the vicinity of the fracture, an ordinary bandage should be applied from the distal extremity to within a few inches of the break. The hyperaemia should be maintained for several hours (six to twelve) daily. An apparatus should be adjusted to enable the patient to get into the open air, and in fractures of the lower extremity the patient should move about with crutches in the intervals, putting weight on the fractured bone. This method of treatment should be persevered with for three or four weeks, and the limb should be massaged daily while the constricting bandage is off.

Among the other methods which have been recommended are the injection between the fragments of oil of turpentine (Mikulicz), a quantity of the patient's own blood (Schmieden), or alcohol and iodine; the forcible rubbing of the ends together, under an anaesthetic if necessary; and the administration of thyreoid extract. If these methods fail, the case should be treated as one of un-united fracture. As a rule, satisfactory union is ultimately obtained, although much patience is required.

Non-Union.—Sometimes the fragments become united by a dense band of fibrous tissue, and the reparative process goes no further—fibrous union. This is frequently the case in fractures of the patella, the olecranon, and the narrow part of the neck of the femur.

False Joint—Pseudarthrosis.—In rare cases the ends of the fragments become rounded and are covered with a layer of cartilage. Around their ends a capsule of fibrous tissues forms, on the inner aspect of which a layer of endothelium develops and secretes a synovia-like fluid. This is met with chiefly in the humerus and in the clavicle.

Failure of Union—"Un-united Fracture."—As the time taken for union varies widely in different bones, and ossification may ultimately ensue after being delayed for several months, a fracture cannot be said to have failed to unite until the average period has been long overpassed and still there is no evidence of fusion of the fragments. Under these conditions failure of union is a rare complication of fractures. In adults it is most frequently met with in the humerus, the radius and ulna (Fig. 6), and the femur; in children in the bones of the leg and in the forearm.



In a radiogram the bones in the vicinity of the fracture, particularly the distal fragment, cast a comparatively faint shadow, and there may even be a clear space between the fragments. When the parts are exposed by operation, the bone is found to be soft and spongy and the ends of the fragments are rarefied and atrophied; sometimes they are pointed, and occasionally absorption has taken place to such an extent that a gap exists between the fragments. The bone is easily penetrated by a bradawl, and if an attempt is made to apply plates, the screws fail to bite. These changes are most marked in the distal fragment.

The want of union is evidently due to defective activity of the bone-forming cells in the vicinity of the fracture. This may result from constitutional dyscrasia, or may be associated with a defective blood supply, as when the nutrient artery is injured. Interference with the trophic nerve supply may play a part, as cases are recorded by Bognaud in which union of fractures of the leg failed to take place after injuries of the spinal medulla causing paraplegia. The condition has been attributed to local causes, such as the interposition of muscle or other soft tissue between the fragments, or to the presence of a separated fragment of bone or of a sequestrum following suppuration. In our experience such factors are seldom present.

If the treatment recommended for delayed union fails, recourse must be had to operation, the most satisfactory procedure being to insert a bone graft in the form of an intra-medullary splint. In certain cases met with in the bones of the leg in children, the degree of atrophy of the bones is such that it has been found necessary to amputate after repeated attempts to obtain union by operative measures have failed.

In the tibia we have found that with the double electric saw a rod of bone can be rapidly and accurately cut, extending well above as well as below the site of fracture but unequally in the two directions; the rod is then reinserted into the trough from which it was taken with the ends reversed, so that a strong bridge of bone is provided at the seat of non-union.

CLINICAL FEATURES OF SIMPLE FRACTURES

In the first place, the history of the accident should be investigated, attention being paid to the nature of the violence—whether a blow, a twist, a wrench, or a crush, and whether the violence was directly or indirectly applied. The degree of the violence may often be judged approximately from the instrument inflicting it—whether, for example, a fist, a stick, a cart wheel, or a piece of heavy machinery. The position of the limb at the time of the injury; whether the muscles were braced to meet the blow or were lax and taken unawares; and the patient's sensations at the moment, such as his feeling something snap or tear, may all furnish information useful for purposes of diagnosis.

Signs of Fracture.—The most characteristic signs of fracture are unnatural mobility, deformity, and crepitus.

Unnatural mobility—that is, movement between two segments of a limb at a place where movement does not normally occur—may be evident when the patient makes attempts to use his limb, or may only be elicited when the fragments are seized and moved in opposite directions. Deformity, or the part being "out of drawing" in comparison with the normal side, varies with the site and direction of the break, and depends upon the degree of displacement of the fragments. Crepitus is the name applied to the peculiar grating or clicking which may be heard or felt when the fractured surfaces are brought into contact with one another.

The presence of these three signs in association is sufficient to prove the existence of a fracture, but the absence of one or more of them does not negative this diagnosis. There are certain fallacies to be guarded against. For example, a fracture may exist and yet unnatural mobility may not be present, because the bones are impacted into one another, or because the fracture is an incomplete one. Again, the extreme tension of the swollen tissues overlying the fracture may prevent the recognition of movement between the fragments. Deformity also may be absent—as, for instance, when there is no displacement of the fragments, or when only one of two parallel bones is broken, as in the leg or forearm. Similarly, crepitus may be absent when impaction exists, when the fragments completely override one another, or are separated by an interval, or when soft tissues, such as torn periosteum or muscle, are interposed between them. A sensation simulating crepitus may be felt on palpating a part into which blood has been extravasated, or which is the seat of subcutaneous emphysema. The creaking which accompanies movements in certain forms of teno-synovitis and chronic joint disease, and the rubbing of the dislocated end of a bone against the tissues amongst which it lies, may also be mistaken for the crepitus of fracture.

It is not advisable to be too diligent in eliciting these signs, because of the pain caused by the manipulations, and also because vigorous handling may do harm by undoing impaction, causing damage to soft parts or producing displacement which does not already exist, or by converting a simple into a compound fracture.

It is often necessary for purposes of diagnosis to administer a general anaesthetic, particularly in injuries of deeply placed bones and in the vicinity of joints. Before doing so, the appliances necessary for the treatment of the injury should be made ready, in order that the fracture may be reduced and set before the patient regains consciousness.

Radiography in the Diagnosis of Fractures.—While radiography is of inestimable value in the diagnosis of many fractures and other injuries, particularly in the vicinity of joints, the student is warned against relying too implicitly on the evidence it seems to afford.

A radiogram is not a photograph of the object exposed to the X-rays but merely a picture of its shadow, or rather of a series of shadows of the different structures, which vary in opacity. As the rays emanate from a single point in the vacuum tube, and as they are not, like the sun's rays, approximately parallel, the shadows they cast are necessarily distorted. Hence, in interpreting a radiogram, it is necessary to know the relative positions of the point from which the rays proceed, the object exposed, and the plate on which the shadow is registered. The least distortion takes place when the object is in contact with the plate, and the shadow of that part of the object which lies perpendicularly under the light is less distorted than that of the parts lying outside the perpendicular. The light and the plate remaining constant, the amount of distortion varies directly with the distance between the object and the plate.

To ensure accuracy in the diagnosis of fracture by the X-rays, it is necessary to take two views of the limb—one in the sagittal and the other in the coronal plane. By the use of the fluorescent screen, the best positions from which to obtain a clear impression of the fracture may be determined before the radiograms are taken. Stereoscopic radiograms may be of special value in demonstrating the details of a fracture that is otherwise doubtful.

Imperfect technique and faulty interpretation of the pictures obtained lead to certain fallacies. In young subjects, for example, epiphysial lines may be mistaken for fractures, or the ossifying centres of epiphyses for separated fragments of bone. The os trigonum tarsi has been mistaken for a fracture of the talus. In the vicinity of joints the bones may be crossed by pale bands, due to the rays traversing the cavity of the joint. In this way fracture of the olecranon or of the clavicle may be simulated. The neck of the femur may appear to be fractured if a foreshortened view is taken.

It is possible, on the other hand, to overlook a fracture—for example, if there is no displacement, or if the line of fracture is crossed by the shadow of an adjacent bone. In deeply placed bones such as those about the hip, or in bones related to dense, solid viscera—for example, ribs, sternum, or dorsal vertebrae—it is sometimes difficult to obtain conclusive evidence of fracture in a radiogram.

It is to be borne in mind also, and especially from the medico-legal point of view, that, as early callus does not cast a deep shadow in a radiogram, the appearance of fracture may persist after union has taken place. The earliest shadow of callus appears in from fourteen to twenty-one days, and can hardly be relied upon till the fourth or sixth week. The disturbed perspective produced by divergence of the rays may cause the fragments of a fracture to appear displaced, although in reality they are in good position. If the limb and the plate are not parallel, the bones may appear to be distorted, and errors in diagnosis may in this way arise. In this relation it should be mentioned that perfect apposition of the fragments and anatomically accurate restoration of the outline of the bones are not always essential to a good functional result.

* * * * *

As most of the remaining signs are common to all the lesions from which fractures have to be distinguished, their diagnostic value must be carefully weighed.

Interference with Function.—As a rule, a broken bone is incapable of performing its normal function as a lever or weight-bearer; but when a fracture is incomplete, when the fragments are impacted, or when only one of two parallel bones is broken, this does not necessarily follow. It is no uncommon experience to find a patient walk into hospital with an impacted fracture of the neck of the femur or a fracture of the fibula; or to be able to pronate and supinate the forearm with a greenstick fracture of the radius or a fracture of the ulna.

Pain.—Three forms of pain may be present in fractures: pain independent of movement or pressure; pain induced by movement of the limb; and pain elicited on pressure or "tenderness." In injuries by direct violence, pain independent of movement and pressure is never diagnostic of fracture, as it may be due to bruising of soft tissues. In injuries resulting from indirect violence, however, pain localised to a spot at some distance from the point of impact is strongly suggestive of fracture—as, for example, when a patient complains of pain over the clavicle after a fall on the hand, or over the upper end of the fibula after a twist of the ankle. Pain elicited by attempts to move the damaged part, or by applying pressure over the seat of injury, is more significant of fracture. Pain elicited at a particular point on pressing the bone at a distance, "pain on distal pressure,"—for example, pain at the lower end of the fibula on pressing near its neck, or at the angle of a rib on pressing near the sternum,—is a valuable diagnostic sign of fracture. When nerve-trunks are implicated in the vicinity of a fracture, pain is often referred along the course of their distribution.

Localised swelling comes on rapidly, and is due to displacement of the fragments and to haemorrhage from the torn vessels of the marrow and periosteum.

Discoloration accompanies the swelling, and is often widespread, especially in fracture of bones near the surface and when the tension is great. It is not uncommon to find over the ecchymosed area, especially over the shin-bone, large blebs containing blood-stained serum. In fractures of deep-seated bones, discoloration may only show on the surface after some days, and at a distance from the break.

Alterations in the relative position of bony landmarks are valuable diagnostic guides. Alteration in the length of the limb, usually in the direction of shortening, is also an important sign. Before drawing deductions, care must be taken to place both limbs in the same position and to determine accurately the fixed points for measurement, and also to ascertain if the limbs were previously normal.

Shock is seldom a prominent symptom in uncomplicated fractures, although in old and enfeebled patients it may be serious and even fatal. During the first two or three days after a fracture there is almost invariably some degree of traumatic fever, indicated by a rise of temperature to 99 deg. or 100 deg. F.

Complications.Injuries to large arteries are not common in simple fractures. The popliteal artery, however, is liable to be compressed or torn across in fractures of the lower end of the femur; extravasation of blood from the ruptured artery and gangrene of the limb may result. If large veins are injured, thrombosis may occur, and be followed by pulmonary embolism.

Injuries to nerve-trunks are comparatively common, especially in fractures of the arm, where the radial (musculo-spiral) nerve is liable to suffer.

The nerve may be implicated at the time of the injury, being compressed, bruised, lacerated, or completely torn across by broken fragments, or it may be involved later by the pressure of callus. The symptoms depend upon the degree of damage sustained by the nerve, and vary from partial and temporary interference with sensation and motion to complete and permanent abrogation of function.

In rare instances fat embolism is said to occur, and fat globules are alleged to have been found in the urine. In persons addicted to excess of alcohol, delirium tremens is a not infrequent accompaniment of a fracture which confines the patient to bed.

Prognosis in Simple Fractures.Danger to life in simple fractures depends chiefly on the occurrence of complications. In old people, a fracture of the neck of the femur usually necessitates long and continuous lying on the back, and bronchitis, hypostatic pneumonia, and bed-sores are prone to occur and endanger life. Fractures complicated with injury to internal organs, and fractures in which gangrene of the limb threatens, are, of course, of grave import.

The prognosis as regards the function of the limb should always be guarded, even in simple fractures. Incidental complications are liable to arise, delaying recovery and preventing a satisfactory result, and these not only lead to disappointment, but may even form a ground for actions for malpraxis.

The chief and most frequent cause of permanent disability after fracture is angular displacement. A comparatively small degree of angularity may lead to serious loss of function, especially in the lower limb; the joints above and below the fracture are placed at a disadvantage, arthritic changes result from the abnormal strain to which they are subjected, and rarefaction of the bone may also ensue.

Fibrous union is a common result in fractures of the neck of the femur in old people and in certain other fractures, such as fracture of the patella, of the olecranon, coronoid and coracoid processes, and although this does not necessarily involve interference with function, the patient should always be warned of the possibility.

Impairment of growth and eventual shortening of the limb may result from involvement of an epiphysial junction.

Stiffness of joints is liable to follow fractures implicating articular surfaces, or it may result from arthritic changes following upon the injury.

Osseous ankylosis is not a common sequel of simple fractures, but locking of joints from the mechanical impediment produced by the union of imperfectly reduced fragments, or from masses of callus, is not uncommon, especially in the region of the elbow.

Wasting of the muscles and oedema of the limb often delay the complete restoration of function. Delayed union, want of union, and the formation of a false joint have already been referred to.

Treatment.—The treatment of a fracture should be commenced as soon after the accident as possible, before the muscles become contracted and hold the fragments in abnormal positions, and before the blood and serum effused into the tissues undergo organisation.

Care must be taken during the transport of the patient that no further damage is done to the injured limb. To this end the part must be secured in some form of extemporised splint, the apparatus being so designed as to control not only the broken fragments, but also the joints above and below the fracture.

When the ordinary method of removing the clothes involves any risk of unduly moving the injured part, they should be slit open along the seams.

The patient should be placed on a firm straw, horse-hair, or spring mattress, stiffened in the case of fractures of the pelvis or lower limbs by fracture-boards inserted beneath the mattress. Special mattresses constructed in four pieces, to facilitate the nursing of the patient, are sometimes used.

In many cases, particularly in muscular subjects, in restless alcoholic patients, and in those who do not bear pain well, a general anaesthetic is a valuable aid to the accurate setting of a fracture, as well as a means of rendering the diagnosis more certain.

The procedure popularly known as "setting a fracture" consists in restoring the displaced parts to their normal position as nearly as possible, and is spoken of technically as the reduction of the fracture.

The Reduction of Fractures.—In some cases the displacement may be overcome by relaxing the muscles acting upon the fragments, and this may be accomplished by the stroking movements of massage. In most cases, however, it is necessary, after relaxing the muscles, to employ extension, by making forcible but steady traction on the distal fragment, while counter-extension is exerted on the proximal one, either by an assistant pulling upon that portion of the limb, or by the weight of the patient's body. The fragments having been freed, and any shortening of the limb corrected in this way, the broken ends are moulded into position—a process termed coaptation.

The reduction of a recent greenstick fracture consists in forcibly straightening the bend in the bone, and in some cases it is necessary to render the fracture complete before this can be accomplished.

In selecting a means of retaining the fragments in position after reduction, the various factors which tend to bring about re-displacement must be taken into consideration, and appropriate measures adopted to counteract each of these.

In addition to retaining the broken ends of the bone in apposition, the after-treatment of a fracture involves the taking of steps to promote the absorption of effused blood and serum, to maintain the circulation through the injured parts, and to favour the repair of damaged muscles and other soft tissues. Means must also be taken to maintain the functional activity of the muscles of the damaged area, to prevent the formation of adhesions in joints and tendon sheaths, and generally to restore the function of the injured part.

Practical Means of Effecting Retention—By Position.—It is often found that only in one particular position can the fragments be made to meet and remain in apposition—for example, the completely supine position of the forearm in fracture of the radius just above the insertion of the pronator teres. Again, in certain cases it is only by relaxing particular groups of muscles that the displacement can be undone—as, for instance, in fracture of the bones of the leg, or of the femur immediately above the condyles, where flexion of the knee, by relaxing the calf muscles, permits of reduction.

Massage and Movement in the Treatment of Fractures.—Lucas-Championniere, in 1886, first pointed out that a certain amount of movement between the ends of a fractured bone favours their union by promoting the formation of callus, and advocated the treatment of fractures by massage and movement, discarding almost entirely the use of splints and other retentive appliances. We were early convinced by the teaching of Lucas-Championniere, and have adopted his principles in fractures.

In the majority of cases the massage and movement are commenced at once, but circumstances may necessitate their being deferred for a few days. The measures adopted vary according to the seat and nature of the fracture, but in general terms it may be stated that after the fracture has been reduced, the ends of the broken bone are retained in position, and gentle massage is applied by the surgeon or by a trained masseur. The lubricant may either be a powder composed of equal parts of talc and boracic acid, or an oily substance such as olive oil or lanolin. The rubbing should never cause pain, but, on the contrary, should relieve any pain that exists, as well as the muscular spasm which is one of the most important causes of pain and of displacement in recent fractures. The parts on the proximal side of the injured area are first gently stroked upwards to empty the veins and lymphatics, and to disperse the effused blood and serum. The process is then applied to the swollen area, and gradually extended down over the seat of the fracture and into the parts beyond. In this way the circulation through the damaged segment of the limb is improved, the veins are emptied of blood, the removal of effused fluid is stimulated, and the muscular irritability allayed. The joints of the limb are gently moved, care being taken that the broken ends of the bone are not displaced. After the rubbing has been continued for from fifteen to twenty minutes, the limb is placed in a comfortable position, and retained there by pillows, sand-bags, or, if found more convenient, by a light form of splint.

The massage is repeated once each day; the sittings last from ten to fifteen minutes. The sequence should be, first, massage; second, passive movement; and third, active movement. At first massage predominates, and more passive than active movement; gradually massage is lessened and movements are increased, active movements ultimately preponderating.

Splints and other Appliances.—The appropriate splints for individual fractures and the method of applying them will be described later; but it may here be said that the general principle is that when dealing with a part where there is a single bone, as the thigh or upper arm, the splint should be applied in the form of a ferrule to surround the break; while in situations where there are two parallel bones, as in the forearm and leg, the splint should take the form of a box.

Simple wooden splints of plain deal board or yellow pine, sawn to the appropriate length and width; or Gooch's splinting, which consists of long strips of soft wood, glued to a backing of wash-leather, are the most useful materials. Gooch's splinting has the advantage that when applied with the leather side next the limb it encircles the part as a ferrule; while it remains rigid when the wooden side is turned towards the skin. Perforated sheet lead or tin, stiff wire netting, and hoop iron also form useful splints.

When it is desirable that the splint should take the shape of the part accurately, a plastic material may be employed. Perhaps the most convenient is poroplastic felt, which consists of strong felt saturated with resin. When heated before a fire or placed in boiling water, it becomes quite plastic and may be accurately moulded to any part, and on cooling it again becomes rigid. The splint should be cut from a carefully fitted paper pattern. Millboard, leather, or gutta-percha softened in hot water, and moulded to the part, may also be employed.

In conditions where treatment by massage and movement is impracticable, and where movable splints are inconvenient, splints of plaster of Paris, starch, or water-glass are sometimes used, especially in the treatment of fractures of the leg. When employed in the form of an immovable case, they are open to certain objections—for example, if applied immediately after the accident they are apt to become too tight if swelling occurs; and if applied while swelling is still present, they become slack when this subsides, so that displacement is liable to occur.

When it is desired to enclose the limb in a plaster case, coarse muslin bandages, 3 yards long, and charged with the finest quality of thoroughly dried plaster of Paris, are employed. The "acetic plaster bandages" sold in the shops set most quickly and firmly. Boracic lint or a loose stocking is applied next the skin, and the bony prominences are specially padded. The plaster bandage is then placed in cold water till air-bubbles cease to escape, by which time it is thoroughly saturated, and, after the excess of water is squeezed out, is applied in the usual way from below upward. From two to four plies of the bandage are required. In the course of half an hour the plaster should be thoroughly set. To facilitate the removal of a plaster case the limb should be immersed for a short time in tepid water.

A convenient and efficient splint is made by moulding two pieces of poroplastic felt to the sides of the limb, and fixing them in position with an elastic webbing bandage; this apparatus can be easily removed for the daily massage.

Padding is an essential adjunct to all forms of splints. The whole part enclosed in the splint must be covered with a thick layer of soft and elastic material, such as wool from which the fat has not been removed. All hollows should be filled up, and all bony projections specially protected by rings of wadding so arranged as to take the pressure off the prominent point and distribute it on the surrounding parts. Opposing skin surfaces must always be separated by a layer of wool or boracic lint. A bandage should never be applied to the limb underneath the splints and pads, as congestion or even gangrene may be induced thereby.

Operative Treatment of Simple Fractures.—Operation in simple fracture is specially called for (1) in fracture into or near a joint where a permanently displaced fragment will cause locking of the joint; (2) when fragments are drawn apart, as in fractures of the patella or olecranon; (3) when displacement, especially shortening, cannot be remedied by other means; (4) when complications are present, such as a torn nerve-trunk or a main artery; (5) when non-union is to be feared, as in certain cases of fracture of the neck of the femur in old people. Under such circumstances it is necessary to expose the fracture by operation, and to place the fragments in accurate apposition, if necessary, fixing them in position by wires, pegs, plates, or screws (Op. Surg., p. 52). Operative interference is usually delayed till about five to seven days after the injury, by which time the effect of other measures will have been estimated, accurate information obtained by means of the X-rays regarding the nature of the lesion and the position of the fragments, and the tissues recovered their normal powers of resistance. Such operations, however, are not to be undertaken lightly, as they are often difficult, and if infection takes place the results may be disastrous. Arbuthnot Lane and Lambotte advocate a more general resort to operative measures, even in simple and uncomplicated fractures, and it must be conceded that in many fractures an open operation affords the only means of securing accurate apposition and alignment of the fragments.

Both before and after operation, massage and movement are to be carried out, as in fractures treated by other methods.

COMPOUND FRACTURES

The essential feature of a compound fracture is the existence of an open wound leading down to the break in the bone. The wound may vary in size from a mere puncture to an extensive tearing and bruising of all the soft parts.

A fracture may be rendered compound from without, the soft parts being damaged by the object which breaks the bone—as, for example, a cart wheel, a piece of machinery, or a bullet. Sloughing of soft parts resulting from the pressure of improperly applied splints, also, may convert a simple into a compound fracture. On the other hand, a simple fracture may be rendered compound from within—for example, a sharp fragment of bone may penetrate the skin; this is the least serious variety of compound fracture.

As a rule, it is easy to recognise that the fracture is compound, as the bone can either be seen or felt.

The prognosis depends on the success which attends the efforts to make and to keep the wound aseptic, as well as on the extent of damage to the tissues. When asepsis is secured, repair takes place as in simple fracture, only it usually takes a little longer; sometimes the reason for the delay is obvious, as when the compound fracture is the result of a more severe form of violence and where there is comminution and loss of one or more portions of bone that would have contributed to the repair. Sometimes the delay cannot be so explained; Bier suggested that it is due to the escape of blood at the wound, whereas in simple fractures the blood is retained and assists in repair.

If sepsis gains the upper hand in a compound fracture there is, firstly, the risk of infection of the marrow—osteomyelitis—which in former times was liable to result in pyaemia; in the second place, not only do loose fragments tend to die and be thrown off as sequestra, but the ends of the fragments themselves may undergo necrosis; involving as this does the dense cortical bone of the shaft, the dead bone is slow in being separated, and until it is separated and thrown off, no actual repair can take place. The sepsis stimulates the bone-forming tissues and new bone is formed in considerable amount, especially on the surface of the shaft in the vicinity of the fracture; in macerated specimens it presents a porous, crumbling texture. Sometimes the new bone—which corresponds to the involucrum of an osteomyelitis—imprisons a sequestrum and prevents its extrusion, in which case one or more sinuses may persist indefinitely. Cases are met with where such sinuses have existed for the best part of a long life and have ultimately become the seat of epithelioma.

It should be noted that all the above changes can be followed in skiagrams.

Treatment.—The leading indication is to ensure asepsis. Even in the case of a small punctured wound caused by a pointed fragment coming through the skin it is never wise to assume that the wound is not infected. It is much safer to enlarge such a wound, pare away the bruised edges, and disinfect the raw surfaces.

In cases of extensive laceration of the soft parts, all soiled, bruised, or torn portions of tissue should be clipped away with scissors, blood-clots removed, and the bleeding arrested by forci-pressure or ligature. If there is any reason to believe that the wound is infected, any fragments of bone completely separated from the periosteum should be removed. In comminuted fractures, extension applied by strips of plaster or by means of ice-tong callipers or Steinmann's apparatus (p. 150) often facilitates replacement of the fragments and their retention in position. Plates and screws are not recommended for comminuted fractures, owing to the mechanical difficulty of fixing a number of small fragments and the risks of infection. The wound should be purified with eusol, and the surrounding parts painted with iodine. On the whole, it is safer not to attempt to obtain primary union by completely closing such wounds, but rather to drain or pack them. To increase the local leucocytosis and so check the spread of infection, a Bier's constricting bandage may be applied.

In other respects the treatment is carried out on the same lines as in simple fractures, provision being made for dressing the wound without disturbance of the fracture. Massage and movement should be commenced after the wound is healed and the condition has become analogous to a simple fracture.

Question of Amputation in Compound Fractures.—Before deciding to perform primary amputation of a limb for compound fracture, the surgeon must satisfy himself (1) that the attainment of asepsis is impossible; (2) that the soft parts are so widely and so grossly damaged that their recovery is improbable; (3) that the vascular and nervous supply of the parts beyond has been rendered insufficient by destruction of the main blood vessels and nerve-trunks; (4) that the bones have been so shattered as to be beyond repair; and (5) that the limb, even if healing takes place, will be less useful than an artificial one.

In attempting to save the limb of a young subject, it is justifiable to run risks which would not be permissible in the case of an older person. To save an upper limb, also, risks may be run which would not be justifiable in the case of a lower limb, because, while a serviceable artificial leg can readily be procured, any portion of the natural hand or arm is infinitely more useful than the best substitute which the instrument-maker can contrive. The risk involved in attempting to save a limb should always be explained to the patient or his guardian, in order that he may share the responsibility in case of failure.

Whether or not the amputation should be performed at once, depends upon the general condition of the patient. If the injury is a severe one, and attended with a profound degree of shock, it is better to wait for twenty-four or forty-eight hours. Meanwhile the wound is purified, and the limb wrapped in a sterile dressing. Means are taken to counteract shock and to maintain the patient's strength, and evidence of infection or of haemorrhage is carefully watched for. When the shock has passed off, the operation is then performed under more favourable auspices. Clinical experience has proved that by this means the mortality of primary amputations may be materially diminished, especially in injuries necessitating removal of an entire limb.

Having decided to amputate, it is important to avoid having bruised, torn, or separated tissues in the flaps, as these are liable to slough or to become the seat of infection. In this connection it should be borne in mind that the damage to soft tissues is always wider in extent than appears from external examination.

The attempt to save a limb may fail and amputation may be called for later because of spreading infective processes, osteomyelitis, or gangrene; to prevent exhaustion from prolonged suppuration and toxin absorption; or on account of secondary haemorrhage.

Gun-shot Injuries of Bone.—Fractures resulting from the impact of bullet or fragments of shell are of necessity compound, and are usually infected from the outset by organisms carried in by the missile or by portions of clothing or other foreign material. Not infrequently the missile lodges in the bone.



The extent of the injury to the bone varies infinitely, from a mere chip or gutter-shaped wound to complete pulverisation of the portion struck. The fracture is of the comminuted and fissured variety, the cracks radiating from the point of impact and extending for a considerable distance, sometimes even implicating the articular surface of the bone some inches away. In comminuted fractures of the shafts of long bones there is often a large wedge-shaped fragment completely isolated from the rest, and in the presence of infection this may form a sequestrum. Healing is often delayed by the separation of sequestra, which takes place slowly, and union is attended with excessive formation of callus. When a considerable section of the shaft has been lost, want of union, fibrous union, or the formation of a false joint may result.

The treatment is carried out on the same lines as in other forms of compound fracture, except that mention should be made of the irrigation method of Carrel, found to be the most potent means of overcoming the associated infection.

SEPARATION OF EPIPHYSES[1]

[1] We do not employ the term "diastasis," which has been used in different senses by different writers.

In young subjects before the bones are fully developed the epiphyses may be separated from the diaphyses. The use of the X-rays has added greatly to our knowledge of these lesions.

It is useful to remember that in the upper extremity the epiphyses in the regions of the shoulder and wrist, and, in the lower extremity, those in the region of the knee, are the latest to unite; and that it is in these situations that growth in length of the bone goes on longest and most actively (twenty to twenty-one years). Injuries of these epiphyses, therefore, are most liable to interfere with the growth of the limb.

An epiphysis is nourished from the articular arteries and through the vessels of the periosteum.

Pathological Separation of Epiphyses.—There are certain pathological conditions, such as rickets, scurvy, congenital syphilis, tubercle, suppurative conditions, and tumour growths, which render separation of the epiphyses liable to occur from injuries altogether insufficient to produce such lesions under normal conditions.

Traumatic Separations.[2]—Speaking generally, it may be said that injuries which in an adult would be liable to produce dislocation, are in a young person more apt to cause separation of an epiphysis. Indirect violence, especially when exerted in such a way as to combine traction with torsion,—for example, when the foot is caught in the spokes of a carriage wheel,—is the commonest cause of epiphysial separation. Direct violence is a much less frequent cause. Muscular action occasionally produces separation of the epiphyses—for example, the anterior superior iliac spine, the small trochanter of the femur, or the upper end of the fibula.

[2] We desire here to acknowledge our indebtedness to Mr. John Poland's work on Traumatic Separation of the Epiphyses.



The majority of separations take place between the eleventh and the eighteenth years, chiefly because during this period the injuries liable to produce such lesions are most common. They do not occur after twenty-five, because by that time all the epiphyses have united. In females this form of injury is rare, and almost invariably occurs before puberty.

The following are the most common seats of separation in the order of their frequency: (1) the lower end of the femur; (2) the lower end of the radius; (3) the upper end of the humerus; (4) the lower end of the humerus; (5) the lower end of the tibia; and (6) the upper end of the tibia.

Morbid Anatomy.—In a true separation the epiphysial cartilage remains attached to the epiphysis. As a rule the epiphysis is not completely separated from the diaphysis, the common lesion being a separation along part of the epiphysial line, with a fracture running into the diaphysis (Fig. 8). It is not uncommon for more than one epiphysis to be separated by the same accident—for example, the lower end of the femur and the upper ends of the tibia and fibula. Epiphysial separations, like fractures, may be simple or compound. Incomplete separations are liable to be overlooked at the time of the accident, but there is reason to believe that they may form the starting-point of disease. Strain of the epiphysial junction—the juxta-epiphysial strain of Ollier—is a common injury in young children.

Clinical Features.—The symptoms simulate those of dislocation rather than of fracture. Thus, unnatural mobility at an epiphysial junction may closely resemble movement at the adjacent joint, especially when the epiphysis is an intra-capsular one. The relationship of the bony points, however, serves to indicate the nature of the lesion. The degree of deformity is often slight, because the transverse direction of the lesion, the breadth of the separated surfaces, and the firmness of the periosteal attachment along the epiphysial line often prevent displacement. In many cases a distinct, rounded, smooth, and regular ridge, caused by the projection of the diaphysis, can be felt. The peculiar "muffled" nature of the crepitus is one of the most characteristic signs. The older the patient, and the further ossification has progressed, the more does the crepitus resemble that of fracture.

Of the subsidiary signs, loss of power in the limb is one of the most constant; indeed, in young children it is sometimes the first, and may be the only, sign that attracts attention. Pain and tenderness along the epiphysial line are valuable signs, particularly when the lesion is due to indirect or muscular violence and there is no bruising of soft parts. Localised swelling, accompanied by ecchymosis, is often marked; and the adjacent joint may be distended with fluid.

As distinguishing this injury from a dislocation, it may be noted that in epiphysial separation there is no snap felt when the deformity is reduced, the tendency to re-displacement is greater, and the amount of relief given by reduction less than in dislocation. The use of the Roentgen rays at once establishes the diagnosis.

Prognosis and Results.—In the majority of cases union takes place satisfactorily by the formation of callus in the spongy tissue of the diaphysis and on the deep surface of the periosteum. In spite of the favourable nature of the prognosis in general, however, the friends of the patient should be warned that a completely satisfactory result cannot always be relied upon.

Deformity, with stiffness and locking at the adjacent joint, especially at the elbow, may result from imperfect reduction, or from exuberant callus. Arrest of growth of the bone in length is a rare sequel, and when it occurs, it is due, not to premature union of the epiphysis with the shaft, but to diminished action at the ossifying junction.

When the growth of one of the bones of the leg or forearm is arrested after separation of its epiphysis while the other bone continues to grow, the foot or hand is deviated towards the side of the shorter one.

Partial separations may be overlooked at the time of the accident and cause trouble later from bending of the bone, as in one variety of coxa vara. The epiphysis at the lower end of the femur may be displaced into the ham and press on the popliteal vessels.

Treatment.—The general principles which govern the treatment of fractures apply equally to epiphysial separations, the essential being the accurate replacement of the epiphysis.

In compound separations of epiphysis, the end of the diaphysis may be pushed through the skin. The entrance of sepsis may prove an obstacle to any operative measure that would otherwise be indicated.



CHAPTER II

INJURIES OF JOINTS

SURGICAL ANATOMY—INJURIES: Contusions; Wounds; Sprains; Dislocations—TRAUMATIC DISLOCATIONS: Causes: Varieties; Clinical features; Treatment—Compound dislocations—Old-standing dislocations.

Surgical Anatomy.—The function of a joint is to permit of the movement of one bone upon another. The articular surfaces are covered with a thin layer of hyaline cartilage, and are retained in apposition by the tension of ligaments and of the muscles surrounding the joint. The articular capsule (capsular ligament) is directly continuous with the periosteum, and is lined by a synovial layer, which at the line of attachment of the capsule is reflected on to the bone as far as the articular cartilage. The synovial layer invests intra-articular ligaments, and is projected into the interior of the joint in the form of loose folds wherever the articulating surfaces are not in immediate contact. The surface of the synovial layer is covered with minute processes or villi, which in diseased conditions may become hypertrophied. The synovia owes its lubricating property to mucin, derived from the solution of the endothelial cells on the free surface of the synovial layer. The opposing surfaces of a joint being always in accurate contact, the so-called cavity is only a potential one. If fluid is poured out into the joint, the synovial layer and the capsule are put upon the stretch, causing discomfort or actual pain, which is partly relieved by slightly flexing the joint. If the distension persists, the ligaments become elongated and the joint unstable.

The common origin of bone, cartilage, periosteum, and synovial layer from one parent tissue of the embryo, accords with the readiness with which any one of these tissues may be converted into another under traumatic or pathological influences; and how in ligaments and in synovial membrane foci of hyaline cartilage may form and, after increasing in size, undergo ossification.

Joints derive an abundant blood supply through the articular arteries. The lymphatics, which take origin in the synovial layer, pass to efferent vessels which run in the intermuscular and other connective-tissue planes of the limb. The nerve supply is derived chiefly from the nerves distributed to the muscles acting on the joint and to the skin over it.

Sources of Joint Strength.—The capacity of a joint to resist dislocation depends upon (1) the shape of its osseous elements; (2) the strength and arrangement of its ligaments; (3) the support it receives from muscles or tendons placed in relation to it; and (4) the relative stability of adjacent structures. While all these factors contribute to the strength of a given joint, one or other of them usually predominates, so that certain joints are osseously strong, others are ligamentously strong, while a few depend chiefly upon adjacent muscles for their stability.

The hip and elbows are the best examples of joints deriving their strength mainly from the architectural arrangement of the constituent bones. These joints are dislocated only by extreme degrees of violence, and not infrequently—especially in the elbow—portions of the bones are fractured before the articular surfaces are separated.

The knee, the wrist, the carpal, the tarsal, and the clavicular joints depend for their stability almost entirely on the strength of their ligaments. These joints are rarely dislocated, but as the main incidence of the violence falls on the ligaments they are frequently sprained.

The shoulder is the typical example of a joint depending for its security chiefly upon the muscles and tendons passing over it, and hence the frequency with which it is dislocated when the muscles are taken unawares. At the same time the great mobility of the scapula and clavicle materially increases the stability of the shoulder-joint. The tendons passing in relation to the knee, ankle, and wrist add to the stability of these joints.

The proximity of an easily fractured bone also contributes to prevent dislocation of certain joints—for example, fracture of the clavicle prevents an impinging force expending itself on the shoulder-joint; and the frequency of Colles' fracture of the radius, and of Pott's fracture of the fibula, doubtless accounts to some extent for the rarity of dislocation of the wrist and ankle-joints respectively. The immunity from dislocation which the joints of young subjects enjoy is partly due to the ease with which an adjacent epiphysis is separated.

The mechanical axiom that "what is gained in movement is lost in stability" applies to joints, those which have the widest range of movement being the most frequently dislocated.

* * * * *

The injuries to which a joint is liable are Contusions, Wounds, Sprains, and Dislocations.

Contusions of Joints.—Contusion is the mildest form of injury to a joint. Whether the violence is transmitted from a distance, as in contusion of the hip from a fall on the feet, or acts more directly, as in a fall on the great trochanter, the bones are violently driven against one another, and the force expends itself on their articular surfaces. The articular cartilages and the underlying spongy bone, as well as the synovial lining, are bruised, and there is an effusion of blood and serous fluid into the joint and surrounding tissues.

The most prominent clinical features are swelling and discoloration. The swelling, especially in superficially placed joints, is an early and marked symptom, and is mainly due to the effusion of blood into the joint (haemarthrosis). In deeply placed joints, discoloration may not appear on the surface for some days, especially if the violence has been indirect. The joint is kept in the flexed position, and is painful only when moved. In haemophilic subjects, considerable effusion of blood into a joint may follow the most trivial injury.

A slight degree of serous effusion into the joint (hydrarthrosis) often persists for some time, and tuberculous affections of joints not infrequently date from a contusion.

The treatment is the same as for sprains (p. 36).

Wounds of Joints.—The importance of accidental wounds of joints—such, for example, as result from a stab with a penknife or the spike of a railing—lies in the fact that they are liable to be followed by infection of the synovial cavity. The infection may involve only the synovial layer (septic synovitis), or may spread to all the elements of the joint (septic arthritis). These conditions are described with diseases of joints.

Penetration of the joint may sometimes be recognised by the escape of synovia from the wound, or the synovial layer or articular cartilage may be exposed. When doubt exists, the wound should be enlarged. The use of the probe is to be avoided, on account of the risk of carrying infective material from the track of the wound into the joint.

Penetrating wounds of joints are treated on the same lines as compound fractures. If the penetrating instrument is to be regarded as infected,—as, for example, when the spoke of a motor bicycle is driven through the upper pouch of the knee,—the injury is to be looked upon as serious and capable of endangering the function of the joint, loss of the limb, or even life itself. Reliance is chiefly laid on primary excision of the edges and track of the wound, and other measures employed in the treatment of gun-shot wounds. While the wound in the synovialis and capsule is sutured, that in the soft parts is left open. If drainage is employed, the tube extends down to the opening in the synovialis, but not into the joint itself. If sepsis supervenes, the joint is opened and irrigated by Carrel's method. Some form of splint and a Bier's bandage are valuable adjuncts. The final recourse is to amputation.

Gun-shot injuries of joints vary in severity from a mere puncture of the synovial layer by a chip of shell to complete shattering of the articular surfaces. Between these extremes are cases in which the capsular and synovial layer are extensively lacerated without involvement of the bones, and others in which the bones are implicated without serious damage being done to ligaments or synovial layer—for example, by a bullet passing through and through the cancellated part of one of the constituent bones, or by a fissure extending into the articular surface.

In all degrees the great risk is from septic infection, which may be assumed to be present in all but the last-named variety.

The treatment consists in immediately cleansing the wound by excising grossly damaged tissue and removing any foreign body that may have lodged; disinfecting the exposed part of the joint cavity with eusol, "bipp," or other antiseptic, and closing the wound or establishing drainage, according to circumstances. The joint is then immobilised till the wound has healed, after which massage and movement are commenced. When the bones are shattered or when sepsis gets the upper hand and disorganises the joint, amputation is called for.

Sprains.—A sprain results from a stretching or twisting form of violence which causes the joint to move beyond its physiological limits, or in some direction for which it is not structurally adapted. The main incidence of the force therefore falls upon the ligaments, which are suddenly stretched or torn. The synovial layer also is torn, and the joint becomes filled with blood and synovial fluid.

Muscles and tendons passing over the joint are stretched or torn, and their sheaths filled with serous effusion. It is not uncommon for portions of bone to be torn off at the site of attachment of strong ligamentous bands or tendons, constituting a "sprain fracture"; or for intra-articular cartilages to be torn and displaced, as in the knee.

Clinical Features.—The injury is accompanied by intense sickening pain, and this may persist for a considerable time. At first it is aggravated by moving the joint, but if the movement is continued it tends to pass off. The particular ligaments involved may be recognised by the tenderness which is elicited on making pressure over them, or by putting them on the stretch. In this way a sprain may often be diagnosed from a fracture in which the maximum tenderness is over the injury to the bone.

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